VPs flap hymenovaginoplasty(A new method for Hymenovaginoplasty by Dr.V.Prakash).

A new method presented at National conference of Plastic Surgery at Mahabalipuram in AUG 2009

Also taught how to do hymenoplasty to plastic surgeons in Guwahati medical college on 27th Feb 2010

A new method of hymenoplasty-VP,s Flap Hymenovaginoplasty

 
 Hymenoplasty is required to restore the hymen if torn before marriage .Now a days hymenoplasty is also requested by some females at their 25^th anniversary to enjoy revirgination  .However  academic literature has not given much details about hymenoplasty. We have found one report ¹which has just described, in not very descript manner and without photographs, procedure of hymenoplasty.We have described a procedure for hymenoplasty by using the remnants of torn hymen ^2._{However ,on many occasions the remnants are not suitable enough to be used.Particulary in  patient demanding hymenoplasty at later date (25th year of marriage ), remnants are usually not suitable to be used to ret the hymen  .In these patients we have done a flap procedure of hymenoplasty to restore the hymen .}

Material and method

We have done hymenoplasty in nine women  over a period of five years  .Five of  our patients were unmarried girls over the age of 21 years .while four were married women  who had come requesting for tightening of relaxed vagina  and wanted  hymenoplasty at the same time Three of the  five unmarried  females were accompanied by their parents, one girl was accompanied by her boyfriend and fiancée,while one girl was unaccompanied by any body. All the four  married women were accompanied by their husbands The history was taken and all patients were explained that absence of hymen is not a sign of lost virginity; and same is true for bleeding on first night. But all of the girls and their accompanying persons were firm to get  the hymenoplasty done. In those cases in which the women were accompanied by the husbands nothing like this was explained

Technique

 The procedure was done in local or general anesthesia as per wishes of the patient .In 3 patients it was done in local anesthesia and in remaining in general anesthesia The patients were placed in lithotomy position .Area was prepared and a random pattern V shaped flap was raised from posterior vaginal wall.After raising the flap the exposed superficial perineal muscles were reefed .The incision was made on the vaginal rim from 7-8 O clock to 10 O clock on right side and 5 to 3O’clock on left side .The Flap was turnd over itself and stitched to posterior vaginal wall.There would be two free ends of the flap on either side .Similarly two ends would result after incision on the vaginal rim on either side .The ends of the flap were stitched  together in two layers using 5-0 vicryl on cutting needle . Inner layer of flapt was stitched to inner layer of vaginal rim mucosa and  outer layer was stitched to the outer layer. It immediately gave a continuous fold like structure similar to hymen and did not leave behind any scar of any kind... . Neosporine ointment was applied over the suture line and no dressing was given.Post operatively patients were advised to clean the area with warm water and apply the ointment .No dressing is required.For pain ,analgesic tablets are enough as there is not much pain .For five days combination of Metronidazole and Ofloxacine is given .

Discussion

Genital plastic surgery for women has come under scrutiny and has been the topic of discussion in the news media, online and in medical journals. In the absence of measurable standards of care, lack of evidence-based outcome norms and little standardization either in nomenclature or training requirements, concern has been raised by both ethitists and specialty organizations .³

The celebration of  bloody sheet , portrayed in popular cinema , is based on strong religious and cultural beliefs .The Koran states that a bride has to be a virgin , and according to the custom a woman found on her wedding night to have been “Touched” brings shame to her family. Consequences include divorce to death .⁴

Consequently young women go to great lengths to get their hymen repaired .However it is illegal in most Arab country.⁴ _{But now a days many females request hymenoplasty not for fear of being discovered as unchaste but to be  an virgin before marriage and many a times with the consent of their would be husbands. Same is true for females opting for hymenoplasty at 25th anniversary to enjoy revirgination.}

_{Hymenoplasty should not be confused with female genital mutilation –previously known as female circumscision.Unlike FGM hymenoplasty is performed on women who have reached the age of consent and who request the surgery themselves ,therefore the medical, ethical and human rights arguments against FGM are not extendable to revirgination as it is another cosmetic surgery like mammoplasty etc}^.5

Simplest technique of hymenoplasty described uses catgut sutures to approximate hymen remnants with incorporation of gelatin capsules containing bloodlike substances which burst on intercourse ⁶

_{Recently from Taiwan a new cercelage method of hymenoplasty has been described} ^{. 7}  

We are the first person who documented with photographs a procedure of hymenoplasty utilizing torn remnants of the hymen ²

 In Western society and in India hymenoplasty is legal .The concept of deception is not relevant. This operation is done for the woman, and the principle of confidentiality is as old as medicine itself. But factors such as sporting activities and use of tampons mean that bleeding with first sexual intercourse is not essential⁸An intact hymen was seen in only 57% of virgins in previous reports..

The role and need of hymenoplasty is debatable. However it is definitely justifiable in certain circumstances , when the woman would otherwise suffer disgrace or worse .More important , however , young women and more particularly males and their families require appropriate sexual education about their adherence to the” Bloody sheet theory”

Irrespective of the scientific and ethical controversies, demand for hymenoplasty is ever increasing. Hundreds of doctors advertise about their hymenoplasty services over internet. Unfortunately none of them ever show the results of the procedure. Are they doing hymenoplasty or just tightening the vaginal orifice, is not known. It would be appropriate to undertake scientific studies on hymenoplasty before accepting or condemning it. Specifically trained specialists should offer hymenoplasty to their clients should it be necessary. Otherwise, the needy women will be forced to get the procedure done by unexperienced  persons. Contraindications to this operation such as female sexual dysfunction, mental impairment and body-dysmorphic disorders should be emphasized before embarking upon this procedure. Women demanding such procedures should be made aware that, although they may wish to cosmetically or physically alter their external genitalia, this does not mean that they are
structurally abnormal

References

1. A.Longmans, A.Verhoeff (1998) who wants the procedure and why: BMJ, 316,459-460.
2. Vishwa Prakash.(2009) How I do Hymenoplasty .Indian Journal of Surgery(In Press)
3. Goodman MP (2009) Female Cosmetic Genital Surgery. Obstetric Gynec.Jan 113:154-9
4. Kandela P (1996) Egypt’s Trade in Hymen Repair .Lancet, 347:16115.
5. O’Connor M(2008)Reconstructing the hymen :Mutilation or restoration .J Law Med ;16(1);161-75

       6.  Sara Paterson –Brown (1998), Commentary: Education about the hymen is needed, BMJ 316:461.

      7. Ou Mc, Lin C C, Ou D (2008) A cercelage method for hymenoplasty.Taiwan J Obstetric Gynecology .47(3); 355-6

   8. Emans SJ (1994) Hymeneal findings in adolescent women. J .Pediatric, 125:153-60

Legends to Figures

1. Showing woman who has delivered the baby and got episiotomy done .

2. Flap raised from posterior vaginal wall.

3. Flap stitched to posterior vaginal wall .

4.Flap stitched laterally to the vaginal rim incisions