It is important to cut through the constriction and completely separate the tissue during the takedown of vaginal constriction. At this point, you need to decide whether to allow the separated vagina to heal by secondary intention or to cover the defect with a skin graft or other biologic material.
Whichever course you choose, keep the vagina open during the immediate postoperative period. Doing so may require placement of a vaginal stent, numerous postoperative exams, use of a vaginal dilator, or a combination of these measures.
When constriction rings are present in the face of ample vaginal length, you can perform a Z-plasty, in which the lines of a letter Z are incised transversely or longitudinally across the constricted region and the two flaps that have been created from the Z are transposed. This maneuver releases constriction well.
When constriction extends distally, the procedure used is, basically, a reverse perineoplasty: Cut the constriction band longitudinally, undermine the vagina, and then sew it back transversely. This relieves the distal band.
In a severe case of vaginal constriction, thigh flaps that are left on their vascular pedicle can be brought into the vagina to fill the gap created by cutting through the constriction. Initial incisions are made laterally in the vagina (unilaterally or bilaterally, depending on the degree of constriction) and extended to the perineum/vulva. Measurements are made to determine the length and width of flap(s) needed. The flaps are then mobilized, rotated into the defect(s), and sutured into place. This technique significantly increases the diameter of the vagina and can add length, if needed.
What about correcting shortening?
An iatrogenically shortened vagina presents the most challenging of cases. The vagina must be opened up at the cuff; ideally, this produces adequate length without having to enter the peritoneum.