Double-Opposing Z-Plasty for Reconstruction of Narrow Introital Caliber

INTRODUCTION: In this video, we discuss the double-opposing or “mirrored” z-plasty technique for reconstruction of a narrowed introitus. We present the case of a 59-year-old para 0 followed for a longstanding history of entry dyspareunia. She was recommended local estrogen therapy, hyaluronic acid suppositories, and vaginal dilator therapy, and underwent pelvic floor physical therapy, but remained with significant symptoms. Serial exams did not demonstrate findings concerning for lichen sclerosus or planus. There are several approaches to the management of dyspareunia due to a narrowed introitus. Conservative management, including treatment of any underlying skin condition, vaginal dilator therapy, or pelvic floor physical therapy, is considered first-line treatment. If these are unsuccessful, surgical management can be considered. Perineoplasty is a frequently reported procedure for introital stenosis and dyspareunia, with success rates as high as 90% in some studies. Z-plasty flaps and vaginal advancement flaps have been described to treat iatrogenic or post-op constriction with subjective cure rates reported around 75%. The z-plasty is a transpositional local tissue transfer technique of two triangular flaps, commonly used in plastic and reconstructive surgery, burn surgery, and pediatric orthopedics. By raising two triangular flaps and transposing them in the single z-plasty, the axis of a contracture can be lengthened by 50–70% in areas of high tension. There are several modifications of the z-plasty, such as using multiple z-plasties in series for reconstruction and revision of an extended, linear incision. Contrastingly, if there is limited availability of local tissue, as in the case of a narrowed introital caliber, two mirrored z-plasties can be used. Colloquially called the “jumping man flap,” this is done in the case of first webspace deepening of the hand, typically in pediatric patients. This video demonstrates utilizing this modified surgical technique for reconstruction of the stenosed vaginal introitus, and maximizing lengthening while taking into consideration the limited local tissue availability. OBJECTIVE: n/a. METHODS: n/a. RESULTS: n/a. CONCLUSIONS: n/a.