Genital Aesthetic Surgery

Aesthetic Surgery Journal

2021, Vol 41(3) 333–337
A New Practical Surgical Technique for © 2020 The Aesthetic Society.
Reprints and permission:
Hymenoplasty: Primary Repair of Hymen With journals.permissions@oup.com
DOI: 10.1093/asj/sjaa077
Vestibulo-Introital Tightening Technique www.aestheticsurgeryjournal.com

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Suleyman Eserdağ, MD; Didem Kurban, MD; Mine Kiseli, MD;
Yasemin Alan, MD; and Murat Alan, MD

Abstract
Background: Hymenoplasty is distinct from other genital surgeries with its ethical and psychological issues. It is per-
formed to narrow the vaginal opening to ensure vaginal bleeding with penetration. There are various kinds of techniques
with different success rates.
Objectives: The authors sought to report a new hymenal reconstruction technique with vestibulo-introital tightening with
the results of 145 procedures.
Methods: The new technique included a diamond-shaped incision to the vestibulum with the base in the posterior mid-
line and superior corner 2 to 3 cm higher above the hymen. The angles were accommodated according to the degree of
tightening, and the submucosal layer was closed from the apex downwards involving the vaginal mucosa.
Results: The satisfaction rate of the patients was 99.3%. No adverse events were observed.
Conclusions: Compared with previous techniques described, this hymenal reconstruction technique is an alternative with
the advantage of low risk of loosening because the tension on the hymen alone is decreased. Additional tightening of the
introitus increases the satisfaction rates in some patients.

Level of Evidence: 4

Editorial Decision date: February 21, 2020; online publish-ahead-of-print March 31, 2020. Therapeutic

The demand for aesthetic surgery of female external gen-
italia is increasing day by day, but still, there is insufficient
experience on genital aesthetic surgery.1 Hymenoplasty
is different from other gynecologic surgeries with contro-
versial ethical and pychological issues. It is performed to
narrow the vaginal opening.2 The aims are reconstruction
of the perforated hymenal caruncles to their original virgin
position and to ensure bleeding with sexual penetration.
The hymen has a sociological role rather than func-
tional. Virginity is a social expectation in some cultures
such as Muslim, Catholic, Indian, and Chinese populations.
Ethical concerns surrounding hymenoplasty are based on

