Intestinal vaginoplasty. A short segment of bowel (sigmoid colon, ileum, or jejunum) is harvested and attached as a vaginal opening on the perineum. Advantages of the procedure include natural lubrication through bowel mucus production and utility even if the patient has had previous perineal surgery. Potential drawbacks of the procedure include the inherent risks of an abdominal surgery and intestinal anastomosis, visible abdominal scarring (which can be minimized if performed laparoscopically), bowel vaginoplasty loss, stenosis or prolapse, and excessive discharge of odorous bowel mucus requiring daily pad usage.
Myocutaneous flap vaginoplasty. Bilateral flaps are created on the vascular pedicle with the underlying muscle (ie, gracilis) and used for reconstruction. If the blood supply to the flap remains strong, flap loss or contracture are minimized and vaginal dilation may not be required. Disadvantages include high rates of contracture and flap loss, potential for hair growth in the vagina, and significant disfiguring scars produced at the donor site.
The McIndoe procedure. Autologous split-thickness skin grafts are harvested from the buttocks or thigh area (Br J Plast Surg 1950; 2:254-67) and immobilized with a vaginal mold to help prevent stenosis or graft loss. This procedure avoids the complications of abdominal surgery, the grafted tissue typically takes well, and the occurrence of vaginal prolapse is minimal. Unfortunately, the resulting scars at the donor site are significant and often disfiguring, there is still a lack of lubrication as the grafted skin is keratinized, and there is the potential for hair growth in the vagina.
A new vaginoplasty needed?
Alternative graft materials are needed, wherever possible, to minimize previously described adverse complications and expand therapeutic options. In addition, from the patient’s view with older vaginoplasty techniques, cosmesis is often poor and function is often suboptimal, owing to the lack of lubrication and dyspareunia from vaginal stenosis. This places additional social and psychological burdens on patients who are already concerned with their sexuality, genital appearance, and fertility.
In my experience, buccal mucosa is an excellent graft alternative affording a host of advantages. The tissue is thick and, with its underlying layer of dense elastic fibers, provides a high degree of strength with distensibility. Buccal mucosa is a non-keratinized, non-hair-bearing secretory epithelium, providing endogenous lubrication without the unpleasant and excessive bowel mucus and is an excellent color and texture match to the native vaginal epithelium. The graft harvest site heals rapidly, with no visible scarring. As the donor site is well hidden inside the patient’s mouth, its presence is likely only evident if the patient decides to share that fact.