Introduction
There has been rapid growth in the number of available treatment options for female genital aesthetic alteration in the past five years. Labiaplasty procedures saw a 23% increase in 2016 from the previous year, according to The American Society for Aesthetic Plastic Surgery.1 Plastic surgeons performed more than 10,000 labiaplasty procedures in the same year. Vaginal rejuvenation has become the umbrella term for any elective gynecologic procedure designed to alter the appearance of external and internal genitalia and the dimensions of the vaginal canal and perineum. From a surgical point of view, it refers to any surgery (vaginoplasty) done to tighten or restore the vaginal contour.2 These operations are adapted from classic gynecologic surgical treatments for pelvic floor defects, vaginal herniations and attenuation of the perineum. 3 In contrast with these therapeutic treatments, cosmetic rejuvenation procedures focus primarily on achieving better genital appearance and/or providing improvements in sexual function or sexual enhancement.
While the procedures performed within the practice of female genital cosmetic surgery (FGCS) are marketed for aesthetic purposes, it is not uncommon for patients with pathologic distortions of anatomy to seek the same treatment. Some medical indications that might benefit from GGCS include genital pain, persistent vulvar or labial irritation, labial hypertrophy, repair of female genital cutting, and other congenital gynecologic conditions.3 Accordingly, the use of non-surgical techniques for vaginal rejuvenation is also on the rise with more than 500,000 nonsurgical female genital rejuvenation procedures performed in 2016 alone. This rapidly growing field of female patient care, which has generated over $500 million in incremental fees for practitioners, should not be ignored.4
Patient Analysis
In evaluating patients for vaginal rejuvenation, understanding their motivations and expectations is important. The challenges in choosing the best candidate for treatment include careful screening for body dysmorphic disorder, sexual dysfunction, partner-centric motivations, and other pathologic concerns not covered by these procedures.5 The rise of female genital aesthetic alteration indicates the shifting standards of normal or desirable anatomy. Some authors believe that this corresponds to the popularity of total pubic hair removal, which resulted to improved visualization of the genitals by women and their partners.6 In addition, general media exposure and the ease of online access to pornography has led many women to compare their genitalia to unrealistic images of what they perceive as the “perfect vagina”.
Patients seeking vaginal rejuvenation may present with realistic and unrealistic expectations. The physician must be ready to discuss and clarify misconceptions about the procedures involved. The patients’ expectations of the visual and functional outcome should coincide with surgical feasibility. Women’s motivations for undergoing genital corrections are usually aesthetic and/or functional nature. Many women complain of functional changes after childbirth, such as decreased sensation during coitus and the undesirable appearance of vulvovaginal structures. Both premenopausal and postmenopausal women may also complain about:
- Hanging, wrinkled, or excessively redundant labia minora
- Dark pigmentation and asymmetries of external genitalia
- Chafing or irritation during exercise or intercourse
- Embarrassing events of “vaginal gas”
- Hygiene or odor issues
- Decreased friction during intercourse
- Visible prominence of labial tissues (camel toe) when wearing tight clothes
- Atrophy or deflated appearance of the labia majora
Photo-Documentation
As with all aesthetic procedures, photo-documentation is recommended. Prior to labiaplasty, Stefan Gress uses standardized settings for aperture, shutter speed, and lighting conditions, with photographs taken in the same position before the surgery: standing frontal view, lateral oblique in lithotomy position, and frontal view in lithotomy position. Immediately after the procedure, photographs of the lithotomy position are repeated. The surgeon may take follow-up photographs after 6 months, if circumstances permit, to properly visualize the outcome when all the swelling has resolved.
Beyond Aesthetics
Women who seek treatment particularly to achieve orgasm, improve sexual function, or address vaginal laxity, should be referred to a specialist with considerable experience in sexual dysfunction and pelvic floor disorders. Desire and orgasm are complex reactions influenced by emotional and interpersonal factors including aesthetic ones. In some cases, thorough evaluation and counseling by trained psychosexual professionals to exclude other causes of sexual dysfunction may be necessary prior to surgical intervention. Screening for body dysmorphic disorder is essential, as incidence of this problem in women is high.
