Luminal Reduction Hymenoplasty: A Canadian Experience With Hymen Restoration

Hymenoplasty, or the surgical restoration of the vaginal membrane, is one of the least described vulvovaginal procedures in plastic surgery. Veiled in ethical and legal controversy, metrics of demand and numbers of procedures performed in North America are largely unknown. Women pursue hymen reconstruction for various personal and cultural reasons. Patients may seek to restore the native hymen following sexual violence, medical interventions, or other involuntary hymenal injuries to reclaim personal ownership of their bodies.1 Others wish to reexperience their first penetrative sexual encounter with a partner.2 Certainly the most commonly reported motivation is the restoration of physical virginity to align patients with the premarital expectations of their ethnic and religious backgrounds.2 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 an expectation for young women.3 In certain circumstances “certificates of virginity” via a gynecological exam have been requested.4 Failing to meet these cultural requirements may lead women to face familial shame, societal ostracization, abuse, and death.5 Critics cite the perpetuation of virginity as a heteronormative social construct that is based on the commodification of the female body, thus fueling systematic gender discrimination and medicalizing a social problem.6,7 Further concerns are based on the inherent deceit of prospective partners.2 Nevertheless, patient autonomy, justice, and freedom of competent self-determination remain principles in favor of hymenoplasty provision.7-9 Surgeons are encouraged to become familiar with the ethical landscape surrounding these issues and are advised to consult the legal statutes or professional regulatory bodies in their area of practice should there be any concerns for a legislative barrier to providing this procedure. The hymen has no discrete physiologic function in the adult female reproductive system. An understanding of native hymen variation, including the most common annular and crescenteric configurations, is prerequisite to any reconstructive efforts.5 The prevalence of different hymen configurations in adulthood and age-related morphologic changes have not been well described.10 The primary reconstructive goal therefore is the restoration of a narrow membranous introitus at the external opening of the vagina. Several techniques for hymenoplasty have been described.11-16 Ou et al employ a submucosal running suture to create a annular hymenal ring around a Hegar dilator.12 The suture three stratums around the introitus (STSI) technique described by Wei et al employs suture layers along 3 stratums, the inner and outer hymenal mucosa and intervening submucosal fascia.13 We have been performing a technique similar to that described by Goodman.17 This technique is a simple and effective method for hymen reconstruction where sufficient hymen remnants are present.16,17 Outcome expectations are focused on luminal reduction and anatomic restoration given available hymen remnants. The guiding principles of the Declaration of Helsinki were strictly applied and adhered to in this study. A full medical and surgical history precedes a standard pelvic exam. Surgeons may consider bringing a chaperone to the examination room for the duration of the exam for patient comfort and where medicolegal climate dictates it. Native hymen morphology is highly variable in configuration and size.18-20 The hymen remnants, also termed carunculae myrtiformes, should be examined to be of sufficient size for primary reapproximation. This is a prerequisite for the luminal reduction technique. Any masses or lesions to the surrounding soft tissues must be recognized and investigated accordingly. Contraindications to the procedure include any active or untreated pelvic infections or inflammatory processes, malignancy, bleeding disorders, and unrealistic expectations. Vulvodynia or chronic pain in the area is a relative contraindication as this can be exacerbated by genital surgery. Surgical risks of the procedure include wound dehiscence, infection, scarring, distortion of the external vaginal orifice, and creating overly small introitus leading to obstruction of vaginal outflow and hematocolpos, dyspareunia, and feelings of guilt.17 Patients should be educated that bleeding may not occur during first coitus in over half of women with unruptured hymen and that hymenoplasty cannot guarantee bleeding.16,21 The procedure is carried out under general anaesthesia but can be performed under local anesthesia as well. After a dose of prophylactic antibiotics is given the patient is placed in a lithotomy position with bilateral hips flexed and legs abducted in stirrups. The perineal area is prepped with 10% betadine solution. Labia majora and minora are retracted bilaterally (Video 1). The