Neovaginal Construction with Buccal Mucosal
Grafts
Güzin Yeşim Özgenel, M.D., and Mesut Özcan, M.D.
Bursa, Turkey
Several surgical techniques have been designed to con-
struct a neovagina that will be satisfying in appearance,
function, and feeling when the vagina is congenitally ab-
sent. However, no method has yet been approved as a
perfect solution. With the aim of solving the problems with
conventional methods, the authors describe a new surgi-
cal technique that is simple and safe for treating vaginal
agenesis. This technique consists of creating a mucosal
lining of the neovaginal cavity using multiple full-thick-
ness buccal mucosal patch grafts. Four patients with con-
genital absence of the vagina treated with this technique
are presented. This surgical procedure created a mucus-
providing lining inside the neovagina. Selecting the donor
site in the oral region resulted in an inconspicuous donor-
site scar. Histologically, the neovaginal lining was con-
firmed as mucosal, and the cream-colored viscous fluid
found in the neovaginal cavity was confirmed as mucus. At
a mean follow-up period of 15 months, the neovagina
remained adequate in depth and width. All of the patients
were interviewed to evaluate the function of the neova-
gina. Each patient reported having regular sexual inter-
course and that the neovagina had felt normal to their
partners. The encouraging results obtained in four cases
suggest that this new technique deserves further
application. (Plast. Reconstr. Surg. 111: 2250, 2003.)
Congenital absence of the vagina is a rare
condition, with an incidence of 1:5000 to
1:10,000 births.1 Many nonoperative and oper-
ative techniques have been described for the
management of this condition. The primary
goal in all of these procedures is to create a
vaginal canal of adequate size, texture, and
secretion; in the correct axis; and without ex-
cessive donor-site morbidity.
Patients with long rudimentary vaginas (4 to
5 cm) are treated using the nonsurgical tech-
nique of Frank, including serial dilation,2,3 or
by construction of labial flaps with dilation.4
From the Department of Plastic and Reconstructive Surgery, Uludağ University. Received for publication April 22, 2002; revised July 29, 2002.
Presented at the 9th Congress of the European Societies of Plastic, Reconstructive and Aesthetic Surgery, European Section of the International
Confederation for Plastic, Reconstructive and Aesthetic Surgery, in Rome, Italy, September 16 through 20, 2001.
DOI: 10.1097/01.PRS.0000060088.19246.05
2250
However, these techniques are not suitable in
patients with no vagina or only a dimple. The
traditional McIndoe procedure, consisting of
creating a tunnel between the rectum and
bladder and lining it with split-thickness skin
graft, was described as a simple and safe tech-
nique and is still the most popular proce-
dure.5,6 However, it has significant drawbacks.
First, because this method has a high incidence
of neovaginal contracture, it requires the pro-
longed use of molding and even with this has
resulted in a significant incidence of inade-
quate vaginal length and vaginal stenosis. On
the other hand, sometimes the donor scars
may be quite distressing for patients. To lessen
the likelihood of graft contraction and to avoid
donor-site morbidity, a full-thickness skin graft-
ing technique was described.7,8 However, skin
lining has the drawbacks of texture mismatch,
dryness, desquamation, and hair growth, and it
does not produce mucus. Williams used vulval
tissue to create a neovagina.9 However, this
technique requires long-term dilation, which
produces a physiologically abnormal vaginal
angle. Isolated bowel segments such as small
bowel, caecum, or sigmoid colon are used to
provide a mucosa-lined neovagina without pro-
longed stenting or dilating.10 –18 However, these
operations have the disadvantage of being ma-
jor abdominal procedures with high mortality
rates and excessive mucous secretion. Addi-
tional surgical methods include the use of fas-
ciocutaneous and myocutaneous flaps,19 –22
peritoneum,23 amnion,24,25 and others.
In searching for a simpler and more physio-
Vol. 111, No. 7 / NEOVAGINAL CONSTRUCTION
logic technique for clinical practice, we devel-
oped a surgical procedure to create a mucosal
lining of the neovaginal cavity using multiple
full-thickness buccal mucosal patch grafts.
