Female genital surgery

Reasons of interest. Why and for whom?

The interest in highlighting external sexual attributes, ennobled by the art of the most advanced cultures, has now reached a stage of exaltation. With regard to women, in terms of their commitment to improvement, attention to obvious body areas such as breast reshaping and contour stylization, as important before as especially after gestation, has shifted in the last decade, product of the greater general permissiveness and currents of opinion, towards anatomical parts previously reserved for artistic reverie.

The beautification of the external genitals promotes the recovery of juvenile signs by filling or lipo- infiltration of the major and minor lips, adjustment or narrowing of the vulva and vaginal cavity, reaffirming their muscles, and even recreating the himeneal membrane , while correcting disproportions of labia minora and clitoris, remodeling its contour and length.

We also corrected congenital alterations such as absence of vagina, insufficient short cavity, ambiguity or intersex situations with inadequate genitals, or the consequences of endocrine disorders that may manifest with enlarged clitoris.

They are proposed , gestures to treat infections that affect both genders, and also as chronic hidrosadenitis sinus pilonidal, especially damaging the first and sometimes massively, folds hairs as inguinal, gluteal and axilla.

In other cases, the intervention is primarily intended to repair undesirable consequences of a previous condition or intervention, such as deformities and contractures, ritual, traumatic or even surgical mutilations due to previous tumor disease.

Recommendations before treatment

You will find it useful to prepare a written list of questions to avoid forgetting any, since it is important to clarify with the surgeon all the doubts you may have about the procedure to be performed.

Make provision in advance of the list of medications and products for cures prescribed in pre-operative consultations , and have more extensive clothes that allow you to house your genitals without rubbing, such as possible dressings or bandages that we will apply in some recent postoperative .

Who can be the most suitable candidates?

The most timely decision is the result of realistic and balanced deliberation, by exposing different alternatives, weighing benefits against inconveniences, understanding the proposed techniques, possible added operating gestures, and respecting the recommended convalescence.

To obtain the best results, this decision can be complemented by the participation of an experienced psychologist, to whom we express our expectations, in order to obtain objective and effective advice. Also forming a multidisciplinary approach, in cases that require it, the opinion of the gynecologist. When there are glandular disorders, initial endocrinological consultation is essential.

Are surgeries performed for sexual identity reorientation?


The comprehensive and adequate treatment of gender dysphoria is subject to international protocols (www.symposion.com/ijt/soc-01/index.htm), which involve periods of both hormonal and psychiatric preparatory treatment close to 2 years , essential as a stage prior to any definitive surgery that may be irreversible. The generally acceptable aesthetic results can sometimes be debatable.

 

TREATMENTS PERFORMED

1. Labioplasty or ninfoplastia : There are wide variations in both the appearance and dimensions of labia minora, with enlargements which can be from birth, or secondary to maternal age.

The reasons for its remodeling are multiple: discomfort when wearing pants and swimsuits, such as during exercise or sport, and even access dyspareunia (gr. Dys : difficult, and couples : intercourse) is not uncommon in almost 50% of the consultants. Aesthetic motivations are also very important, resulting in a high degree of satisfaction close to 95% of those interested.

There are different techniques, adapted to the type of surplus of the labia minora, which can also be combined with remodeling of the clitoris cap. The most suitable techniques allow you to naturally preserve its contour and coloration.

It is usually performed under local anesthesia associated with sedation, on a walking basis. The period of convalescence, to adapt to each type of work activity, is usually short, around 3 days, with more immediate revisions at 24 and 72 hours. The restart of relationships is possible by 4 weeks.

2. Remodeling of the labia majora: The excess of tissues causes protrusions especially evident when wearing tight clothes, favoring irritations by microorganisms. As in the previous case, it can be congenital, by age or maternity. Its reduction, through internal semilunar reductions in its confluence with the labia minora, allows the scar to be adequately concealed. Both anesthesia and convalescence are similar to nymphoplasty .

3. Lipoinfiltration of the labia majora: Through adipose tissue filling taken from locations where there are surpluses, with the intention of recovering fullness and youthful tone, and also as a correction for sequelae of massive thinning or bariatric surgery.

It is performed under local anesthesia and sedation, and may be associated with other techniques. Relationships are allowed in 2-3 weeks. Depending on the results and time course, it is sometimes complemented by reviews of the procedure.

