(089) Buccal Mucosal Graft Performed Simultaneously With Complete Anterior and Posterior Vestibulectomy With Vaginal Advancement Flap Reconstruction in Patients With Neuroproliferative Vestibulodynia: A Case Series

Abstract Introduction On vulvoscopy with cotton tipped swab testing, patients with neuroproliferative vestibulodynia (NPV) may be found to have severe pain in the anterior (12:00) vestibule extending from the inferior aspect of the clitoris and frenulum to the superior aspect of the urethral meatus and laterally to Hart’s line. Vagina cannot be advanced above the urethral meatus to provide complete anterior vestibule tissue coverage. Buccal mucosal grafts, characterized by ease of harvest, a favorable healing profile, and shown to be highly effective for urethral stricture reconstruction, have been utilized in patients with persistent 12:00 pain as a second stage salvage procedure after complete posterior (1:00-11:00) vestibulectomy with vaginal advancement flap reconstruction. Objective We report on the initial 6 cases of anterior vestibulectomy with buccal mucosal graft coverage simultaneous with posterior vestibulectomy with vaginal advancement flap reconstruction. Methods Two teams are utilized: one performs a posterior vestibulectomy with vaginal advancement flap reconstruction in standard fashion followed by anterior vestibulectomy (Fig. 1); the other harvests a buccal mucosal graft to a dimension predetermined by measuring the extent of the excised anterior vestibule (Fig. 2). The buccal mucosal graft is secured to the anterior vestibule with 5-0 Monocryl suture on a taper needle performed in an interrupted fashion. A small relaxing incision is made at the inferior midline of the graft to allow it to surround the urethral meatus. The graft is secured to the edge of the anterior aspect of the urethral meatus and vulva at Hart’s line. Multiple stab incisions to the graft and underlying graft bed are performed with an 11-blade. Quilting sutures are then placed with 4-0 chromic. Results Mean age of this patient cohort was 31 ± 9 years. Mean surgical time was 4 hours. Mean blood loss was 100 ml. Post-operative photos showed that the mouth, buccal mucosal graft, and vaginal advancement flap reconstruction healed well, with integration of the graft (mean size 2.5 x 2.5 cm) around day 6 (Fig. 3). Vulvoscopy revealed significantly decreased cotton-tipped swab testing scores of both anterior and posterior regions 3-6 months postoperatively. Conclusions Patients with NPV with extensive anterior and posterior vestibular pain may be considered for buccal mucosal grafts concomitant with anterior and posterior vestibulectomy with vaginal advancement flap reconstruction. Accurately assessing degree of pain involvement of the anterior region preoperatively is critical to selecting proper surgical approach and reducing failure and risk of, or need for salvage procedures. Disclosure No.