Perineoplasty: how I restore the aesthetics and function of the perineum

Multidisciplinary partnership: aesthetics and function

One of the characteristics that distinguishes my approach to perineoplasty in Londrina is the partnership with Dr Fabio Minotti, an experienced coloproctologist. This multidisciplinary collaboration is essential to provide a truly complete result.

My role: the external aesthetic reconstruction

As a Consultant Plastic Surgeon, my responsibility in perineoplasty involves:

• Removal of excess skin and scar tissue;
• Reconstruction of the perineal contour with a natural appearance;
• Correction of asymmetries and irregularities in the region;
• Aesthetic treatment of the vaginal furcula -- the point where the labia meet at the bottom;
• Harmonisation with other intimate surgeries when combined.

The role of Dr Fabio Minotti: the internal functional reconstruction

Dr Fabio Minotti is responsible for the functional component of perineoplasty, which includes:

• Reconstruction of the pelvic floor musculature -- particularly the levator ani and transverse perineal muscles;
• Reapproximation of the muscle bundles that separated during childbirth;
• Correction of rectocele -- herniation of the rectal wall towards the vagina;
• Reinforcement of the functional integrity of the perineum to support the pelvic organs.

By working together during the same operative session, we ensure that both the appearance and functionality of the perineum are restored in an integrated manner. This team approach is a hallmark of our practice in Londrina and delivers superior results compared with surgery performed by a single specialist.

The perineoplasty surgery

Perineoplasty is performed in a surgical centre, with the patient in the lithotomy position. The procedure involves two principal stages, carried out together by myself and Dr Fabio Minotti.

Functional stage -- Dr Fabio Minotti

Dr Minotti begins with the reconstruction of the deep musculature. The muscle bundles of the pelvic floor that have been separated or weakened -- whether due to childbirth, episiotomy or ageing -- are identified, dissected and reapproximated with robust sutures. This restores the support of the pelvic organs and narrows the vaginal canal in its lower portion. When there is a rectocele, the posterior vaginal wall is reinforced.

Aesthetic stage -- Mr Walter Zamarian Jr.

Next, I perform the external aesthetic reconstruction. I remove excess skin and scar tissue from the perineal area, shape the contour for a harmonious and natural appearance, and place delicate sutures that are positioned in the natural folds of the area. When necessary, I also correct the vaginal introitus and address asymmetries of the surrounding tissues.

Duration

Perineoplasty lasts, on average, one to two hours, depending on the extent of the repair required and any associated surgeries. When combined with labiaplasty, labia majora reduction or other intimate surgeries, the total surgical time may be slightly longer.

Techniques employed

The surgical approach is individualised. Depending on the degree of compromise of the perineum, I may use:

• Simple perineoplasty: removal of excess skin and scar tissue with basic muscle reapproximation, indicated for mild cases;
• Perineoplasty with deep muscle reconstruction: extensive repair of the pelvic floor musculature, indicated for more advanced degree lacerations;
• Perineoplasty with rectocele correction: when there is prolapse of the posterior vaginal wall, Dr Minotti reinforces this wall in conjunction with the perineal repair.

Causes of perineal injury

To understand the importance of perineoplasty, it is essential to know the most common causes of injury to the perineum:

Vaginal delivery

Vaginal delivery is the principal cause of perineal injury. During the passage of the baby, the tissues of the perineum stretch to the maximum and may suffer lacerations of varying degrees. Perineal lacerations are classified into four degrees:

• Grade 1: superficial laceration, involving only the skin and mucosa;
• Grade 2: involving skin, mucosa and superficial perineal musculature;
• Grade 3: extending to the anal sphincter;
• Grade 4: compromising the anal sphincter and rectal mucosa.

Episiotomy

Episiotomy is the intentional incision made in the perineum by the obstetrician during delivery to facilitate the passage of the baby. Although it is performed with the intention of preventing uncontrolled lacerations, the healing is frequently unsatisfactory -- particularly when the suture is not performed in layers or when there is post-partum infection. Episiotomy scars can cause chronic pain, discomfort during sexual intercourse and significant aesthetic alteration.

Ageing and laxity

As the years pass, even without a history of vaginal delivery, the perineal tissues may lose firmness due to the effects of gravity, hormonal changes associated with the menopause and natural reduction of collagen. This progressive laxity can affect both the aesthetics and function of the area.

Perineoplasty and other intimate surgeries

Perineoplasty is rarely an isolated surgery. In most cases, I combine perineal repair with other intimate surgeries to provide a harmonious and complete result. I specialise in various modalities of female intimate surgery and have the necessary experience to treat the entire genital area.

Labiaplasty

The reduction of the labia minora is one of the most frequent associations with perineoplasty. Many patients who have had vaginal delivery present both perineal laxity and excess labia minora. I perform labiaplasty using wedge or trimming techniques, depending on the individual indication.

Vaginoplasty

Vaginoplasty aims to narrow the vaginal canal throughout its length, whilst perineoplasty focuses on the lower portion -- the perineum itself. When combined, the result is a complete reconstruction of the vaginal and perineal area.

Labia majora reduction

Laxity of the labia majora often accompanies perineal laxity, particularly in patients who have had multiple deliveries. Labia majora reduction can be performed during the same operative session as perineoplasty.

