SINGAPORE ASSOCIATION OF PLASTIC SURGEONS

Genital Reconstruction

GENITAL RECONSTRUCTION

Author: Dr Wong Manzhi
Genital reconstruction encompasses a variety of procedures to restore form and function to the male and female genitalia.

Some conditions that can result in damage to these structures include but are not limited to:

MALE GENITALIA

  1. Cancer involving the scrotal or penile skin
  2. Foreign body granulomas resulting from injection of substances for penile augmentation
  3. Infection or Trauma
  4. Congenital deformities
  5. Cosmetic procedures

FEMALE GENITALIA

1. Birth Trauma
There can be a significant amount of tearing or cutting (episiotomy) during childbirth. These tears involve the labia, and can even involve the anal sphincter. Initial repair of these tears may sometimes be done too tightly or result in abnormal scarring at the vaginal entrance. This can cause acute discomfort and pain during sexual intercourse. Plastic surgeons can revise the scars and repair the damage that has been done.  
2. Congenital Causes
Some babies are born with rare vaginal abnormalities which can be minor or more major. Surgical correction of cases where the hymen has not opened properly or vaginal stenosis (constriction/blockage) is relatively straightforward. When there is total absence of the vagina, reconstructive strategies include vaginal dilators or skin-grafting (grafting of a thin layer of skin to line the new vaginal vault) Other options include replacement with an intestinal segment or skin/soft tissue from the surrounding thigh or groin (vascularized flap repair).
3. Cancer of the Gentalia
Plastic surgeons are often called in to reconstruct defects after cancer surgery. This may involve partial or complete loss of the vulva or vagina. There may also be a external skin defect if the anus and surrounding skin has to be removed due to cancer. The pelvic floor can be disrupted leading to a risk of intestinal herniation downwards. Sometimes fistulas (abnormal connections) can develop between the urethra/bladder/vaginal/rectum after surgery or radiation. Skin/soft tissue from the inner or outer thigh or the abdomen are often used for the reconstruction, so as to restore sexual function, replace any skin defects, support the pelvic floor and as part of a fistula repair. 
4. Cosmetic Surgery
Cosmetic procedures are available to tighten or enlarge certain parts of the vagina, which aim to improve both the aesthetics and function of the area.
  • Labiaplasty: The inner lips of the vulva, known as the labia minora, can be oversized or elongated. These can be cosmetically troubling and can prolapse into the vagina or interfere during sexual intercourse. They can also cause discomfort due to friction when walking or with wearing certain clothes. Labiaplasty is a surgical procedure designed to reduce the size of the labia minora. 
  • Vaginal tightening: “Loosening” of the vagina can occur after childbirth, resulting in sexual dysfunction. A posterior repair can be performed, wherein the vagina is separated from the rectum and the muscles pulled together to tighten the vaginal structures.
  • Augmentation of the Labia majora (outer lips of vulva): When the labia minora may appear too small, fat transfers and grafts can be used to increase the size.
  • Suspension/recontouring of the mons pubis: The mons pubis is the fat pad just above the external genitalia which overlies the pubic bone. The mons pubis can droop, causing an aesthetically unappealing bulge. This can be treated by liposuction or surgical suspension of the loose skin around the mons pubis. This procedure can be performed as part of a tummy-tuck procedure.

MALE GENITALIA

The goals of reconstruction include creating a functional and aesthetically acceptable external genitalia, with the ability to void standing and to achieve sexual function.
1. Scrotal or Penile Defects
Cancer can involve the scrotum or penile skin, necessitating wide excision of these tumors. The skin can also be lost due to severe soft tissue infection (Fournier’s gangrene) or trauma. In addition, patients may present after injection of “Jamaican oil”, paraffin or silicone by unlicensed practitioners. This results in a foreign body reaction with ulceration, infection and painful erections. Removal of the involved skin and reconstruction with tissue eg. from the scrotum can reliably restore sexual function. 

Reconstruction can be performed using skin grafting for scrotal defects. Skin grafting is generally less satisfactory for penile defects as it can result in scar contracture and erectile dysfunction. Other alternatives for penile defects include using tissue from the scrotum or groin which are “expansile” and can restore function and appearance. 
2. Congenital Deformities
Some babies may be born with an abnormal urethral opening, which does not end at the tip of the penis but may instead end on the underside of the penis (Hypospadias). Due to the intimate connection with the urinary system, repair of congenital deformities is often carried out by or together with pediatric surgeons or urologists.
3. Cosmetic Procedures
Micropenis can be caused by hormonal, structural or genetic syndromes and requires investigation. In children, testosterone injections have been used. Surgery procedures are available for adults unresponsive to testosterone treatment. Penile enhancement can be performed for purely aesthetic reasons and can be achieved using fat transfers or penile implant. In patients with “buried penis”, the penis is usually of normal length and function, but it is hidden. The causes can include obesity, post-circumcision changes and scrotal lymphedema. This can result in urinary difficulties, urinary tract infections, skin irritation/infections, psychological and erectile problems. Penile lengthening may be achieved by methods such as obesity management, mons reduction/tummy tuck or release of the penile suspensory ligaments. 
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