Preoperative surgical considerations
Given there are many anatomic variants in need of vaginoplasty, many vaginoplasty techniques have been described. In order to guide technique choice, several preoperative surgical questions should be answered:
Is the vaginoplasty a primary procedure (no prior vaginal or perineal operation) or a secondary procedure (vaginal or perineal reoperation) fraught with extensive scarring?
Is the quantity and quality of native vaginal tissue available for use in the vaginoplasty sufficient to correct the anomaly?
Where is the healthy native vaginal tissue located (if any is present)?
If the available native vaginal tissue is totally sufficient for vaginal reconstruction and the vaginal introitus is stenotic, then perhaps a simple pulldown procedure with scar excision could be performed. However, if there is some usable native tissue available but the amount is insufficient for reconstruction, a composite vaginoplasty must be performed. A composite vaginoplasty would consist of native vaginal tissue augmented by neovaginal tissue taken from a donor site.
Lastly, if there is a complete absence of the vagina, a total neovagina must be constructed from donor tissue. If neovaginal tissue is needed, then a decision for the surgeon is the choice of the best donor tissue source.