gynecologist, Department of Obstetrics and Gynecology, University

Dr Eserdağ is a faculty member, Department of Obstetrics and of Health Sciences Tepecik Educational and Research Hospital,
Gynecology, Altınbaş University, Istanbul, Turkey. Dr Kurban is a Izmir, Turkey.
gynecologist in private practice in Ankara, Turkey. Dr Kiseli is an
associate professor, Department of Obstetrics and Gynecology, Corresponding Author:
Ufuk University, Ankara, Turkey. Dr Y. Alan is a gynecologist, Dr Murat Alan, SBU Tepecik Ek Binası Kazım Dirik District. Sanai Str.
Department of Obstetrics and Gynecology, İzmir Metropolitan No: 7, 35100 Bornova, İzmir, Turkey.
Municipality Eşrefpaşa Hospital, İzmir, Turkey. Dr M. Alan is a E-mail: gozdealan@hotmail.com
334
the “value of chastity” where hymenal integrity is tradition-
ally associated with sexual purity and bleeding during first
marital coitus is an expectation for young women.3 Willing
or involuntary sexual intercourse, trauma to the genital
region, or insertion of a substance into the vagina during
masturbation may result in the perforation of the hymen.
The regret impels women to search for hymenal repair,
which may also be designated as a “revirgination.”
We describe and report the results of a new hymenal
reconstruction technique with vestibulo-introital tightening
technique (VITT), which can be performed easily under
local or sedation anesthesia with the advantages of out-
patient management and high success rates. The success
of revirgination operations depend on 2 factors: bleeding
during the nuptial as if it were the first sexual intercourse
and forming an intact structure appearance.
METHODS
After fully informed consent forms were obtained in ac-
cordance with Turkish Ministry of Health standards, 145
hymenoplasty procedures were performed between
January 2016 and May 2018 by only one senior sur-
geon. Eleven of the patients were excluded, so 134 pa-
tients were included in this study. Inclusion criteria was
primary hymen reconstruction. This study was not institu-
tional review board approved. World Medical Association
Declaration of Helsinki Ethical Principles for medical re-
search involving human patients of guiding principles
were followed.
Preoperative Evaluation and
Contraindications
Initially, the surgeon and an assistant examined all patients
in the lithotomy position by stretching the labia bilaterally
to observe hymen remnants. Then, the patients were in-
formed about the findings, sides of perforations, surgery
techniques, anesthesia methods, and postoperative care
issues. If there was any clinical sign of vaginal infection, it
was first treated by medications and then surgery was per-
formed. Contraindications to the surgery included patients
who were menstruating, delayed menses without blood
pregnancy test, active genital infections, vestibular inflam-
matory diseases, unrealistic expectations, and patients
younger than 18 years of age and unaccompanied by their
parents. Also, patients who had insufficient amount of
hymen remnants were excluded from VITT.
All the patients signed informed consent forms, in-
cluding detailed information about the surgery, poten-
tial risks of the operation, anesthesia, and medications.
Infection, wound dehiscence, bleeding, oozing, hema-
toma formation, and allergic reactions—depending on
Aesthetic Surgery Journal 41(3)
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Figure 1. Vestibulo-introital tightening technique (VITT) for
hymenoplasty.
medications—are short-term complications after the sur-
gery, and dyspareunia, vaginismus (anxiety of feeling pain
and involuntary contractions during sexual penetration),
and psychological mood changes such as regression or
depression are long-term complications.
Surgical Technique
There were 135 (93.1%) procedures performed under
local anesthesia, and only 10 (6.9%) patients required
sedation. After properly cleansing the surgical area with
10% povidone, iodine solution, and sterile draping in lith-
otomy position, 40 mg of articaine hydrochloride with
0.012 mg epinephrine hydrochloride local anesthetic
injection was applied to the operational area by 30G
needles. Allis clamps were grasped bilaterally in the ves-
tibular area, and a diamond-shaped incision including
the hymenal caruncles, vestibulum, and vaginal introitus
was performed by curved iris scissors (Figures 1 and 2;
Supplemental Figure 1, and Video, available online at
www.aestheticsurgeryjournal.com). The lowest point was
located in the posterior midline vestibule at the 6 o’clock
position just above the fourchette. The superior apex was
extended 2 to 3 cm above the hymenal ring through the
vaginal wall with lateral borders involving the caruncles
(Figure 1). If allis clamps were located at the 4 and 8 o’clock
positions, the vaginal entry would be tighter. If less tight-
ening was needed, the side corners were then located at
the 5 and 7 o’clock positions. Marking can be done prior
to surgery.
The mucosa was removed by scissors. After hemo-
static control, we closed together the submucosal and
mucosal layers of the vagina from the apex downwards
until the hymen via 4-0 vicryl rapide sutures (Johnson
Eserdağ et al335

A B

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C D

Figure 2. This 23-year-old female patient requested hymenoplasty. (A) Dissection of vulvar vestibulum and posterior vaginal
canal. (B) Removal of mucosa and then primary closure of layers by 4-0 vicryl rapide sutures uninterruptedly. Suturing of
posterior wall both ensures vaginal tightening effect and diminishes the tension on perforated edges to be repaired. (C)
Closure of hymenal mucosa by 4-0 single vicryl rapide sutures, apex, dorsal, and ventral edges, respectively. (D) Closure of
vulvar vestibulum as single layer. (E) Intact hymen appearance just after the operation.

