Otto Placik’s Disgusting Commentary
Our letter to the editor was rejected by ASJ because I discussed it on my Instagram. But this was published.
https://doi.org/10.1093/asj/sjaa290
The text here is fair use as it is posted for the sake of criticism and purpose of educating the public about misogyny in medicine. My added comments are in brackets in italics.
Hymenoplasty (also termed hymenorrhaphy, hymen reconstruction, hymen repair, hymen surgery, revirgination, and hymen restoration) is a highly charged topic and one of the least described among the array of elective vulvovaginal female genital aesthetic (plastic) procedures. The authors are to be congratulated for sharing their techniques and presentation of the largest known series of patients [victims] undergoing this operation [genital mutilation].1 They have provided references to the commonly reported historical series. For the most part, the literature is limited, and the lessons have remained highly guarded “secrets” among surgeons who perform these procedures. Although I have been invited to comment and some of the following remarks may sound critical, this article is a welcome addition providing insights about this clandestine intervention.
Hymenoplasty is controversial from sociological and ethical perspectives; this has been discussed in numerous previous publications.2 It is unique among elective surgical procedures; I take issue with the authors referring to it as cosmetic. The authors also confound issues of sexual satisfaction as a secondary benefit, yet this is rarely the reason patients seek the procedure. In my limited experience women undergo the procedure to appear chaste and have a limited sexual history [research has shown an intact hymen is not evidence of virginity, nor is a broken hymen indicative of a lack thereof], although in some cases the procedure is a novel “second honeymoon gift.” It is a restorative/reconstructive procedure carried out primarily for ritualistic indications whose results are intended to be transient and prevent cultural/familial ostracism and, in some instances, even life-threatening situations.3
First and foremost, we are obligated as physicians to provide education to and obtain informed consent from patients before proceeding with surgery. This includes discussing that surgery may neither guarantee bleeding nor a “tight” vagina with initial coitus; and that bleeding, if it does occur, is not necessarily a sign of virginity. In one such study, 75% of women who were counseled decided to not proceed with surgery.4 The authors’ first paragraph states that the goal is “to narrow the vaginal opening,” citing Mirzabeigi et al5 as their reference. A review of their source reveals only one statement on hymenoplasty: “Repair/reconstruction of the hymen in an attempt to recreate a virgin state; also referred to as ‘revirgination.’” This nearly identical wording is reiterated in the ACOG committee opinion [The American College of OB/GYNs endorses hymenoplasty].6 The goal of hymenopasty is more likely reconstruction of the hymen in an attempt create a physical barrier to entrance to the vagina that will bleed upon disruption, most commonly accomplished via coitus. One of the first published reports by Prakash7 (also cited by the authors) states specifically that surgery is “to approximate hymen remnants” and Prakash differentiates the 2 procedures by stating: “Are they doing hymenoplasty OR just tightening the vaginal orifice is not known.”
Second, there is muddling of intent. The authors state the goal is sociological rather than functional. Although there is a consensus of medical agreement3 to this effect, the authors’ insistence on the secondary benefits of the vestibulo-introital tightening technique (VITT) for sexual gratification is misdirected. The primary, and essentially the only, perceived advantage of VITT for the purpose of this study is that it may lessen tension on the hymen repair, thereby diminishing the risk of dehiscence. If the goal is vaginal tightening, a full perineoplasty or vaginoplasty with musculofascial plication should be recommended or undertaken. I do have concerns with achieving any significant tightening based on mucosal excision and repair only. The authors would fare better to adhere to their statement: “The success of revirgination operations is dependent on two factors: Bleeding during nuptial as if the first intercourse and forming and intact structure [sic] appearance.”
In my personal experience, these patients, in contrast to labiaplasty patients, anticipate the procedure with greater anxiety, making local anesthesia undesirable. I am impressed that 93% of the authors’ procedures were performed with local anesthetic agents. The surgical procedure is described and appears straightforward, taking less than 30 minutes in total. Key to the surgical procedure is excision of the mucosa from the 5 to 7 o’clock areas of the introitus (VITT) followed by approximation of the residual hymenal caruncles. The repair is completed with 4–0 Vicryl Rapide. In my opinion, that is a large suture for small fragments which is prone to tear the delicate mucosa and create marked inflammation, resulting in a higher incidence of dehiscence. Paradoxically, this may lead to an increased incidence of bleeding with trauma during coitus, eventually providing the desired result if the timing is correct. In addition, the authors do not discuss what to do if a large hymenal remnant is located in the area of planned excision (VITT). Although the authors address the potential comparison to a “minor perineoplasty” which was my initial impression, they state that it differs by its purpose to approximate the hymen and by its ending proximal and anterior to the vaginal fourchette. Another very important distinction is that perineoplasty typically involves some form of musculofascial approximation. The abstract states “no adverse events were observed” but I believe this should be modified to say no major complications or serious adverse events were reported. Only 98 of 143 patients (67%) were examined postoperatively (understandable given the requirement for discretion and secrecy), and of those 98, 8 would have benefited from revision surgery; an additional patient required antibiotic therapy to treat an infection. Approximately 69% of women [who have had hymenoplasty] reported bleeding with sexual penetration [actually the rate was 100% among those who had sex], whereas it has been reported that 34% of virgins [who have not ever had hymenoplasty] recall bleeding on first intercourse.8 So this method effectively doubles [no, triples] the occurrence of bleeding, which then begs the question: are we attempting to reproduce an event that would be expected but would not otherwise have occurred without our intervention? To the credit of the authors, this question can now be raised in light of their report, but further reinforces the need for preoperative counseling.
