Hymenoplasty Article in Aesthetic Surgery Journal
They would not publish our letter to the editor because I discussed it on my Instagram.
This is labeled as an “EDITOR’S CHOICE” article. Here are the editors.
This post is copied here for the sake of educating the public and criticism of the unethical paper, which advocates unnecessary harm to women. As such, it is fair use.
A New Practical Surgical Technique for Hymenoplasty: Primary Repair of Hymen With Vestibulo-Introital Tightening Technique
https://doi.org/10.1093/asj/sjaa077
Abstract
Background
Hymenoplasty is distinct from other genital surgeries with its ethical and psychological issues. It is performed to narrow the vaginal opening to ensure vaginal bleeding with penetration. There are various kinds of techniques with different success rates.
Objectives
The authors sought to report a new hymenal reconstruction technique with vestibulo-introital tightening with the results of 145 procedures.
Methods
The new technique included a diamond-shaped incision to the vestibulum with the base in the posterior midline and superior corner 2 to 3 cm higher above the hymen. The angles were accommodated according to the degree of tightening, and the submucosal layer was closed from the apex downwards involving the vaginal mucosa.
Results
The satisfaction rate of the patients was 99.3%. No adverse events were observed.
Conclusions
Compared with previous techniques described, this hymenal reconstruction technique is an alternative with the advantage of low risk of loosening because the tension on the hymen alone is decreased. Additional tightening of the introitus increases the satisfaction rates in some patients.
Level of Evidence: 4 [highest level of evidence — they consider this a good paper]
Topic: ethics diamond hymen reconstructive surgical procedures surgical procedures, operative vagina vaginal hemorrhage genital system vaginal mucosa levels of evidence adverse event
Issue Section: Original Article
The demand for aesthetic surgery of female external genitalia is increasing day by day, but still, there is insufficient experience on genital aesthetic surgery.1 Hymenoplasty is different from other gynecologic surgeries with controversial ethical and pychological issues. It is performed to narrow the vaginal opening.2 The aims are reconstruction of the perforated hymenal caruncles to their original virgin position and to ensure bleeding with sexual penetration.
The hymen has a sociological role rather than functional. Virginity is a social expectation in some cultures such as Muslim, Catholic, Indian, and Chinese populations. Ethical concerns surrounding hymenoplasty are based on the “value of chastity” where hymenal integrity is traditionally associated with sexual purity and bleeding during first marital coitus is an expectation for young women [52% of sexually active teens had intact hymens in this study].3 Willing or involuntary sexual intercourse, trauma to the genital region, or insertion of a substance into the vagina during masturbation may result in the perforation of the hymen. The regret impels women to search for hymenal repair, which may also be designated as a “revirgination.”
We describe and report the results of a new hymenal reconstruction technique with vestibulo-introital tightening technique (VITT), which can be performed easily under local or sedation anesthesia with the advantages of outpatient management and high success rates. The success of revirgination operations depend on 2 factors: bleeding during the nuptial as if it were the first sexual intercourse and forming an intact structure appearance.
METHODS
After fully informed consent forms were obtained in accordance with Turkish Ministry of Health standards, 145 hymenoplasty procedures were performed between January 2016 and May 2018 by only one senior surgeon. Eleven of the patients were excluded, so 134 patients were included in this study. Inclusion criteria was primary hymen reconstruction. This study was not institutional review board approved. World Medical Association Declaration of Helsinki Ethical Principles for medical research involving human patients of guiding principles were followed.
Preoperative Evaluation and Contraindications
Initially, the surgeon and an assistant examined all patients in the lithotomy position by stretching the labia bilaterally to observe hymen remnants. Then, the patients were informed about the findings, sides of perforations, surgery techniques, anesthesia methods, and postoperative care issues. If there was any clinical sign of vaginal infection, it was first treated by medications and then surgery was performed. Contraindications to the surgery included patients who were menstruating, delayed menses without blood pregnancy test, active genital infections, vestibular inflammatory diseases, unrealistic expectations, and patients younger than 18 years of age and unaccompanied by their parents. Also, patients who had insufficient amount of hymen remnants were excluded from VITT.