Four patients with congenital absence of the
vagina treated with this technique are
presented.
PATIENTS AND METHODS
During the 2-year period from 2000 through
2002, four women aged 19, 21, 22, and 24 years
were operated on using this new surgical tech-
nique at our institution. All patients had pri-
mary amenorrhea and müllerian dysgenesis.
One patient had normal ovaries and fallopian
tubes, hypoplasia of the uterus, and a 1-cm-
long long blind pouch as a lower vagina. An-
other patient had both duplication and hyp-
oplasia of the uterus. In the two remaining
patients, these structures were completely ab-
sent. Both patients were phenotypically female
and genotypically XX. Abdominal sonography
revealed no abnormality in the urinary system.
Surgical Technique
All operations performed for vaginal agene-
sis were primary procedures. Under general
anesthesia, an elliptical full-thickness mucosal
graft, 6 to 7 cm long and 2 to 3 cm wide, was
harvested from the oral surface of both cheeks.
The donor site was closed primarily with 4-0
chromic catgut interrupted sutures. After the
submucosal fat undersurface of the grafts was
cleaned, the mucosal grafts were expanded 2:1
by using multiple stab incisions and then di-
vided into several smaller pieces 2 to 4 cm2 in
area. Next, these graft pieces were sutured over
the stent using 5-0 chromic catgut at a distance
of 2 to 3 cm from one to another. The grafts
were placed in an inside-out fashion with the
dermis facing outward. A soft, condom-
covered, foam rubber stent measuring 5 cm in
diameter and 10 cm in length was used. Next,
the patient was placed in the lithotomy posi-
tion, and a silicone Foley catheter was placed in
the bladder to avoid urethral injury during
dissection. A V-shaped, inferiorly based inci-
sion was used to dissect a flap, which would be
inserted later into the neovaginal cavity to pre-
vent stenosis at the vaginal introitus. The new
vaginal cavity, appropriate to normal vaginal
size, was made with blunt dissection between
the rectum and the bladder upward to the
peritoneal cavity. Careful hemostasis of the
neovaginal pocket was achieved with electroco-
2251
agulation to ensure a perfect take of the buccal
mucosal grafts. The stent with its overlying
patch buccal mucosal grafts was meticulously
inserted into the neovaginal cavity, and both
sides of the labia minora were sutured together
to retain the stent in position. Finally, a pelvic
girdle was placed for additional support.
Postoperative Follow-Up
Patients were given a prophylactic antibiotic
until the stent was removed. The mean dura-
tion of hospitalization was 3 days (range, 2 to
4), after which the patient was required to
remain in bed for 10 days at home. A question-
naire was given to patients to assess postopera-
tive sexual function and satisfaction.
At the end of the third postoperative week,
the stent was removed. After the neovaginal
cavity was cleaned, the mucosal grafts were
found to have taken well; hypergranulated tis-
sue observed between them was treated with
topical application of triamcinolone acetonide
ointment applied to the vaginal space as a thin
film two times a day. Triamcinolone flattens
hypergranulation by diminishing fibroplasia in
a healing wound.26 –28 The stent was then
cleaned and reinserted. Subsequently, the pa-
tient reinserted the stent once a day and per-
formed daily cleansing and douching of the
neovagina. This routine was continued for 2
months because the mucosal proliferation
grew to cover the whole neovaginal cavity (Fig.
1). During this period, sexual intercourse was
interdicted. Once the cavity was covered with
mucosa, patients could begin regular vaginal
intercourse and replace the soft, condom-
covered, foam stent (5 cm in diameter and 10
FIG. 1. Postoperative view of a mucosal laminated vagina
2 months after construction.
2252 PLASTIC AND RECONSTRUCTIVE SURGERY, June 2003
cm in length) during periods of sexual inactiv-
ity (at night only) for 3 months.

RESULTS
All patients responded to the questionnaire
and stated that they were able to have satisfac-
tory sexual intercourse (presence of lubrica-
tion, no dyspareunia). Currently, the patients
have been followed up for 22, 16, 12, and 10
months, respectively. All of the neovaginas
have remained adequate in depth and width.
