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    Vaginoplasty and the role of autologous buccal mucosa

    Buccal mucosa is an ‘excellent graft alternative’ for simple and complex repairs

     

    Buccal mucosa graft harvest, preparation

    Briefly, a 12- to 24-cm2 section of full-thickness mucosa can be harvested from the inner cheek—bilaterally, if needed—along the mandible, from the angle of the jaw toward the lip. The orifice to Stensen’s duct should be unharmed. The autologous buccal mucosa is then manually fenestrated to enable neovascularization and surface area expansion if needed and also to prevent hematoma or seroma accumulation beneath the graft.

    After incisions for a neovaginal vault or vaginal stenosis repair are made, the graft tissue is then inserted and anastomosed to the native vaginal tissue if present. A vaginal mold is placed and immobilized by suturing the labia minora across it.

    Postoperative care

    Inpatient care requires pain management, strict bed rest for 7 days with log rolling, minimal hip flexion, and an indwelling Foley catheter. Beginning in the recovery room, the patient must do hourly mouth exercises consisting of maximally opening their jaws then stretching their cheeks bilaterally with fingers and/or tongue to prevent oral contracture. The exercises should be continued throughout the entire hospital stay. At day 7, the urethral catheter and vaginal mold are removed at the bedside and the first dilation is performed.

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    At home, vaginal discharge should be expected for up to 7 days. Dilation exercises should continue, starting with the largest tolerated Syracuse vaginal dilator and advancing sequentially through larger sizes. Sexual intercourse should not be attempted for at least 4-6 weeks, depending on healing times.

    Surgical outcomes

    Since beginning in 2004, I have had excellent results with both composite and total vaginoplasties in over 65 primary and secondary surgeries (J Pediatr Urol 2006; 2:486-8; Pediatr Surg Int 2014; 30:533-5; Obstet Gynecol 2014; 123:947-50), with limited complications. Of the follow-up surveillance biopsies performed, no evidence of dysplasia or malignant degeneration has been detected (J Urol 2011; 185[suppl]:e103, abs. 257). Interestingly, in all biopsy cases the pathologist’s report has been unable to differentiate the tissue sample as being buccal mucosa rather than vaginal mucosa.

    Summary

    There is clearly a need for improved vaginoplasty methods. When native vaginal tissue is in limited quantity, vaginoplasty is more complex with increased risks. I have found autologous buccal mucosa vaginoplasty gives excellent early results when used in both simple and complex repairs.

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