4. Pubic remodeling of excess adipose tissue, with or without “ lifting ”: The bulge of the pubis, especially evident when wearing garments, happens even without being overweight, and sometimes it is secondary to previous abdominoplasty ; interferes with relationships, and even hygiene care.

The reduction of its fullness, in an ambulatory way under sedation with local anesthesia, allows in a short time, to restore a morphology more in line with the feminine aspect. When there are also surpluses of skin and soft parts, it is combined with a “ lifting ” leaving the scars hidden in the most immediate folds.

5. Vaginal rejuvenation: Multiple motherhood or the course of age, cause relaxation of the normal tone of the soft structures that make up the pelvic floor, thus, bulbocavernosus muscle fibers that act as a superficial vaginal constrictor, can be readjusted to improve Intensity during relationships. It is performed under epidural or general brief anesthesia, in half-stay regime.

6. Hymeneal membrane recreation : Independently and outpatient, or in relation to the refinements of the previous procedure, some women who wish to promote the youthful appearance of their external genitals can undergo this rapid technique, under local anesthesia and sedation. Relationships are deferred until the 4th week.

7. Reduction of the enlarged clitoris: The excessive development of the body and glans of the clitoris, considering the normality of the glans between 3.7 and 10 mm, may exist from birth, secondary to endocrine disorders such as adrenal hyperplasia, or be acquired by Steroid administration.

Its dimensions are restored under general anesthesia of short duration, respecting its sensitivity, usually in half a morning stay.

8. Readaptation of ambiguous genitalia: Abnormalities in the congenital differentiation of the external genitals cover a wide range of alterations, among which are intersex states.

The specifically personalized treatment allows these patients to harmonize their external appearance, with their orientation avoiding ambiguity situations.

9. Treatment of vaginal agenesis: At present, it is possible through several flap techniques, both vulva and vulva and perineal, allowing some degree of sensitivity, but we propose one that reduces sequelae in tissue donor areas, in addition, without the annoying inconvenience of including hairs in the new cavity. As a minor inconvenience, the use of dilators is required for a limited period of 3 months.

10. Other restorative treatments: As a consequence of congenital malformations or sequelae of previous interventions, whether due to tumor and traumatic diseases: burns and accidents, or by ritual mutilations, which cause flanges or scars on the vulva, narrowing of the vaginal entrance may occur, and even limitations on the mobility of lower limbs, affecting the functions of daily life. We perform its correction by displacing healthy tissues sometimes combined with grafts.

FREQUENTLY ASKED QUESTIONS:

In interventions on external genitalia, and more specifically, labia minora and clitoris, is their function or erogenous sensitivity altered?
Transitional modifications, ranging from greater sensitivity to the opposite situation or crushing, are common after most interventions, due to immediate inflammation. After the period of remission and in the absence of complications, sensitivity is gradually restored. Other more lasting alterations are uncommon.

Is there any alteration in urinary capacity?
This function is primarily respected, with that intention in addition to preserving the intervened region, in some cases we apply a transient bladder catheter, while in more complex and prolonged techniques, its withdrawal is delayed around the first 48 to 72 hours postoperatively.

When can sexual intercourse resume?
In most techniques that reshape the vulva, they should be delayed at least until the full course of the next 4 weeks. In any case, its restoration or onset will depend on the correct evolution during the postoperative period.

What other inconveniences can I expect?
In most of the shorter duration remodeling, inflammation in the vulva may last for the first 2 to 3 weeks; The pain is usually not intense, preventing its appearance during the first days by oral analgesics. The presence of the sutures we use, of resorbable material in order to avoid manipulation and additional discomfort, usually produces a sensation of traction, which will usually cease with the maturation of the scar process .

When does work reintegration occur?
It depends on the procedures used, and the work activity performed. In some treatments, one week’s work leave is recommended. In case of performing activities with especially intense physical effort, another week could be added.

Can several interventions be done together?
It depends on each one of the problems to be treated, both of its individual complexity and of the whole. They can always be complemented after a careful study of each particular case, remodeling of the pubis, with “ lifting ”, and even correction techniques of the labia majora and labia. In any case, the inflammatory process will be increased, and its resolution prolonged over time.

 What is monitoring and care in the recent postoperative?
The first review and cure the next day; successively, removing the possible drains towards 48-72 hours, giving recommendations to start, generally, the washing and drying of the intervened region. The sutures are usually made of material that is reabsorbed although they can be checked by 8 or 10 days. Meanwhile in some techniques, dressing is recommended to reduce inflammation, in addition to abstention from sports activity and sexual intercourse during the first 4 weeks.

