Patients that present with conformational defects of the vulva and perivulvar region are often predisposed to chronic vulvar fold dermatitis, vaginitis, and recurrent UTI. In many cases with redundant perivulvar skin folds, an increased amount of perivulvar fat deposition may be a confounding factor.
This patient has both redundant perivulvar folds as well as increased fat deposition that are significantly contributing to her conformational defect. When considering surgical correction, it is important that the skin and underlying fat be removed to ensure proper exposure of the vulva and adequate removal of the perivulvar folds.
The patient is placed in perineal position and the tail is tied over the dorsum of the back. The perivulvar skin and vaginal vault are aseptically prepared. The surgeon recommends use of a sterile scribe to draw the boundaries of the proposed skin excision. The dorsal-most aspect of the skin incision is determined by grasping the dorsal aspect of the vulva and elevating it proximally toward the anus until the entire vulva is exposed and no longer covered by the skin folds. A single dot is made with the scribe marking this location. Beginning at this point, a curved incision is made on each side of the perivulvar skin to include the redundant vulvar skin folds. A second curved incision is made starting at the dorsal aspect of the vulva and ending at the most distal points of the initial incision.
The skin, subcutaneous tissue, and fat are undermined to the level of the constrictor vulvae and constrictor vestibuli muscles and are resected. In this case, the surgeon is using a #10 scalpel blade; however, a #15 scalpel blade may offer more control when making curved incisions. Here the skin fold and subcutaneous fat are almost completely resected. Notice a horseshoe-shaped piece of skin and fat that have been resected.
Subcutaneous tissues are closed with a simple interrupted pattern, allowing the newly exposed vulva and remaining perivulvar skin to fan out to the peripheral incision. Knots are tied carefully to ensure they are buried under the skin and do not protrude. Skin is then closed in a routine fashion.