Patients should be informed about the lack of data supporting the effectivity of these procedures for sexual enhancement and the risk of potential adverse events, including infection, scarring, altered sensation, pain during intercourse, and possible dissatisfaction with the functional and aesthetic outcomes. The perceived cosmetically unappealing appearance of the female genitalia can greatly affect a woman’s sex life. Some surgeons, unfortunately, are not aware of the importance of achieving optimal appearance and the best possible function in female genital surgery. Patients affected by botched procedures and undesirable outcome may be traumatized further. Surgical procedures should be avoided in patients who plan to have more children, due to possible vaginal laxity issues that may warrant repeat treatments.7
Female Genital Surgery Techniques
Labiaplasty (Labia Minora Reduction)
The desire for this treatment is usually based on dissatisfaction with external genitalia appearance and not on functional issues. Hypertrophy is the most common concern although no criteria exist to provide a definition of labia minora hypertrophy. The ideal appearance of the labia minora varies among women, practitioners, and cultures. Labiaplasty can be performed through several techniques which involve the removal of unwanted labial tissue bilaterally or unilaterally, in cases of asymmetries. Some of these procedures include wedge resection technique, composite reduction labiaplasty, and Z-plasty.
Vaginoplasty (Vaginal Rejuvenation)
Vaginal rejuvenation is one of the most controversial genital surgical interventions and is often used interchangeably to refer to laser vaginal rejuvenation. However, the latter may not provide the same outcome as surgical vaginoplasty. Gynecologists and plastic surgeons perform vaginoplasty to reduce the normal diameter of the vaginal canal, often for sexual reasons. There is no clear clinical indication for vaginoplasty; it is suggested, in general, to women who want to remedy the “wide vagina” sensation caused by vaginal delivery or aging. The surgical goals of this procedure are to enhance the vaginal tone and thus sexual friction.8 The technique used for vaginal rejuvenation is very similar to colporrhaphy, the traditional procedure used in correcting vaginal prolapse or pelvic floor defects. In a multicenter study by Goodman and colleagues, about 86% of 341 patients undergoing cosmetic genital procedures, 81 of which were for vaginal rejuvenation, reported enhancement in sexual function. However, 16% reported problems with healing, pain, or dyspareunia, and postoperative bleeding, which eventually resolved.9
Hymenoplasty (Hymen Restoration)
The practice of hymen restoration or “revirgination” remains controversial and undesirable, with limited published literature. The fact that the hymen is still being regarded as the sole proof of virginity in some regions of the world further muddles the ethical aspect of the procedure. Hymenoplasty or hymenorrhaphy can be considered therapeutic when it is intended to contribute to a rape victim’s rehabilitation or alleviate the effects of medical surgeries.10 Women pursue surgical restoration of the vaginal membrane for personal and cultural reasons. Others claim it is for reclaiming personal ownership of their bodies.11 The procedure is a fairly new addition to the process of surgical medicine and there is no one standard way of performing it. Hymenoplasty is not part of any medical school curriculum; physicians who perform this procedure are likely to have acquired or developed their own technique in clinical practice.
G-Spot Amplification
G-spot augmentation is a simple procedure performed by administering human-engineered hyaluronan into the anterior vaginal wall to enhance or augment the g-spot in women. Christian Herold et al. claimed to have successfully performed autologous fat transplantation or lipofilling for g-spot augmentation. There were no respected side effects, and the 29-year old patient was pleased with the procedure’s outcome of enhanced sexual sensation.12 G-spotplasty, on the other hand, is a new surgical intervention introduced by Dr. Adam Ostrzenski, the same doctor who claimed to have identified the location of the female g-spot within the vagina. G-spotplasty aims to improve G-spot sensitivity and increase a woman’s ability to achieve vaginal orgasm. The procedure involves removal of a small, diamond-shaped piece of tissue from the vaginal wall (at the supposed G-spot location) and then stitching the vaginal wall back.
Non-Surgical Techniques
The newest non-surgical modalities for vaginal rejuvenation include lasers and radiofrequency devices that target vaginal connective tissues, and electromagnetic therapy that targets muscles. Laser technology is a welcome addition to vaginal rejuvenation mainly for the convenience of the procedure and for its limited thermal damage compared to other energy-based treatments. Contact lasers such as erbium:YAG and fractional CO2 are the most commonly used lasers for vaginal rejuvenation.
Er:YAG 2940 nm is one of the most popular laser systems for vaginal rejuvenation worldwide.13 Due to the wavelength’s extremely high absorption in water, human tissues, with their high water percentage especially in the vaginal area, are good targets for 2940 nm wavelength. Erbium laser technology is used to treat vaginal relaxation, urinary incontinence, and vaginal atrophy. This technology works by selective stimulation of mucosal tissue, resulting in the contraction of tissues and acceleration of collagen synthesis.
