Department of Obstetrics and Gynecology, China Medical College Hospital, No. 2, Yuh-Der Road, Taichung 404, Taiwan
1 To whom correspondence should be addressed. e-mail: d4754{at}hpd.cmch.org.tw
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Abstract |
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Key words: buccol mucosa/vaginoplasty
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Introduction |
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There are many methods for constructing neovaginas, such as Franks method (Frank, 1938) and the AbbeMcIndoe (McIndoe and Bannister, 1938
) procedure. Other surgical methods include constructing neovaginas out of bowel segments (Burger et al., 1989
; Franz, 1996
; Hensle and Reiley, 1998
), pudendal-thigh flaps (Joseph, 1997
), fasciocutaneous flaps (Morton et al., 1986
), gracilis myocutaneous flaps (McCraw et al., 1976
), labia minora flaps (Flack et al., 1993
), flaps raised following tissue expansion of the labial pocket (Chudacoff et al., 1996
), peritoneum and bladder mucosa (Martinez-Mora et al., 1992
; Soong et al., 1996
), amnion (Ashworth et al., 1986
; Nisolle and Donnez, 1992
), and the interceed absorbable adhesion barrier (Jackson and Rosenblatt, 1994
).
Although Franks method is non-surgical, its success has proven variable and unpredictable (Ashworth et al., 1986). Procedures including free skin grafts, peritoneal grafts, local skin flaps, and bladder mucosal grafts may scar the patient. Bowel segments have the disadvantages of abdominal scarring and the possibility of bowel obstruction. The use of human amnion is complicated because it requires amnion banking, lengthy preparation time, and scheduled concomitant elective Caesarean deliveries. It also has an added risk of donorpatient viral infection.
The use of autologous buccal mucosa is uncommon, but has been employed for urethral reconstruction when local epithelial tissue and bladder mucosa were not available (Burger et al., 1992; Dessanti et al., 1992
). In this case series, we describe our limited experience with autologous buccal mucosa as graft material for vaginoplasty. Our aim was to create a functionally and cosmetically normal neovagina using the simplest available techniques.
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Materials and methods |
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The eight patients underwent neovaginoplasty with autologous buccal mucosa as graft material in between August 2000 and February 2002. All patients were placed in the lithotomy position, under general anaesthesia and nasal tracheal intubation. We began by creating a vaginal vault capable of accommodating the length of two fingers by blunt dissection in the plane between the urinary bladder and rectum. A Foley catheter and a rectal tube were inserted in order to prevent bladder and rectum trauma during construction of the new vaginal canal. Before harvesting the graft, the surgeon cleaned the buccal mucosa with an iodine solution and identified the opening of the Stensens duct and the duct of parotid gland. The donor site on the inner aspect of the cheek was marked (Figure 1). The length of the graft was 2.5x6 to 8 cm. A mouth retractor was applied and a full-thickness graft was harvested by a knife and scalpel. Haemorrhaging was controlled by electrocautery and gauze. Great care was taken to avoid injuring the Stensens duct and the neurovascular supply to the buccinator muscle. Incisions deeper than the submucosal layer were avoided since dissection of the buccinator muscle can lead to damage of the buccal neurovascular bundle. Branches of the facial nerve lying deep within this muscle will most likely not be damaged by the incision. We made pin-hole size incisions on the grafted buccal mucosa to increase the size of the graft. The graft was then irrigated with warm saline to retard desiccation. The donor site was closed with 30 absorbable running sutures. The buccal mucosal graft was fixed to the newly created vaginal space and the edge was sutured to the minor labia and perineal skin. The mould was then inserted into the newly created cavity and sutured to the perineal skin after haemostasis (Figure 2).
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Results |
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Discussion |
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Autologous buccal mucosa as graft material was first reported by Humby (1941) for use in repairing hypospadias. In addition, buccal mucosal grafts have been used by ophthalmologists, orthodontic and maxillofacial surgeons for reconstructive surgery of the conjunctiva, tongue, cheek, larynx and trachea. In the late 1980s buccal mucosa began to be employed for urethral reconstruction (Caldamone et al., 1998
). Buccal mucosa as suitable implantable graft material for urethral reconstruction was first tested on dogs. The macroscopic and light microscopic examination of the embedded buccal mucosa 3 months post-operatively demonstrates well-vascularized, non-scarred tissue and intact mucosa with slight atrophy of the squamous epithelium (Burger et al., 1992
). In addition, histological examination of the buccal mucosal graft compared with skin grafts has revealed that the buccal mucosa has a thicker epithelium and thinner lamina propria which should promote revascularization of the graft from the recipient bed (Duckett et al., 1995
). These properties lend themselves to a good free graft reconstruction. The majority of buccal mucosa graft procedures have used the inner lip as the donor site which completely heals after 2 weeks (Lopes et al., 1996
). In our series, during the first 2 days after the procedure, the patients suffered some pain and swelling of the buccal area but these patients were able to eat ice cream on day 2 and a soft diet on day 4, and a normal diet on day 6. Damage of the buccal neurovascular bundle, haemorrhage and infection are potential complications of the donor site. Avoiding incisions of the submucosal layer of the buccal area, local compression and external cooling of the donor site may prevent these complications. Liquid or soft diet and daily cleaning of the wound may avoid post-operative discomfort.
Autologous buccal mucosa has successfully substituted skin and bladder mucosa grafts in urethroplasty because it is an easily accessible, non-hair-bearing material, provides excellent cosmetic results and a constant and adequate blood supply. In this series, we performed vaginoplasty using buccal mucosa as a graft. Our patients had a normal diet, no difficulties opening their mouth, adequate vaginal length without stricture, and no scarring of the donor site 6 months after the procedure. Maintenance of vaginal dilation via a vaginal mould is suggested until normal sexual intercourse is resumed. In summary, although no conclusive recommendation can be made based on these limited cases, the results achieved with our patients are encouraging.
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References |
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Submitted on April 19, 2001; resubmitted on September 20, 2002; accepted on November 13, 2002.