Perineal excess skin—just excision, or muscle repair too? Differences in post-delivery perineal surgery

Perineal surgery (between the vaginal opening and anus) can involve either excising excess skin or scar tissue alone, or reconstructing the muscles beneath the skin through "perineal reconstruction."[1][2]The choice of method depends on whether you are concerned only with the appearance of the skin, or whether you also experience laxity or pain during intercourse.[1]Neither method has been compared in large-scale research.[3].

Skin-only excision versus perineal reconstruction—what is the difference?

The difference lies in the depth of intervention. Skin excision removes protruding skin or scar tissue to refine the surface appearance.[1].

Perineal reconstruction excises excess skin and then reconnects the perineal muscles that separated during delivery, restoring the anatomy closer to its pre-delivery state.[2][3]This approach is sometimes chosen when scar tissue is causing pain during intercourse.[1].

Why does excess skin or scarring remain in the perineum after delivery?

Perineal injury is very common during delivery. Vaginal delivery results in perineal trauma in 75–85% of women, according to reports.[4]Some reports cite rates as high as 90%.[5].

Depending on how the wound heals, persistent pain or pain during intercourse may remain.[5]Reports also indicate that perineal injury can lead to emotional distress and loss of body confidence.[4]Cosmetic concerns are as valid as physical symptoms and deserve professional consultation.

What should be tried before surgery for a painful scar?

When pain is present, non-surgical options are usually considered first. European guidelines list physical rehabilitation, steroid or PRP injections, light-based therapy, and surgical revision.[6].

However, there are few focused studies on perineal scar tissue after childbirth, and this guideline has not determined which method is best[6]. When pain that does not improve with medication persists, some opinions suggest considering surgery to revise the scar tissue[6].

What is known about the effectiveness of perineal reconstruction surgery?

There are reports of effectiveness, but the number and scale of studies remain small. In reports combining surgery to tighten the deep vaginal muscles with perineal reconstruction surgery, satisfaction at 12 months was 93.3%[7].

In comprehensive reports on female external genitalia surgery, researchers have noted that the methods used in different studies are not standardized and sample sizes are small[3]. We found no studies comparing skin-only cutting methods and perineal reconstruction surgery under identical conditions.

What factors affect scar healing?

Perineal scar healing is influenced by the body's condition. Perineal surgery outcomes are affected by nutritional status, blood sugar control, smoking, bacteria, past surgery, and pressure on the scar[8].

If you smoke or have diabetes, inform your surgeon before the procedure. You should also discuss precautions such as posture and underwear choices to avoid pressure on the scar[8].

How do you decide which method is right for you?

The guideline is based on what concerns you.

If you are concerned about the appearance of skin protrusion or scar tissue: skin-cutting methods are being discussed[1]

If you also experience laxity or a sense that muscles have separated: perineal reconstruction surgery is considered[2][3]

If the scar tissue is painful: discuss this together with non-surgical options[6]

What does the examination check?

Which method is suitable cannot be determined from an article alone. The extent of excess skin, the firmness of scar tissue, and the condition of the muscles cannot be understood without a physical examination.

During the examination, confirm how much will be cut, whether the muscles will be addressed, how pain will be managed if it persists, and how to approach the procedure if another pregnancy is planned.