The authors classify hymenoplasty as being achieved with 4 techniques: primary repair, lateral wall flap technique, submucosal suture technique, and cerclage technique. I have described these differently: flap technique, surgical adhesions, luminal reductions, and suture-only techniques with or without artificial membranes and reservoirs.9 The authors did not cite Goodman10 who reports a comparable procedure in which multiple “diamond-shaped excisions similar to those utilized for a PP [perineoplasty] are performed.” The authors tout the advantages of VITT for its vaginal tightening effects; but I would counter that this is not the reason women seek the procedure. Rather, I interpret the primary gain to be a reduction in the wound tension of the hymenal remnant repairs. The authors astutely state that not all bleeding from initial coitus emanates from the hymen but may instead arise from vestibular injuries [only if sex is violent or anatomy has been surgically altered]. Therefore, they imply, but do not explicitly state, that postcoital bleeding may arise from their vestibular repair. Other methods do exist for diminished tension repair on the hymenal fragments, including double opposing turnover flaps or tension-relieving suture.9 An illustration of one of these techniques without VITT, using exclusively the hymenal fragments, is shown in Figures 1 — 4.
Figure 1.
(A) Retract the labia minora to reveal vaginal introitus and achieve exposure of hymenal remnants. (B) Identify at least 3 opposing hymenal remnant pairs (A-A′, B-B′, C-C′).
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(A) Retract the labia minora to reveal vaginal introitus and achieve exposure of hymenal remnants. (B) Identify at least 3 opposing hymenal remnant pairs (A-A′, B-B′, C-C′).
Figure 2.
(A) Inject 1% lidocaine without epinephrine to expand and hydrodissect the tissues. (B) Inject opposing hymenal remnant.
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(A) Inject 1% lidocaine without epinephrine to expand and hydrodissect the tissues. (B) Inject opposing hymenal remnant.
Figure 3.
(A) Incise anterior surface of one remnant (B′) to create a turnover flap based on the posterior surface of remnant. (B) Carefully elevate the hydrodissected flap based on posterior circulation. (C) Incise the posterior surface of opposing remnant (B) to create a turnover flap based on the anterior surface of remnant. Carefully elevate the hydrodissected flap based on anterior circulation. (D) Cross section illustration showing overlapping of double opposing flaps with minimal tension.
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(A) Incise anterior surface of one remnant (B′) to create a turnover flap based on the posterior surface of remnant. (B) Carefully elevate the hydrodissected flap based on posterior circulation. (C) Incise the posterior surface of opposing remnant (B) to create a turnover flap based on the anterior surface of remnant. Carefully elevate the hydrodissected flap based on anterior circulation. (D) Cross section illustration showing overlapping of double opposing flaps with minimal tension.
Figure 4.
(A) Suture flaps in place beginning with the posterior suture line, followed by the anterior suture line. (B) Ease retraction on labia minora during the suturing process to minimize tension on suture lines. Repeat process with remaining opposing remnant pairs.
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(A) Suture flaps in place beginning with the posterior suture line, followed by the anterior suture line. (B) Ease retraction on labia minora during the suturing process to minimize tension on suture lines. Repeat process with remaining opposing remnant pairs.
Another issue that is not discussed is the timing of repair, other than that the authors re-examine patients 1 — 2 weeks before the marriage. When bleeding is imperative and an impending marriage is scheduled (and a visual inspection of the hymenal integrity is not culturally required), it is often best to time the hymenoplasty to about 3 weeks prior to sexual penetration. In these instances, even if the repair fails, the tissues are sufficiently fragile or lined with granulation tissue to induce bleeding with coitus [because the goal is bleeding and pain].
In summary, there are many nuanced aspects to hymenoplasty. Although this is a critical review, the authors are to be congratulated for openly discussing their methods and sharing their experience with a surgery that has remained shrouded in secrecy.