The majority of techniques, except for the most complex reconstructions, are ambulatory driving, during the day surgery regime, in whose postoperative period the abstention of sports activity and relationships during the first month must be followed.

Are surgeries performed for sexual identity reorientation?
The comprehensive and adequate treatment of gender dysphoria is subject to international protocols (www.symposion.com/ijt/soc-01/index.htm), which involve periods of both hormonal and psychiatric preparatory treatment close to 2 years , essential as a stage prior to any definitive surgery that may be irreversible. The generally acceptable aesthetic results can sometimes be debatable.

What types of anesthesia may be necessary?
Both pubic liposculpture, as well as most procedures for remodeling the labia majora and labia in collaborating patients, can be performed under local anesthesia and intravenous or even epidural sedation. If necessary, general anesthesia of short duration is used.

Rehabilitation or “ lifting ” techniques of the pubis, vaginal rejuvenation and clitoris reduction, preferably under general anesthesia lasting around 2 hours, with morning stay and subsequent outpatient follow-up.

Other longer interventions such as the creation of a new vagina due to previous lack, or the readaptation of ambiguous genitals, under general anesthesia and hospital stay for at least 24 to 48 hours.

The definitive decision of the type of anesthesia corresponds to the medical team, although the preferences that can be made compatible with the act to be performed are always considered, adjusting in each patient to their individual needs.

What can be the risks in this type of specific interventions?
Any intervention involves common risks that are considered general, others that depend on the anesthetic technique used, and finally the specific risks derived from both the procedure itself and the area treated. General risks: Immediate (first 24 to 48 hours), hemorrhage, with or without hematoma (usually prevented by drainage), edema or swelling (cold prevention); Some usually delay its appearance sometimes up to three weeks, such as: seroma or accumulation of clear fluid, local infection, separation of wound edges (dehiscence), skin loss. Intolerance reactions to suture material or cures such as: adhesives, antiseptics. Finally, when there is a skin scar, since those that are confined to the mucous membranes tend to obtain a better result, it can be visible or thickened, evolving at least during the first 11 months.

Anesthetic risks: From those derived from local anesthesia (such as pain in the puncture area), less invasive versus epidural, or even general anesthesia, with possible nausea and / or vomiting during the first 12-24 hours. The availability of adequate means in the operating room can reverse major complications such as medication intolerance reactions.

Specific risks: Sensitivity modifications of the skin and mucous membranes, usually temporary due to the most recent inflammation. In some cases, due to the complexity of the problem to be treated, the possible need for reintervention should also be considered, also due to the occurrence of early or late complications such as scar contractures, or due to dissatisfaction with the results.

EXTERNAL GENITALS: ANATOMICAL REMEMBER in ADULT WOMEN

The set of external genitals constitutes the vulva, which includes labial folds, slit or space limited laterally by the foregoing, and erectile organs.

LABAL TRAININGS

Mons pubis or: Located in most anterior portion of the vulva, consistency cellulo bounded laterally by inguinal folds -adiposa containing elastic fibers, and. Of very variable thickness, depending on the adipose tissue housed, it ranges between 2-3 cm in normal constitutions, while in obese ones, it exceeds 7 cm.

Lips: Cutaneous folds, behind the previous one, consisting of five tunics. They measure approximately 7-8 cm long by 2-3 cm wide, and thickness in their intermediate portion of 15-20 mm. The meeting of both ahead, constitutes the anterior arch or commissure, thicker with respect to the posterior commissure, thin and curled, and its most immediate decline to the vaginal opening, navicular fossa. Conditions such as multiparity and age, modify their appearance by becoming flaccid and in a perpetually ajar attitude, expanding the vulvar cleft or defined space between them.

Minor or nymph lips: Flattened skin-membranous folds, internal to the greater, according to Testut, of average length: 30-35 mm, width 10-15 mm, and thickness 4-5 mm, but subject to great variability in morphology and dimensions, both by age, in this way, in newborns they exceed the elderly, investing later; individual variability, being able to be hidden by the elderly, descend to its free edge, even externalize, then appear more pigmented; as by racial variations, in some ethnicities they reach 15-20 cm. Its anterior ends are divided into secondary leaves, constituting those that meet behind the clitoris, by way of insertion with the opposite, the frenulum of the clitoris; while those that merge ahead, much longer, make up a semicircular envelope, clitoris cap or foreskin, underdevelopment developed in European races, and more pronounced in Asians and Africans.