hymen remnants are identified at the outermost aspect of the vaginal introitus as an annular array of hymenal fragments separated by clefts. Remnants can appear flaccid and should be gently stretched to ascertain their actual length. Approximately 2 to 3 mL of 0.25% marcaine with 1:400,000 epinephrine is injected to the submucosal plane of the vagina deep to the hymen remnants so as not to distort and efface the fragments. The epithelialized free edges of each hymen fragment are gently excised along the clefts with scissors or a scalpel, leaving only the tip of the fragments intact. The free margin close to the tips of the remnants is sutured first using a simple interrupted 4-0 Vicryl rapide suture (Johnson & Johnson, Markham, Ontario, Canada), ensuring accurate approximation without step-off at the edge of the hymenal ring (Figure 1). This is followed by a simple interrupted 4-0 Vicryl rapide suture on the internal surface and another suture on the external surface of the remnants. This is completed in a sequential fashion for clefts around the lateral and posterior aspects of the vaginal canal until the luminal reduction is accomplished by closure across all clefts. Sutures are not placed at the anterior aspect of the vaginal canal where the hymen remnants can arise from adjacent to the urethra. Luminal reduction hymenoplasty. (A) The edges of the hymen remnants are excised. (B) The free margin close to the tips of the remnants is sutured first using a simple interrupted 4-0 Vicryl rapide suture. This is followed by a simple interrupted 4-0 Vicryl rapide suture on the internal surface and another suture on the external surface of the remnants. Sutures are not placed at the anterior aspect of the vaginal canal where the hymen remnants can arise from adjacent to the urethra. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy023 The width of the aperture is confirmed to be of sufficient size to allow for expulsion of menstrual flow and vaginal secretions. No additional dressing is required and patients are advised that they may wear pads to prevent blood staining of clothes. All patients are advised to return for follow up on postoperative day one as well as one month and three months following surgery. Patient are instructed to gently wash external to the vaginal orifice four times a day and each time after using the washroom. Nothing is to be inserted into the vaginal canal postoperatively to prevent rupture of the reconstructed hymen. A total of nine cases have been performed by the senior authors (F.L. and J.A.) between April 2011 and June 2017 and were compiled as a comprehensive and consecutive case series (Figure 2). Inclusion criteria were primary hymenoplasty repair. No exclusion criteria were applied. The average patient age was 26.9 years old (range, 21.8-37.7 years old) with an average BMI of 21.9 kg/m2 (range, 18.3-30.0 kg/m2). The average operative time was 23 minutes (range, 10-42 minutes). The average length of follow up was 64 days (range, 4-146 days) postoperatively. Seven (77.8%) patients presented at 30 days follow up, while only three (33.3%) presented at 90 days follow up. No complications were noted in any case. Due to the high follow-up attrition rates in this patient population, we are unable to collect metrics of patient satisfaction in the context of patient expectations and desired outcomes. The 32-year-old female patient shown in Video 1. (A) Preoperative view of the hymen with retraction of labia minora. (B) Preoperative view with retraction of the introitus showing hymen remnants and intervening clefts. (C) Postoperative view of the hymen 6 weeks following luminal reduction hymenoplasty. This article offers the first comprehensive technical description of hymenoplasty in the plastic surgery literature and serves to broaden the understanding of the procedure amongst plastic surgeons. This technique for hymenoplasty can be offered to patients seeking reconstruction of the ruptured hymen with reasonable expectations. Surgeons should counsel patients that there is significant variation in hymen morphology with no ideal size or diameter of the hymen ring. Hymen restoration may not lead to bleeding during the first vaginal intercourse following reconstruction. Given the cultural stigma facing many patients, surgeons are advised to approach patients with the highest level of professionalism and sensitivity. Long-term follow up in this patient population is limited primarily by patients’ desire for discretion, as well as, the short-lived state of the hymen construct in many cases. This article contains supplementary material located online at www.aestheticsurgeryjournal.com. The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The authors received no financial support for the research, authorship, and publication of this article.

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