Eur J Plast Surg (1997) 20:152-153
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© Springer-Verlag 1997
Vaginal delivery following vaginal inlay grafting S. Marin-Bertolin, R. Gonz~lez-Martinez, P. Marquina Vila, J. Amorrortu-Velayos Department of Plastic and Reconstructive Surgery, University General Hospital, Valencia, Spain
Abstract. W e r e p o r t the case o f a 3 0 - y e a r - o l d w o m a n with a c q u i r e d v a g i n a l stenosis s e c o n d a r y to r e l a p s i n g vaginitis, w h o b e c a m e p r e g n a n t after p a r t i a l split-thickness skin graft vaginoplasty. She h a d a n o r m a l p r e g n a n cy e x c e p t for two e p i s o d e s o f vaginitis c a u s e d b y H. influenzae, w h i c h is an u n c o m m o n i n f e c t i o n d u r i n g p r e g nancy, and a n o r m a l v a g i n a l delivery. To our k n o w l e d g e there is o n l y one a d d i t i o n a l r e p o r t o f v a g i n a l d e l i v e r y f o l l o w i n g this k i n d o f surgery. N e v e r t h e l e s s , these isolated cases p r o b a b l y do not d e m o n s t r a t e the suitability o f a t o t a l l y r e c o n s t r u c t e d v a g i n a b y split skin s e r v i n g as a p o t e n t i a l l y e x p a n s i l e c o n d u i t for n o r m a l delivery.
Key words: Vaginal surgery - Vaginal r e c o n s t r u c t i o n Skin transplantation - Pregnancy -Vaginal delivery
Case report A 30-year-old woman presented with an inability to accomplish intercourse. A normal history of sexual development was recorded, along with a history of relapsing vaginitis. Normal female body habitus, with normal female breasts and external genitalia were found. Vaginal examination showed a severe stenosis of the middle third (Fig. 1). No other noteworthy findings resulted from physical examination and diagnostic tests (hormone assays, ultrasound). Under general anesthesia the vagina was dilated using Hegar's dilators. Stricture release created a large circumferential mucosal defect over the entire middle third of the vagina. Additional defects were created on the distal third, some of them also being circumferential. The total raw area was estimated to be about 50% of the vaginal surface. Spontaneous epithelization of such a large defect would have needed a prolonged period of time, so it was decided top use split-thickness skin for mucosal replacement. The patient was placed in a lateral decubitus position and the buttocks exposed and prepared. A 6x12 cm graft was harvested from the buttock. The donor site was covered with a hydrocolloid dressing, and the patient was repositioned into the dorsal lithotomy position.
Correspondence to: S. Marfn-Bertolfn, Department of Plastic and Reconstructive Surgery, University General Hospital, Av. Tres Cruces s/n, E-46014-Valencia, Spain
A vaginal mould was constructed with a medical plastic robe, a urinary catheter, a rectangular piece of polyurethane sponge, a silk suture and a latex rubber condom (Fig. 2). The plastic tube and the urinary catheter were shortened, and several small holes were made along the catheter. The sponge was then rolled around the tubes to mold a cylinder. The length and diameter of the cylinder were adapted to the cavity dimensions by trimming the excess sponge. Finally, the free edge of the sponge was fixed in position by silk sutures and the whole mould ans introduced into the condom, in which numerous punctures had previously been made. The graft was sutured over the mould and inserted into the vagina. The labia majora were sutured across the introitus to keep the mould in place (Figs. 3, 4). Postoperatively, daily washings with normal saline and gentamicin were performed through the urinary catheter inserted into the mould (Fig. 4). After one week, the mould was removed and graft take was judged to be complete. With minor modifications the vaginal mould was used as postoperative dilator. The tubes were removed and a new condom applied and tied at its open end. The patient was instructed in dilator use and maintenance and was discharged from the hospital. The vaginal dilator was continuously used for 6 months. Soon after, the patient married and quickly became pregnant. Gestation was uneventful except for two episodes of vaginitis caused by H. influenzae, which promptly responded to antibiotic treatment. Vaginal delivery occurred after 42 weeks, and was uneventful. The newborn was a 3960 g healthy female. Although it was the patient's first delivery, and the newborn was large at birth, the grafted skin tolerated the confinement well, with only slight erosions that healed spontaneously in less than two weeks.