All the patients signed informed consent forms, including detailed information about the surgery, potential risks of the operation, anesthesia, and medications. Infection, wound dehiscence, bleeding, oozing, hematoma formation, and allergic reactions — depending on medications — are short-term complications after the surgery, and dyspareunia, vaginismus (anxiety of feeling pain and involuntary contractions during sexual penetration), and psychological mood changes such as regression or depression are long-term complications.
Surgical Technique
There were 135 (93.1%) procedures performed under local anesthesia, and only 10 (6.9%) patients required sedation. After properly cleansing the surgical area with 10% povidone, iodine solution, and sterile draping in lithotomy position, 40 mg of articaine hydrochloride with 0.012 mg epinephrine hydrochloride local anesthetic injection was applied to the operational area by 30G needles. Allis clamps were grasped bilaterally in the vestibular area, and a diamond-shaped incision including the hymenal caruncles, vestibulum, and vaginal introitus was performed by curved iris scissors (Figures 1 and 2; Supplemental Figure 1, and Video, available online at www.aestheticsurgeryjournal.com). The lowest point was located in the posterior midline vestibule at the 6 o’clock position just above the fourchette. The superior apex was extended 2 to 3 cm above the hymenal ring through the vaginal wall with lateral borders involving the caruncles (Figure 1). If allis clamps were located at the 4 and 8 o’clock positions, the vaginal entry would be tighter. If less tightening was needed, the side corners were then located at the 5 and 7 o’clock positions. Marking can be done prior to surgery.
Figure 1.
Vestibulo-introital tightening technique (VITT) for hymenoplasty. [Note this cannot be considered a “reconstruction” of the hymen as it also involves cutting out pieces of the vestibule and vagina in order to make the introitus narrower and to increase the chances of tearing and bleeding upon penetration].
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Vestibulo-introital tightening technique (VITT) for hymenoplasty.
Figure 2.
This 23-year-old female patient requested hymenoplasty. (A) Dissection of vulvar vestibulum and posterior vaginal canal. (B) Removal of mucosa and then primary closure of layers by 4–0 vicryl rapide sutures uninterruptedly. Suturing of posterior wall both ensures vaginal tightening effect and diminishes the tension on perforated edges to be repaired. (C) Closure of hymenal mucosa by 4–0 single vicryl rapide sutures, apex, dorsal, and ventral edges, respectively. (D) Closure of vulvar vestibulum as single layer. (E) Intact hymen appearance just after the operation.
Play Video
Watch now at http://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjaa077 [sick fucks]
The mucosa was removed by scissors. After hemostatic control, we closed together the submucosal and mucosal layers of the vagina from the apex downwards until the hymen via 4–0 vicryl rapide sutures (Johnson and Johnson, Ethicon, Ankara, Turkey) continuously. Involving the vaginal mucosa enabled tightening of introitus and additionally decreased the tension on the hymenal mucosa, which is critically important for the success of this operation. After vaginal mucosa and submucosa was closed, the apical, posterior and anterior aspects of hymenal edges were sutured by 4–0 vicryl rapide single sutures, respectively. For fixation of hymen integrity, we recommended 2 methods. First, injection of local anesthetics into the hymen caruncles, which are very thin, may simplify this suturing procedure and also prevent bleeding. Second, dissection by fine scissors into both sides of hymenal remnants can provide some space for a better fixation of the wound edges. After suturing of hymen mucosa, the posterior part of the vestibulum was sutured continuously with a final check for hemostasis.
The diamond shape of VITT for hymenoplasty looks like a “minor perineoplasty” operation. However, it differs from perineoplasty with some of its features. Firstly, the primary goal here is to repair the hymen caruncles and to suture the 3 edges of hymen to ensure this reconstruction, though perineoplasty does not have this goal. Secondly, in VITT, the base of the operation area is located in the vulvar vestibule just above fourchette, not as below as the perineal body.
