Lichen Sclerosus

It is a complex autoimmune disease that needs to be understood before being treated locally. Regenerative strategies lead to results once unthinkable, and the expansion of stenosis is possible, but always with caution and a comprehensive approach.”

Prp

Indication

Dryness/Aging/Need for Regeneration

Surgical Technique

Blood Withdrawal, Appropriate Treatment of the Same, Injection with a Fine Needle into the Vulva and/or Vagina

Procedure

40 minutes

Complications

extremely rare

Postoperative Pain

no

, Recovery

immediate

Nanofatgraft

Indication

Dryness/Aging/Need for Regeneration

Surgical Technique

Adipose Tissue Harvesting, Appropriate Treatment of the Same, Injection with a Fine Needle into the Vulva and/or Vagina

Procedure

40 minutes

Pain

poor

Complications

extremely rare

Recovery

immediate

Femifill® Vulvar for Lichen Sclerosus

Indication

Dryness/Aging/Need for Regeneration/Volume Loss

Surgical Technique

Harvesting of Adipose Tissue, Appropriate Treatment of the Same, Multilayer Implantation of Different Adipose Preparations + CO2 Vulvar Laser

Procedure

60 /90 minutes

Complications

Rare (infections, hematomas)

Postoperative Pain

Poor if common pain relievers are used

Recovery

2/4 weeks

Femifill® Vulvar for Lichen Sclerosus + prp

Indication

Dryness/Aging/Need for Regeneration/Volume Loss

Technique

Harvesting of Adipose Tissue, Appropriate Treatment of the Same, Multilayer Implantation of Different Adipose Preparations + CO2 Vulvar Laser + prp

Procedure

60 /90 minutes

Pain

Poor if common pain relievers are used

Complications

Rare (infections, hematomas)

Recovery

2/4 weeks

CO2 Laser for Lichen Sclerosus

Indication

Dryness/Aging/Need for Regeneration/Volume Loss

Surgical Technique

“CO2 Vulvar Laser

Procedure

20 minutes

Complications

extremly rare

Postoperative Pain

no

Recovery

immediate

Correction of Stenosis + Femifill® Vulvar for Lichen Sclerosus + PRP

Indication

Dryness/Aging/Need for Regeneration/Volume Loss

Technique

Expansion for Flaps/Grafts + Harvesting of Adipose Tissue, Appropriate Treatment of the Same, Multilayer Implantation of Different Adipose Preparations + CO2 Vulvar Laser + PRP

Procedure

120 minutes

Pain

Poor if common pain relievers are used

Complications

Rare (infections, hematomas)

Recovery

2/4 weeks

A complex pathology

Lichen Sclerosus is an autoimmune-based pathology that causes progressive sclerosis of vulvar tissues. In most cases, there is an associated pathology, such as thyroiditis, connective tissue disorders, inflammatory bowel diseases, diabetes, and chronic inflammations of the genital area. Even in the absence of a clearly detectable autoimmune disease, often comorbidities such as frequent irregularities of the intestine (constipated or diarrhea-prone bowel) are observed

Tissue Changes (Histology)

Tissues progressively change over the years. Superficial involvement gradually becomes involvement of full-thickness tissues. Literature data indicate that about 10% of patients with lichen develop, over the years, degeneration of the skin with transformations into premalignant or frankly neoplastic lesions. This is due to chronic inflammatory stimulation

Changes in shape

Over the years, the vulva undergoes reform with progressive fusion of the clitoral prepuce, the labia minora merging onto the labia majora, with narrowing of the vulvar opening. The tissues become thin, fragile, easily irritated, and therefore more predisposed to inflammation and infections.

The problems it causes

The thin and fragile tissues become easily irritated, prone to itching and burning, sometimes even to pain caused by tissue lacerations that periodically appear. The narrowing of the vulvar opening or stenosis initially causes difficulties in sexual intercourse, often leading to impossibility. In cases of further progression of the disease, there may be partial or total closure of the opening, leading to inflammation or infections due to urinary retention. The reduction of the opening over the years results in hypofunction of the muscles near the vulva, causing progressive stiffness. In some cases, this is the basis for possible associated pelvic pain.

standard treatments

The standard treatments for lichen involve the use of local emollients and topical cortisone, which help reduce itching and burning.

Our approach

We take into maximum consideration the primary cause of lichen, which we do not believe is a disease of local origin but a systemic disease in which the vulva becomes a target of an autoimmune pathology that is nevertheless systemic. Therefore, the treatment of the related pathology becomes fundamental. For example, in the case of thyroiditis, balancing thyroid function as much as possible, properly balancing blood sugar in the case of diabetes or hyperglycemia, and systemic treatment of connective tissue disorders if possible. We also believe that the intestine plays a fundamental role in causing inflammation that affects the genital area. Even in cases where an intestinal disease is not clearly recognized, we think it is important to investigate food intolerances and resort to a diet that reduces constipation as much as possible. The rehabilitative aspect plays a fundamental role in maintaining toned muscles that often can no longer be used due to the stenotic phenomenon. The psychosocial aspect is extremely important to us because, like all chronic diseases, it requires understanding from the partner and family.