and Johnson, Ethicon, Ankara, Turkey) continuously. the hymenal mucosa, which is critically important for
Involving the vaginal mucosa enabled tightening of the success of this operation. After vaginal mucosa
introitus and additionally decreased the tension on and submucosa was closed, the apical, posterior and
336
Video. Watch now at http://academic.oup.com/asj/
article-lookup/doi/10.1093/asj/sjaa077
anterior aspects of hymenal edges were sutured by 4-0
vicryl rapide single sutures, respectively. For fixation
of hymen integrity, we recommended 2 methods. First,
injection of local anesthetics into the hymen caruncles,
which are very thin, may simplify this suturing proce-
dure and also prevent bleeding. Second, dissection by
fine scissors into both sides of hymenal remnants can
provide some space for a better fixation of the wound
edges. After suturing of hymen mucosa, the posterior
part of the vestibulum was sutured continuously with a
final check for hemostasis.
The diamond shape of VITT for hymenoplasty looks
like a “minor perineoplasty” operation. However, it differs
from perineoplasty with some of its features. Firstly, the pri-
mary goal here is to repair the hymen caruncles and to
suture the 3 edges of hymen to ensure this reconstruction,
though perineoplasty does not have this goal. Secondly,
in VITT, the base of the operation area is located in the
vulvar vestibule just above fourchette, not as below as the
perineal body.
Postoperative Care and
Recommendations
The patients were recommended to return 2 weeks and
2 months after the operation and 1 month before marriage
for routine follow-up. They were also informed that we would
call them by phone 6 months after. No medical dressing
was recommended after surgery. Only oral antibiotics
(ampicillin tb 500 mg twice a day) and antiinflammatory
drugs for 5 days were prescribed. Heavy sports and heavy
lifting were restricted for 1 month. Penetrative sexual inter-
course should be avoided for at least 1 month, because the
sutures would not disappear in this period. Psychological
support was also suggested for some of the patients after
the procedure.
Aesthetic Surgery Journal 41(3)
RESULTS
The patients’ mean age was 25.5 years (range, 18.5-
45.1 years), and they all requested revirgination on their own
volition. The mean operative time was 20 minutes (range,
15-28 minutes). The duration was higher in obese and anx-
ious women. No major complications were reported.
One assistant called the patients by phone to obtain
their feedback 6 months after the operation. Eleven (7.5%)
of the patients neither answered our repeated phone calls
nor attended the follow-ups, so they were excluded from
the study. The average length of follow-up was 32 days
postoperatively (range, 2-158 days). Ninety-eight (73.1%)
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of the patients were present for at least 1 gynecologic fol-
low-up. Twelve (8.9%) of the patients had wound dehis-
cence, and 2 had revision surgery by the same method,
although 6 did not accept any revision surgery. One pa-
tient who revealed signs of infection on the wound area
with minimal purulent discharge was treated with oral anti-
biotics at postoperative day 7.
A total of 130 (97.0%) of the patients stated satisfaction
after the surgery, because they tolerated postoperative
period quite comfortably. Minor discomforts were also re-
ported. Seven (5.2%) of the patients complained of oozing
problems for 2 weeks, 18 (13.4%) complained of stinging
and mild pain, and 26 (19.4%) had itching postoperatively.
A total 92 (68.6%) of the patients informed us that they
had sexual penetration with bleeding in small amounts (a
few drops) to larger volumes (5-6 tablespoons). Forty-two
(31.3%) of the patients declared that they had no marriage
plan soon.
On the other hand, most patients mentioned their satis-
faction due to pressure by introital tightening during inter-
course, which imitated the first trial of intercourse.
DISCUSSION
Anatomic shapes and tissue properties of the hymen
greatly differ among individuals. After first penetration,
small tears called hymenal caruncles occur with minor
bleeding in some. There are different techniques for hy-
menal repair: primary repair, lateral wall flap technique,
submucosal suture technique, and cerclage technique.4-6
Recently, Wei et al described a new suture three stratums
around the introitus technique, which involved the fa-
scial layers as well.7 All techniques produce narrowing of
introital opening with temporary tightening.
Hymenoplasty is sometimes a very critical operation
for women who are expected to exhibit “bloody sheet.”
Although the satisfaction rates were 92.2% with the tech-
nique Wei et al described, only 54.9% reported blood loss
during first intercourse.7
Eserdağ et al337
In our technique, because the vestibulum is so fragile
and delicate, approximating the vestibulum increases the
bleeding possibility during intercourse. Moreover, fixation
of hymenal edges is easily performed by the tightening of
the vestibulum and vaginal canal. The surgical tension on
the hymenal ring is strengthened, the risk of loosening and
the need for a second revision is quite low. For instance,
the approximation method8 was criticized with frequent
wound dehiscence rates.7
Vojvodic et al described luminal reduction hymenoplasty,
and in this technique, the edges of hymen remnants are
excised and then sutured by interrupted rapide sutures.9
They suture the hymenal membrane as we do but do not
include vestibule and vaginal canal parts.
CONCLUSIONS
The VITT for hymenoplasty can become an alternative
and a good choice with the additional advantage of
tight vestibulum and introitus and high success rates
and low complication rates. Posterior tightening of the
vagina provides a narrowing effect, primary suturing of
hymen by single stitches ensures formation of an in-
tact hymen appearance, and tightening the vestibule
both narrows the vaginal entry and increases the pos-
sibility of bleeding after coitus. Surgical tightening of
the posterior wall of the vagina and vestibulum pro-
vides hymen edges to merge easily without adding any
tension.
After VITT for hymenoplasty, bleeding can occur by the
perforation of hymen or sometimes tearing of the vesti-
bule, because the vestibulum is very sensitive to mechan-
ical thrust. However, the patients were not examined for
the origin of bleeding after coitus.
Young gynecologists need further experience in these
surgical procedures, which people hesitate to speak about.
This technique offers a good practical method for prac-
titioners. However, more data are still needed regarding
the efficacy and superiority of different hymenoplasty
techniques.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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