Postoperative Care and Recommendations
The patients were recommended to return 2 weeks and 2 months after the operation and 1 month before marriage for routine follow-up. They were also informed that we would call them by phone 6 months after. No medical dressing was recommended after surgery. Only oral antibiotics (ampicillin tb 500 mg twice a day) and antiinflammatory drugs for 5 days were prescribed. Heavy sports and heavy lifting were restricted for 1 month. Penetrative sexual intercourse should be avoided for at least 1 month, because the sutures would not disappear in this period. Psychological support was also suggested for some of the patients after the procedure.
RESULTS
The patients’ mean age was 25.5 years (range, 18.5–45.1 years), and they all requested revirgination on their own volition. The mean operative time was 20 minutes (range, 15–28 minutes). The duration was higher in obese and anxious women. No major complications were reported.
One assistant called the patients by phone to obtain their feedback 6 months after the operation. Eleven (7.5%) of the patients neither answered our repeated phone calls nor attended the follow-ups, so they were excluded from the study. The average length of follow-up was 32 days postoperatively (range, 2–158 days). Ninety-eight (73.1%) of the patients were present for at least 1 gynecologic follow-up. Twelve (8.9%) of the patients had wound dehiscence, and 2 had revision surgery by the same method, although 6 did not accept any revision surgery. One patient who revealed signs of infection on the wound area with minimal purulent discharge was treated with oral antibiotics at postoperative day 7.
A total of 130 (97.0%) of the patients stated satisfaction after the surgery, because they tolerated postoperative period quite comfortably. Minor discomforts were also reported. Seven (5.2%) of the patients complained of oozing problems for 2 weeks, 18 (13.4%) complained of stinging and mild pain, and 26 (19.4%) had itching postoperatively.
A total 92 (68.6%) of the patients informed us that they had sexual penetration with bleeding in small amounts (a few drops) to larger volumes (5–6 tablespoons). Forty-two (31.3%) of the patients declared that they had no marriage plan soon. [This amounts to a 100% bleeding rate — far higher than natural 33% in Western Europe].
On the other hand, most patients mentioned their satisfaction due to pressure by introital tightening during intercourse, which imitated the first trial of intercourse.
DISCUSSION
Anatomic shapes and tissue properties of the hymen greatly differ among individuals. After first penetration, small tears called hymenal caruncles occur with minor bleeding in some. There are different techniques for hymenal repair: primary repair, lateral wall flap technique, submucosal suture technique, and cerclage technique.4–6 Recently, Wei et al described a new suture three stratums around the introitus technique, which involved the fascial layers as well.7 All techniques produce narrowing of introital opening with temporary tightening.
Hymenoplasty is sometimes a very critical operation for women who are expected to exhibit “bloody sheet.” Although the satisfaction rates were 92.2% with the technique Wei et al described, only 54.9% reported blood loss during first intercourse.7
In our technique, because the vestibulum is so fragile and delicate, approximating the vestibulum increases the bleeding possibility during intercourse. Moreover, fixation of hymenal edges is easily performed by the tightening of the vestibulum and vaginal canal. The surgical tension on the hymenal ring is strengthened, the risk of loosening and the need for a second revision is quite low. For instance, the approximation method8 was criticized with frequent wound dehiscence rates.7
Vojvodic et al described luminal reduction hymenoplasty, and in this technique, the edges of hymen remnants are excised and then sutured by interrupted rapide sutures.9 They suture the hymenal membrane as we do but do not include vestibule and vaginal canal parts.
CONCLUSIONS
The VITT for hymenoplasty can become an alternative and a good choice with the additional advantage of tight vestibulum and introitus and high success rates and low complication rates. Posterior tightening of the vagina provides a narrowing effect, primary suturing of hymen by single stitches ensures formation of an intact hymen appearance, and tightening the vestibule both narrows the vaginal entry and increases the possibility of bleeding after coitus. Surgical tightening of the posterior wall of the vagina and vestibulum provides hymen edges to merge easily without adding any tension.
After VITT for hymenoplasty, bleeding can occur by the perforation of hymen or sometimes tearing of the vestibule, because the vestibulum is very sensitive to mechanical thrust. However, the patients were not examined for the origin of bleeding after coitus.
Young gynecologists need further experience in these surgical procedures, which people hesitate to speak about. This technique offers a good practical method for practitioners. However, more data are still needed regarding the efficacy and superiority of different hymenoplasty techniques.