Regenerative Treatments

“Over 15 years ago, we started using regenerative treatments for lichen sclerosus. PRP and derivatives of adipose tissue have become standard treatments for us in addressing this disease. Dr. Brambilla has performed over 500 regenerative treatments in a public hospital (IRCCS Fondazione Policlinico Mangiagalli). ‘I began implanting small amounts of adipose tissue over 15 years ago when the gynecologists I worked with presented the first cases—complex cases that did not respond to standard topical treatments. At the time, I was not familiar with the disease, so I consulted with the histologists at our hospital who showed me some slides. I was immediately struck by the resemblance to tissues affected by the aftermath of radiotherapy and those affected by scleroderma. At that time, we were successfully treating these pathologies with adipose tissue implants. And that’s where the story of tissue regeneration in lichen began,’ says Dr. Brambilla. ‘Over the years, I have refined the technique of the methodology. I understood that one adipose preparation is different from another, and it is important to establish which adipose preparation, how much of the adipose preparation to inject, where to inject it, and when. Understanding the phase of the disease is a key moment to decide whether to proceed or temporarily suspend a treatment. PRP, NANOFATGRAFT, MICROFATGRAFT bring different growth factors and cellular components, and the careful choice of one preparation over another is crucial for successful treatment. It is essential to understand which tissues are involved because the implant methodology, the quantity, and the quality of the preparation will be different in each case. The many cases treated have made me realize that the preparation for surgery, as well as careful postoperative management and rehabilitation, play a fundamental role in achieving often striking results.

Promising Technologies

Scleroderma and autoimmune diseases are complex conditions that require careful consideration and comprehensive treatment strategies. Regenerative approaches have led to results once thought impossible, with the expansion of stenosis being possible, but always with caution and a 360-degree approach.

Correction of Stenosis

“Regenerative procedures often lead to a significant improvement in stenosis, but in some cases, they are not sufficient to satisfactorily widen the vulva, allowing for easy exploration and, better yet, sexual intercourse. To address these cases, we have devised vulvar orifice enlargement techniques that involve the use of respectful local flaps, sometimes with skin grafts, always associated with regenerative strategies carried out before, during, and after the enlargement procedure. We believe that surgical correction of stenosis is appropriate in all cases of tight stenosis and in cases of moderate or mild stenosis where there is periodic ulceration of the perineum, creating continuous disturbance or impossibility of intercourse in patients who still desire it.

Our treatment protocol, developed over the years at the Mangiagalli Clinic in Milan, involves highly personalized treatments, although they fall within an extremely precise guideline. In milder cases, we only resort to topical hydration therapy and mild use of cortisone. In fact, it may happen that a process in the initial phase stops and does not progress. In initial cases where cortisone treatment has proven ineffective, poorly effective, or induces prolonged use, we suggest resorting to injective therapy with PRP or nanofat (see section on regeneration). In cases of medium to severe intensity, we believe that implanting cells derived from adipose tissue (generically called lipofilling but see the regeneration section for more information) is the winning choice. The choice of the type of cellular preparation to be implanted, as well as the mode of administration, is crucial. In cases where the tissues are still sufficiently elastic, we implant the adipose tissue taken with thin cannulas and implanted with very small caliber cannulas (microfatgraft). If the tissue is inelastic and tense, it is essential to resort to fat grafting associated with percutaneous tissue lysis, where adipose tissue is implanted with a special cutting needle capable of microsecting fibrotic tissue and replacing it with soft adipose tissue. This technique, first used by us in the genital region worldwide, is derived from a procedure used for over 20 years in plastic surgery to treat the effects of radiotherapy, especially in the breast, to elasticize tissues and restore volume where lacking. The effectiveness of regenerative therapy is closely linked to the operator’s familiarity with the disease and regenerative strategies. Performing a procedure at an inappropriate time of illness often proves ineffective. Using inappropriate quantities (often excess) of adipose tissue proves counterproductive, using unnecessary cellular populations makes the procedure a waste of time. The definition of the correct cellular population, the correct cellular quantity, the suitable injection procedure, brings surprising results in an unimaginable time. Cases of a higher degree, characterized by a significant reduction in vaginal ostium, require us to resort to unbridling and the use of pedunculated flaps or skin grafts, which in some cases are made even softer by the implantation of a small amount of adipose tissue. Rehabilitative and psychological therapy is an integral part of our treatment protocol, as well as advice on a personalized diet and the prescription of antioxidant preparations. The symptomatic treatment of pain and discomfort is essential throughout the treatment. Since the benefits of regenerative therapy and, equally, surgical therapy occur over months, we consider it essential to immediately mitigate pain, itching, and any discomfort. Therefore, from the outset, analgesic and anti-inflammatory drugs are prescribed to alleviate acute pain.

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