Discussion A l t h o u g h the split-thickness skin graft t e c h n i q u e m a y b e useful in the m a n a g e m e n t o f patients with g y n e c o l o g i c a l m a l i g n a n c i e s r e q u i r i n g r a d i c a l surgery that causes m a j o r loss o f skin and s u b c u t a n e o u s tissue o f the vulva, g r o i n or v a g i n a [2, 8], it is p r i m a r i l y u s e d to r e p a i r those p a t h o l o g i c a l c o n d i t i o n s o f the v a g i n a with little or no loss o f tissues, such as Congenital a b s e n c e and a c q u i r e d stenosis [4, 8]. T h e average results o f the t e c h n i q u e in these cases allow the patient to have n o r m a l sexual i n t e r c o u r s e and, i f a f u n c t i o n i n g uterus exists, p r e g n a n c y is t h e o r e t i c a l l y
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Fig. 1. Intraoperative vaginal examination showing the stenosis Fig. 2. Materials prepared for the vaginal mould construction Fig. 3. The split-skin graft covered mould ready to be inserted into the vagina
Fig. 4. Last operative stage with the mould fixed to the vulva by silk sutures. Daily washings with antibiotics were performed through the urinary catheter inserted in the mould
possible. Several cases have been reported in the literature, with no reconstruction-related complications [3, 5-7]. Our patient, however, suffered two episodes of vaginitis caused by H. influenzae, which is an uncommon infection during pregnancy. Despite a recent study showing that the regional environment of the artificial vagina is almost the same as that of the normal vagina, including the presence of Doderlein bacilli [9], the persistence of the squamous epithelium in the vagina probably played a role in the pathogenesis of our patient's infections [1, 10]. In this case we did not perform a complete vaginoplasty, because only the release of the contracture was relined with split skin - the rest being normal vaginal mucosa. In leaving mucosa, one would suppose that stretching could occur to accommodate a delivery. A totally reconstructed vagina with circumferential skin would probably not be a suitable conduit for a normal delivery. In fact, in all the reported pregnancies following split-skin graft vaginoplasty Cesarean section proved necessary [5, 7]. However, there is one confusing report in the literature reporting the case of a woman who became pregnant three times after total split-skin vaginal reconstruction and delivered her three children per via naturalis without complications [6]. Probably, this isolated case does not demonstrate the suitability of a totally recon-
structed vagina by split skin serving as a potentially expansile conduit for normal delivery; even less so our own case, in which only a partial vaginoplasty was performed. Nevertheless, the event is certainly u n c o m m o n and so we present this short report.
References 1. Barberini F, Vizza E, Montanino M e t al. (1992) Vaginal reconstruction by skin grafts: a scanning electron microscopic evaluation. Anat Anz 174:517 2. Beemer W, Hopkins ME Morley GW (1988) Vaginal reconstruction in gynecologic oncology. Obstet Gynecol 72:911 3. Hampton HL, Rodney Meeks G, Bates GW, Wise WL (1990) Pregnancy after successful vaginoplasty and cervical stenting for partial atresia of the cervix. Obstet Gynecol 76:900 4. Marshall FF (1980) Vaginal agenesis. Clin Plast Surg 7:175 5. McIndoe A (1950) The treatment of congenital absence and obliterative conditions of the vagina. Br J Plast Surg 2:254 6. Moore FT (1969) Per via naturalis following reconstruction of the vagina. Br J Plast Surg 22:378 7. Ortiz-Monasterio F, Serrano A, Barrera G e t al (1972) Congenital absence of the vagina. Long-term follow-up in 21 patients treated with skin grafts. Plast Reconstr Surg 49:165 8. Stern JL, Lacey CS (1987) Vulvovaginal reconstruction following radical surgery, Bailli~res Clin Obstet Gynaecol 1:277 9. Takashina T, Kanda Y, Tsumura N et al (1988) Postoperative changes in vaginal smears after vaginal reconstruction with a free skin graft. Acta Cytol 32:109 10. Ulfelder H (1968) Agenesis of the vagina. Am J Obstet Gynecol 100:745