Labia majora fat grafting

In cases where the labia majora have lost volume -- due to ageing or weight loss -- autologous fat grafting can restore fullness to this area, complementing the result of perineoplasty.

Mons pubis liposuction

Excess fat in the mons pubis can be treated with liposuction during the same operative session, providing an overall improvement in intimate aesthetics.

Mons pubis lift

For patients with significant laxity of the mons pubis -- common after substantial weight loss -- a lift of this area can be associated with perineoplasty for a complete result.

Perineoplasty and quality of life

The impact of perineoplasty on quality of life is significant. Many women live for years with discomfort, dissatisfaction and even embarrassment caused by perineal injuries, unaware that treatment exists. Here are the principal benefits reported by my patients:

Improvement in sexual life

The restoration of perineal anatomy and the tightening of the vaginal opening improve sensation during sexual intercourse, both for the woman and her partner. Patients who suffered from pain during intercourse due to episiotomy scars also report significant relief after surgery.

Improvement in self-esteem

As with other intimate surgeries, perineoplasty has a profound impact on a woman's self-confidence. Many patients report that they feel comfortable with their own bodies again, resume activities they had avoided -- such as wearing bikinis or tight clothing -- and experience an overall improvement in emotional well-being.

Functional improvement

The strengthening of the pelvic floor muscles performed by Dr Fabio Minotti improves the support of the pelvic organs, contributes to the prevention of prolapses and can assist in cases of mild urinary incontinence associated with perineal looseness.

Frequently asked questions about perineoplasty

Is perineoplasty painful?

The surgery is performed under total intravenous general anaesthesia or spinal anaesthesia, so the patient feels nothing during the procedure. Post-operatively, discomfort is moderate and well controlled with analgesics. Most of my patients report less pain than expected, comparing it to discomfort similar to the post-partum period, but lighter.

What is the difference between perineoplasty and vaginoplasty?

Perineoplasty focuses on repairing the perineum -- the area between the vagina and the anus -- whilst vaginoplasty aims to narrow the vaginal canal throughout its length. They are complementary surgeries and are often performed together. In my practice, I assess each case to determine whether the patient needs one or both.

Why do two surgeons perform perineoplasty?

In my practice in Londrina, I work in partnership with Dr Fabio Minotti because I believe that the best result comes from the combination of specialities. I, as a Consultant Plastic Surgeon, take care of the external aesthetic reconstruction -- skin, contour and appearance. Dr Minotti, as a coloproctologist, takes care of the internal functional reconstruction -- musculature and pelvic support. This division ensures excellence at each stage.

How long does the surgery last?

Perineoplasty lasts on average one to two hours. When combined with other intimate surgeries -- such as labiaplasty or labia majora reduction -- the total time may be longer, but everything is performed during the same operative session so that the patient has a single recovery.

When can I return to work after perineoplasty?

For sedentary jobs, return is usually possible in 7 to 10 days, with the recommendation not to sit for long periods in the first few days. For activities that require physical effort, I recommend waiting 4 to 6 weeks. Each case is monitored individually during follow-up consultations.

Does perineoplasty leave a visible scar?

Scars are located in the perineal area, a naturally concealed area. I position the incisions in the natural folds of the region, so that after complete healing -- between six months and one year -- the marks become practically imperceptible.

Do the stitches need to be removed?

No. I exclusively use absorbable threads, which dissolve naturally in the weeks following surgery. This eliminates the need for a return visit to remove stitches and ensures greater comfort.

Can I have a vaginal delivery after perineoplasty?

Although it is technically possible, vaginal delivery after perineoplasty may compromise the surgical result, as the repaired tissues would be distended once again. For this reason, I recommend that perineoplasty be performed preferably when the patient does not plan to have any further vaginal deliveries. If pregnancy occurs after surgery, a caesarean section is the most appropriate route to preserve the result.

Is it possible to combine perineoplasty with other intimate surgeries?

Yes, and this is very common. In my practice, I combine perineoplasty with labiaplasty, labia majora reduction, mons pubis liposuction and other surgeries as needed. The advantage of performing everything during the same operative session is a single anaesthetic, a single recovery and a harmonious overall result.

Does perineoplasty resolve urinary incontinence?

Perineoplasty itself is not the surgery indicated for urinary incontinence. However, the strengthening of the pelvic floor musculature performed by Dr Fabio Minotti can contribute to the improvement of mild urinary incontinence associated with perineal looseness. More severe cases of incontinence should be evaluated by a urogynaecologist.

What is the ideal age for perineoplasty?

There is no ideal age. Perineoplasty is indicated when there is a functional or aesthetic complaint, regardless of age. I receive patients from 25 to 65 years of age. The most important factor is not age, but the completion of family planning -- ideally, the patient should not plan any further vaginal deliveries after surgery.

What is the initial consultation for perineoplasty like?

In the initial consultation, I discuss your concerns and expectations in detail. I perform a complete physical examination of the intimate area, assessing the perineum, pelvic floor muscles, vaginal opening and all adjacent structures. I explain the procedure, the partnership with Dr Fabio Minotti, post-operative care and answer all your questions. The consultation lasts on average 30 to 40 minutes and is conducted with complete respect and discretion.