Invited Discussion: Experience With Neovaginal Construction Using the Full-Thickness Skin Graft in Vaginal Agenesis

Dr. Selcuk Akin has written a great paper contributing to our knowledge of vaginal construction and to our knowledge of wound healing. The surgeon in this world who has performed as many full-thickness skin grafts (FTSG) for neovaginal construction (neocolporrhaphy) as anybody is Professor Charles Horton of the Medical College of Eastern Virginia. I have therefore contacted him directly. He reports that these operations do work well. It is his opinion, and it is my own opinion, that FTSG for surgical treatment of Mullerian agenesis (mesodermal agenesis of the vagina) works well. The most important factor is that the FTSG contracts very little (ie, not to any significant amount or any perceptible amount). In contradistinction, a split-thickness skin graft vagina does contract; it is an ongoing “battle” to control the contraction with mechanical means (a stent worn for intermediate to long term). The technical strategy includes methods to achieve freedom from infection and freedom from hematoma, and freedom from either a straight-line longitudinal scar or a circular “purse string” scar at the graft-skin junction. Methods to control these factors are as follows: freedom from infection is reduced with skin preparation to reduce the number of bacteria in the skin appendages (glands); antibiotics parenterally administered and topically administered in solution (for example, a silicon tube through the center of the stent, as in a Mentor stent), suction to prevent hematoma, and a rather huge dart flap at the introitus (eg, 4 2.5 cm) will help prevent introital stenosis. Introital stenosis will occur whenever this flap is not used. If the stent had been left in place for 10 days, better healing would have occurred, but the foreign body may cause a generous amount of serosanguinous drainage (almost a state of preinfection). The results are indeed excellent, and they reflect a superior class of surgical and postoperative management. The 10-cm length is of course sufficient. Many patients, however, desire a longer vaginal length, and they hope to achieve that with aggressive application of the stent. And this “deficiency” in length is more than compensatory because the FTSG is much more elastic than the thick-split thickness skin graft. The donor site is the glabrous skin of the groin, with the unique aspect being the relaxing incisions of the lower abdomen to help close the donor site with a well-healing scar line. The competitive procedure is the Singapore Flap, one of many names applied to the fasciocutaneous flaps of the groin. These flaps are taken from the same area as the skin grafts. The flaps are fortunately thin and well-vascularized by a branch of the internal pudendal artery lying on top of the fascia and usually consisting of 12.5 cm of usable length in the form of an island flap. Professor Ted Huang of Galveston and others popularized that procedure. The algorithm for vaginal construction now consists of: 1) in cases of Mullerian agenesis, the FTSG or perhaps the fasciocutaneous flaps of the groin 2) for gender dysphoria, rectosigmoid flap, or perhaps penile inversion 3) to reconstruct after cancer extirpation, the rectus abdominis musculocutaneous free flap.