The posterior convergence between both nymphs, less apparent and sharp, when fused with the greater lip of its side, constitutes a skinfold called the pudendal frenulum of the labia minora, or vulvar hairpin , evident in young women, but often lacerated in postpartum.

INTERLABIAL SPACE or VULVAR CONDUCT

The aforementioned ones delimit the orifice of access to the genital pathway, which, in an attitude of rest or closed, is reduced to a simple indentation, while when separating they expose a space of 6-7 cm in length, by 20-25 mm in width, with infundibular or funnel morphology, housing from front to back: Lobby, triangular area confined laterally between the labia minora, continued by the mucosa of the clitoris in front, hole or urethral meatus 3-4 mm in diameter, located 2-3 cm behind , and lower vaginal opening that adopts oval conformation in case of maternity, except in cases where there is still an incomplete mucous septum inserted between vulvar and vaginal canal , called hymen, in a very variable way: semilunar, annular or labial, as found perforated, oscillating is between two digital crossings , and barely a mm.

Imperforates accumulate menstrual bleeding in the vaginal cavity or hematocolpos.

Its complete congenital absence has also been described. In postpartum, rounded traces called myrtiform caruncles may persist.

Adjacent to the urethral orifice, there are two juxtaurethral drainage or Skene drains , glands considered as rudiments of the female prostate. Also on each side but posterior and lateral situation, Bartholino vestibular glands , 12-15 mm in length, lubricants during the relationship life, and atrophic to their extinction are located.

In case of infection or bartholinitis , they can be enlarged up to 5 cm.

ERECTILE BODIES (capable of turgidity or increasing its volume )

Odd and a half or clitoris, homologous to the virile member, held by a suspensory ligament, but lacking a spongy body and completely separated from the urethral orifice. Composed of a hidden portion: two roots or lateral halves inserted in ischiopubic branches , similar to the cavernous bodies of the penis, ascending and converging in the midline to end in a cylindrical free portion, more distal body and its end or glans.

Its dimensions at rest although variable, according to Testut: roots 30-35 mm, body 25-30 mm, and glans diameter 6-7 mm. More recent studies, the first in 200 and the second in 50 women, extend the variability of this last interval between 3 and 10 mm.

Vestibular or vaginal bulbs, two elliptical formations, lateral to the urethra and vaginal orifice, homologous to male urethral bulbs and spongy body, covered by muscle fibers of the vulvar constrictor , lateral to the vaginal orifice, of normal dimensions: length 30-35 mm, width 12 -15 mm, and transverse thickness 8-10 mm, and interconnected by veins to the glans of the clitoris.

Between the muscles of the perineum (set of soft tissues that close the pelvis, crossed by rectum, urethra and genitals) anterior or genital, which contribute especially to sexual function:

Ischiocavernosus , or hamstring , oblique in the forward direction , is inserted in the root of the clitoris, with double action: it causes descent and application of the clitoral glans on the dorsal side of the penis, and compresses the corpus cavernosum of the clitoris.

Bulbocavernosum, surrounds lower holes of the vagina and urethra, constituted as a double arched structure of medium concavity, with multiple functions: erect when compressing dorsal vein of the clitoris, and also mobilizing, lowering it to apply to the penis, compresses vaginal bulb and evacuates blood into the vestibule , Bartholin gland drainage , and superficial constrictor of the lower vaginal opening, oppressing the penis. Its spasmodic contraction constitutes vaginismus.

BIBLIOGRAPHY

1. L. Testut and A. Latarjet . Treaty of Human Anatomy. 9th edition, 1976. Volume IV, urogenital apparatus. Chapter II. Salvat editors. Pp 1,169-1,312.

2. K. L Moore. Anatomy with clinical orientation. 2nd edition, 1985. Williams & Wilkins Panamerican publishing house. Chapter 6, pp 929-952.

3. BS Verkauf , J. Vonthron , WF O’Brien. Cltoral size in normal women . Obstetrics and Gynecology 80 (1): 41-44 Jul 1992.

4. J. Lloyd, NS Crouch , CL Minto et al. Female genital appearance : ” normality ” unfolds . BJOG, May 2005, Vol 112, pp 643-646.

5. V. Purushothaman . Horse shoe flap vaginoplasty -a new technique of vaginal reconstruction with labia minora flaps for primary vaginal agenesis.BJPS , (2005) 58, 934-939