CHAPTER 76

Plastic Repair of the Perineum (Perineorrhaphy)

Perineal reconstruction is indicated for patients who have dyspareunia associated with any number of causes, including, but not limited to, scar formation secondary to lichen sclerosus; tearing secondary to childbirth; excessively tight closure of an episiotomy; scar formation due to episiotomy breakdown, secondary infection, or suture reactive inflammation; faulty attempts at perineal repair; trauma; ulcer formation secondary to poor blood supply; burn scar formation due to electrosurgery, laser, or chemicals; chronic infection; and atrophy (Figs. 76–1 through 76–3).

Despite a long-held belief that tightening of the perineum and introitus will improve a woman’s sexual response, invariably this action leads to dyspareunia. The anatomy of the vulva and vagina was described earlier; however, a few points should be considered here. First, the levator ani muscles do not cross the midline beneath (posterior to) the vagina. These muscles insert laterally into the wall of the lower vagina under the bulb. The levators insert lateral to and into the anterior anal sphincter. Second, the superficial muscles of the perineum are very thin structures and add little mass to the ill-defined perineal body. The bulk of that structure consists of the anterior external sphincter ani. Third, no well-defined fascial plane exists in the area of the perineum with the exception of Colles’ fascia and the investment fascia overlying the external sphincter ani. Fourth, picking up muscle mass and plicating across the midline posterior to the lower vagina creates an unnatural hump; additionally, placement of a large number of absorbable sutures into the same tissue produces an inflammatory response, diminishes the blood supply to the overlying epithelium, and results in gross scar formation. These factors will result in painful intercourse because the normal anatomy is distorted. All of the procedures listed under the fourth point therefore should be avoided. Finally, unless the patient is symptomatic, surgery in this area should not be done. Even though the physical attributes of an individual woman’s perineum may not be pleasing to an examiner’s eyes, this is not an indication to perform surgery to “improve” it. Similarly, surgery to “tighten things up” based on the mindset of better sex for the patient’s partner is unjustified. Perineal plastic and reconstructive surgery is based on the provision of easy vaginal ingress and the limitations of gross scar formation. Preservation or reconstruction of normal anatomy to restore physiologic function is the goal of perineal surgery.

The area of the vestibule or lower vagina that preoperatively has objectively demonstrated hypersensitivity and production of pain when provoked will be removed. Patients who have atrophy should be pretreated with topical and systemic estrogen at least 1 to 2 months before surgery. Testosterone topically applied does nothing whatsoever to nourish or improve the epithelium. More often, application of testosterone ointment produces an uncomfortable burning sensation.

The patient is placed in the dorsal lithotomy position, prepared, and draped. The area of the vagina, vestibule, or perineum to be excised is traced with a marking pen (Fig. 76–4A, B). The surgeon should check vaginal mobility with Allis clamps before excising the perineal tissue. Because the vagina will be advanced, the surgeon will need to estimate the distance between the advanced vagina and the perineal edge to avoid excessive tension during suture line closure. When the markings have satisfied the surgeon’s eye, a 1 : 100 vasopressin solution is injected subdermally with a 1½, 27-gauge needle. A transverse incision is made across the posterior vaginal wall with a No. 15 scalpel blade. This line will form the base of a triangle (see Figs. 76–4B

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