In vaginoplasty, the most challenging problem for plastic surgeons is finding a "tissue substitute" that most closely resembles the natural vagina — in terms of moisture, elasticity, width, and depth of the constructed vaginal canal.
Dr. Sanguan Kunaporn, Director of the PPSI Institute and pioneer of the technique using the "jejunum" segment of the small intestine for neovaginal construction, has analyzed the scientific rationale that makes the jejunum a premium choice in advanced procedures — particularly in patients with limited skin availability or those seeking the most natural outcomes possible.
1. Graft Survival
The fundamental principle of tissue transfer — moving tissue from one site to another — is tissue survival, which in this context is analogous to the healing process seen in skin grafting.
A jejunal graft does not rely on microsurgical vascular anastomosis, but instead depends on the passive diffusion of oxygen and nutrients from the surrounding tissue against which the graft is placed, until a complete new vascular and lymphatic system is established over time.
2. Epithelial Physiology: Natural Moisture and Sensation
One of the key pain points of the penile inversion technique is vaginal dryness. The use of the jejunum addresses this problem permanently on a physiological basis.
Natural Lubrication: The epithelial lining of the jejunum consists of mucus-secreting cells capable of producing continuous moisture, reducing the need for synthetic lubricants and providing a sensation closely resembling that of the natural vaginal mucosa.
Elasticity & Stability: The jejunum exhibits high elasticity and a lower rate of secondary contraction compared to skin, allowing patients to better maintain vaginal depth and caliber — though vaginal dilation remains necessary during the initial postoperative period.
3. Risk Management Under "The Patient Safety Diamond"
Dr. Kunaporn emphasizes that despite the considerable advantages of the jejunum, this procedure requires entry into the abdominal cavity (intra-abdominal surgery), and therefore safety standards must be elevated to the highest level.
The Patient (Readiness): The patient must pass screening according to WPATH standards and must have no history of intra-abdominal pathology that would contraindicate surgery.
The Surgeon (Expertise): The surgeon must possess a high level of anatomical precision in order to dissect abdominal vessels without compromising the remaining bowel.
The Place (Facility): The procedure must be performed in a hospital accredited by JCI or HA standards, equipped with a positive-pressure operating theatre to prevent intra-abdominal infection, and supported by a fully operational critical care system.
4. Anesthesia Standards and Proactive Safety Protocols
As this procedure is significantly longer than conventional techniques, a dedicated support team is essential.
One-on-One Anesthesiology: The anesthesiologist must maintain close, continuous monitoring of the patient throughout the operation to sustain vital sign stability and blood gas equilibrium during general anesthesia.
Surgical Safety Checklist: A formal Time-In confirmation of the surgical plan with the entire team substantially reduces systemic errors.
References
: APS Journal