The length of the neovaginas ranged from 8 to
10 cm, and the width ranged from 4 to 5 cm
(Fig. 2). No vaginal stenosis was encountered,
either from mucosal graft loss or shrinkage. In
addition to the donor-site scarring being in a
well-concealed area, in all cases the donor sites
healed uneventfully with no change in mouth
opening.
Histologically, the neovaginal lining was con-
firmed as mucosal (Fig. 3), and the cream-
colored viscous fluid found in the neovaginal
FIG. 3. Histologic results from a biopsy of a mucosa-lined
cavity was confirmed as mucus (Fig. 4). neovagina (hematoxylin and eosin, ⫻100).

DISCUSSION
The main goal of reconstructive surgery is to
restore the defect with a tissue as similar as
possible to the original. To achieve this main
principle, mucosa-lined flaps have been used
in nasal and eyelid reconstructions in clinical
cases.29,30 However, the availability of donor
sites for harvesting mucosa is limited. To over-
come this problem, a prefabricated buccal mu-
cosa-lined flap was described. In this tech-
nique, lined flaps were prefabricated by
grafting full-thickness mucosal grafts, ex-
panded by using multiple stab incisions. A pre-
fabricated buccal mucosa-lined flap was suc- FIG. 4. Cream-colored viscous fluid, confirmed as mucus
histologically, is evident in the neovaginal cavity.

cessfully used for intraoral reconstruction by

FIG. 2. Postoperative view of a mucosa-laminated vagina
12 months after construction.
Rath and colleagues.31–33 In addition, Simman
and associates showed that the prefabricated
buccal mucosa-lined flap could be used for
vaginal reconstruction in an animal model.34
The main disadvantage of this technique is the
requirement of an additional operation. In our
technique, we applied the multiple full-
thickness mucosal patch grafts directly into the
neovaginal space. The mucosal lining provided
enough spread to replace expected scar con-
tracture. Carls and coworkers experimentally
showed the take of small mucosal grafts and
the specific ability of mucosa to spread and
Vol. 111, No. 7 / NEOVAGINAL CONSTRUCTION
merge together to form a sheet.35 Further-
more, clinically and experimentally in mucosal
defects, mucosa will rapidly spread to provide
coverage, whereas in epithelial defects, the
cells from the edge start growing until contact
inhibition occurs and continues to shrink the
defect.36
The amount of mucosa may increase by in
vitro tissue culture. Clinically, cultured palatal
autografts were successfully used to cover de-
fects caused by vestibuloplasty.37 Therefore, the
cell culture technique for intravaginal grafting
seems to be promising. However, tissue culture
is technically difficult and expensive, whereas
our technique is simpler and cheaper.
In one patient, the lower vagina was present
as a 1-cm-long blind pouch. We did not try the
Frank method of dilation, because adequate
results after several months of serial dilation
may be possible only in women with a relatively
long rudimentary vagina (3 to 4 cm) who will
conscientiously follow a treatment regimen.
Furthermore, this method has not been popu-
lar with our patients because it requires active
manipulation on the part of the patient.
In clinical cases, the only method that results
in mucus-providing tissue to the vaginal cavity
has been the transfer of the intestinal seg-
ments. Because of its high mortality and mor-
bidity rates and excessive mucus secretion, this
technique is not currently popular. However,
our technique provides mucus-providing lining
with a normal amount of secretion. Further-
more, an oral-region donor site eliminates the
need for external donor incisions.
In conclusion, our simplified procedure pro-
vided functionally and anatomically adequate
neovaginal construction. The advantages of
our technique are that it is relatively easy to
perform; it provides a thin, mucosa-lined neo-
vagina with a normal amount of secretion; it
reduces the time needed for postoperative
stenting; it has a lower risk of vaginal stenosis;
and it results in improved donor-site cosmesis.
The encouraging results obtained in four cases
suggest that this new technique deserves fur-
ther application.
Güzin Yeşim Özgenel, M.D.
Uludağ Üniversitesi Tıp Fakültesi
Plastik ve Rekonstrüktif Cerrahi AD
16059, Görükle
Bursa, Turkey
gozgenel@yahoo.com
2253
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