Fractional CO2 laser is found to be more advantageous than Er:YAG because of a reported 30% increase in collagen production.14 It is a simple outpatient procedure that does not require anaesthesia and provides a high degree of satisfaction. Vaginal dryness and dyspareunia due to vaginal atrophy may be treated with fractional micro-ablative CO2 laser. The same laser technology may also be helpful in addressing vulvar hyperpigmentation by increasing vulvar capability to retain water molecules.
Temperature controlled radiofrequency (RF) is effective for vulvar and vaginal tightening. This technology promotes the formation of new collagen (neocollagenesis) and blood vessels (angiogenesis), resulting in improved sensitivity and skin tone. RF is also useful in improving overall sensitivity of the clitoral, vulvar, and vaginal tissues.13 Tightening of vaginal tissues could address problems of vaginal laxity, stress incontinence, overactive bladder, and some cases of cystocele and rectocele.
Marketing Vaginal Rejuvenation
Vaginal rejuvenation is often regarded as a marketing term rather than a medical indication. While it is fairly easy to attract patients who seek these procedures online, promoting such services requires a lighter approach that some surgeons or practitioners may find challenging. Aggressive promotion is more likely to elicit a negative reaction. Pamphlets discussing the cosmetic procedures should be readily available; utilizing website landing pages and blog posts with before and after photographs will also be helpful in “addressing the elephant in the room,” helping patients feel more comfortable in learning about these procedures. Take advantage of the opportunity to inform consumers about your expertise in the field and the services you are offering. Because there is a lot of misinformation and unwarranted claims about how these genital interventions work, and the achievable outcomes, creating a solid online presence is a sound investment. You may include a microsite on your practice website, which is a smaller website incorporated into your main website that is designed to promote or provide useful information about a particular subject or product, such as Radiesse. You may also invest in a new domain name with some of your marketing budget allotted to search engine optimization (SEO).
Conclusion
Aesthetic interventions for the female genital area are often viewed as controversial and ethically questionable procedures. However, physicians who do decide to perform genital rejuvenations, proven in both study literature and clinical practice, have seen the effectiveness of these specific procedures in meeting the physical and psycho-social needs of women after completion of the procedure. Despite a lack of evidence detailing the long-term benefits and also the potential harm, it is imperative for surgeons to achieve the best possible outcome while ensuring patient safety, as undesirable results are certain to cause further emotional distress and psychological trauma.
References
- Cosmetic surgery national data bank statistics. Aesthet Surg J (2016)
- Wilkie G, Bartz D, ‘Vaginal Rejuvenation: A Review of Female Genital Cosmetic Surgery’, Wolters Luwer Health (2018)
- Julian TM, Posterior Compartment defects. In: Rock JA, Jones III (eds.). Te Linde’s Operative Gynecology. Wolters Kluwer (2011)
- Medical Insight Annual Aesthetic Practice Survey, January 2017
- Kent D, ‘Vaginal Rejuvenation: An In-Depth Look at the History and Technical Procedure’, American Journal of Cosmetic Surgery (2012)
- Bercaw-Pratt JL, Santos XM, Sanchez J, et al. ‘The incidence, attitudes and practices of the removal of pubic hair as a body modification’, J Pediatr Adolesc Gynecol. (2012)
- Rajshekhar S, Thiagamoorty G, Cardozo L, ‘Vaginal rejuvenation: improving sex by design?’, Elsevier (2018)
- Barbara G, Facchin F, Buggio L et al. ‘Vaginal rejuvenation: current perspectives’, International journal of women’s health (2017) doi:10.2147/IJWH.S99700
- Goodman M, Placik J, Benson R, et al. ‘A Large Multicenter Outcome Study of Female Genital Plastic Surgery’, The Journal of Sexual Medicine (2010)
- Shaw D, Dickens BM, A new surgical technique for hymenoplasty: A solution, but for which problem? Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.023
- Wild V, Poulin H, McDougall CW, et al. Hymen Reconstruction as pragmatic empowerment? Results of a qualitative study from Tunisia. Soc Sci Med (2015)
- Herold C, Motamedi M, Hartmann U, Allert S, ‘G-spot augmentation with autologous fat transplantation’, Journal of the Turkish German Gynecological Association (2015) doi:10.5152/jtgga.2015.15027
- Hamori C, Banwell P, Alinsod R, Female Cosmetic Genital Surgery: Concepts, classification and techniques (2017)
- Hunzeker C, ‘Fractionated CO2 laser resurfacing: Our experience with more than 2000 treatments’, Aesth Surg Jour (2009)
