Perineal skin excision surgery: where to have it done? The key is finding a clinic that can distinguish whether just cutting is enough

Perineal excess skin excision is best chosen at a clinic that can differentiate through examination whether removing excess skin alone is sufficient, or if muscle reconnection is necessary.[1][2]The extent of surgical intervention can affect the likelihood of complications such as dyspareunia.[2]Surveys of obstetricians and gynecologists have also shown that tailoring the surgical scope to each individual is important.[2].

Can the clinic determine whether skin removal alone is enough?

First, you want to know whether the clinic can assess whether the problem is excess skin or damage extending into the underlying muscle. According to plastic surgery textbooks, perineal reconstruction not only removes thinned skin but also reconnects muscles torn during childbirth to restore the pre-delivery form.[1].

Perineal injury during childbirth is common, reported to occur in up to approximately 90% of women.[3]Post-injury symptoms vary depending on the depth of the tear and how it was sutured.[3]Even if the appearance suggests only excess skin, the underlying cause may be deeper, so the surgical extent must be determined by examination.

How thoroughly does the clinic inquire about your concerns?

Beyond appearance, it also matters whether the clinic asks about pain, sexual function, and bowel symptoms. Perineal injury has been reported to be associated with persistent pain, dyspareunia, pelvic dysfunction, and mood changes.[3].

Symptoms of fecal or gas leakage (fecal incontinence) should always be confirmed during history-taking.[4]When needed, the surgical approach should be determined after assessing the condition through ultrasound of the anal area, according to guidelines.[4]Pay attention to whether there is a comfortable atmosphere to disclose difficult-to-discuss symptoms.

How does the clinic explain the risk of dyspareunia?

Dyspareunia is a particularly important risk to confirm when undergoing perineal surgery. A research review of gynecologist surveys noted a report showing new dyspareunia occurred in 53% of cases after perineal reconstruction involving deep muscle.[2]For this reason, extending the surgery into deep muscle warrants caution.[2].

A one-year follow-up study of women who had perineal reshaping after childbirth showed clear improvement in bothersome symptoms affecting daily life.[5]However, while dyspareunia scores decreased somewhat, the difference was not clear.[5]It is important to be able to discuss beforehand which concerns are likely to improve and to what extent.

What may occur after surgery?

You should also ask beforehand about postoperative recovery and potential complications. It has been reported that women undergoing perineal reconstruction concurrent with vaginal surgery had more difficulty with urination compared to those who did not have the perineal procedure.[6].

In a study of 36 women with posterior introital stenosis correction, mild infection occurred in 1 person (2.8%), and scar tightness in 2 people (5.6%), both resolving with local treatment.[7]Since this is a small study, ask your surgeon directly what to expect in your case.

Where should I have it done? A guide when unsure

During consultation, ask about the following points:

Assessment: Can the clinic determine whether skin removal alone is sufficient or if muscle reconstruction is needed?[1][2]

History-taking: Does the clinic ask about pain, sexual function, and fecal leakage?[3][4]

Dyspareunia: Does the clinic explain how the surgical extent may affect dyspareunia?[2][5]

Postoperative: Does the clinic discuss potential complications such as urinary difficulty and infection, and how they will be managed?[6][7]

In your individual case, how much to remove cannot be decided from an article alone. During examination, communicate your specific concerns and your childbirth history, then discuss the surgical extent and dyspareunia risk with your surgeon.