Full Thickness Skin Graft Vaginoplasty After Failed Vecchietti Procedure We present a 17-year-old female with a history of primary amenorrhea, secondary to malarian agenesis, or Meyer-Rokitansky-Custer-Hauser syndrome. She underwent an uneventful vecchietti procedure and was using the largest mold. Unfortunately, she was the victim of a sexual assault and discontinued mold use due to pelvic floor spasticity. After psychotherapy and physical therapy, she had an unsuccessful attempt at dilation of the scarred neovagina, now only 3-4 cm long. After discussing reconstructive options, the patient decided to proceed with a second attempt of creating a neovagina using an abdominal wall full thickness skin graft. As you can see, there was significant scarring of the neovagina. An incision is made at the apex. The obliterated space is developed with sharp and cautery dissection. Care is taken not to inadvertently injure the bladder or bowel. Once the superficial adhesions are taken down, gentle blunt dissection can be attempted to open the more cephalad space. Care is taken as excessive aggressive dissection may lead to inadvertent injury. Care should be taken at the 9 o'clock and 3 o'clock positions, as these areas are prone to bleeding. Meticulous hemostasis is maintained with occasional interrupted vicral and by light electrocautery. Periodic rectal exams during the dissection were also undertaken to ensure bowel integrity. The dissection is continued until the neovaginal space can accommodate 6-8 ratex. The ratex are left in the neovagina to aid in hemostasis while the skin graft is obtained. Once the space is developed, cystoscopy is performed to ensure no inadvertent injury to the bladder. The outline of the graft is delineated in the abdomen so that a minimum 14-18 cm long by 6-8 cm wide skin graft is harvested. The graft should be taken above the pubic hairline to the anterior superior iliac spine bilaterally. The skin is scored with the scalpel and the full thickness skin graft is harvested. Care is taken not to buttonhole the skin. This is aided by using a curved clamp to roll up the graft and to keep it under tension during harvest. The subcutaneous fat layer anterior to the scalpel layer is excised to approximate borders with minimal tension. Three-point fixation between scalpel layer and subcutaneous tissue is done using 2-0 PDS. Additional dermal interrupted 3-0 PDS sutures are placed. The graft is then inserted into the scalpel and the graft is inserted into the dermal interrupted 3-0 PDS sutures. The graft is then inserted into the dermal interrupted 3-0 PDS sutures. The graft is then inserted into the dermal interrupted 3-0 PDS sutures. Subcutaneous closure with 3-0 PDS sutures leaves a well-approximated financial-like incision. To promote graft uptake, the excess subcutaneous fat is removed and the skin graft is perforated with an 11-bladed scalpel. The full-thickness skin graft is then fashioned over a condom-covered soft mold with the dermal layer on the outside. Interrupted 2-0 Vicryls are used to align the edges and an additional 2-0 Vicryl is used to secure the edge. Subcutaneous closure with 2-0 Vicryl leaves a well-approximated financial-like incision. Ratexes are removed and hemostasis is assured. The mold is introduced into the developed neovaginal space. Excess skin graft is trimmed. The graft is secured to the vaginal edges using interrupted 2-0 Vicryl sutures. The graft is secured to the vaginal edges using interrupted 2-0 Vicryl sutures. This is done by starting at the 12 o'clock position and trimming the graft until the vaginal edge is reached. The graft is then trimmed in a clockwise fashion so that it fuses with the vaginal tissue and excess tissue is discarded. The introitus is closed with 2 interrupted sutures to maintain the mold in place and a catheter is placed to allow drainage of the bladder. Approximately one week later, the patient is brought back to the operating room to remove the soft mold. The labial stitches are cut and cochlear clamps are placed on the temporary mold. Applying gentle traction while gently moving the cochlear clamps to and fro allows removal of the mold without disrupting the graft. The take of the graft is then assessed and the neovagina copiously irrigated with sterile saline. Any graft redundancies are trimmed and circumferentially fixed to the lower neovagina using interrupted 2-0 Vicryl sutures. Neovaginal length can be measured by introducing a dilator into the neovaginal cavity. Neovaginal length can be measured by introducing a dilator and using a ruler to assure an optimal length of approximately 10 cm. Bactroban cream is applied and the permanent mold placed in the neovagina. The mold will be worn daily for the next 6 months or until she becomes routinely sexually active.

17-year-old female

Vecchietti procedure

primary amenorrhea

neovagina

full-thickness skin graft