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Aesthetic Female Genital Surgery
by
Susan E. Kolb, M.D., F.A.C.S.
Phone: (770) 457-4677

Introduction

Description of the wave of interest in these Procedures:
There is a class of new procedures that women are seeking out not only in the United States but also in Britain. A recent report in the British Medical Journal criticized the surgery as unnecessary and exploitative, referring to the “designer vagina” trend in the United States. There is no question that this type of surgery is controversial for at the center of the topic of female vaginal rejuvenation is the issue of female sexual expression and enjoyment. And even now in the year 2007 when we live in a country where women enjoy equal opportunity with men in many areas, there is a final hurdle for society to accept that women want to enjoy better sex and want a certain look of their female genitalia. Whether this trend is because women’s insecurities are being exploited by the media as some authors claim, or whether this trend is reflective of the next step of female sexual liberation, is yet to be seen. The women that call my office are primarily professional women such as nurses, physicians, attorneys, and teachers both married and single who simply know what they want. They do not come in with pictures off the Internet, but with specific requests and reasons for those requests which I find entirely reasonable. I figure if this wasn't really bothering them, they would not take the time to visit my office, often traveling halfway across the country to do so.

There is no question that in the popular press descriptions of this procedure are read with great interest by women who are relieved to find that a relatively simple procedure can correct problems that they have had since puberty. The functional problems center around discomfort with certain activities including sports and sex, and can include frequent bacterial and/or fungal infections within the excess tissue of the labia. Cosmetic issues occur because women feel embarrassed or self-conscious about asymmetries or deviations from what they feel is attractive and/or normal. As is often the case, these women seek out information on the Internet, and find that some surgeons specialize in the area of vaginal and vulvar rejuvenation procedures. Websites such as are reporting record visits in 2007 with a monthly average of 40,500 visits compared to a monthly average of 8000 visits in 2002. I had the pleasure of interviewing my friend and colleague Dr. James Apesos on my radio show in September of 2007 on his book Vaginal Rejuvenation which describes these surgical procedures.

Anatomy
The wide variety of normal anatomy is shown in a book my staff presented to me for my birthday called Femalia by Joani Blank. The pertinent points of interest, aside from the large variation in shapes and sizes, are as follows. The outer lips or labia are called the labia majora and the inner lips or labia are called the labia minora and these lips often extend down to the lower part of the perineum. A portion of these lips can also extend up to the clitoral hood which is usually a double hood. It is most important to stay away from the clitoris unless of course your patient is requesting reduction of the clitoris which can sometimes occur when the patient has been taking steroids which has resulted in clitoral hypertrophy. I have not performed this procedure but Dr. James Apesos said he reduced a clitoris that was the size of a small penis by cutting out a wedge in the middle. I replied he was a brave man and that he should publish the case. Other pertinent points of anatomy are the mons pubis which is Latin for “mountains of Venus” and the clitoris which is the embryonic equivalent of the male penis and is packed with 8000 nerve endings which is twice the number of its male counterparts. This might explain the female's ability to have multiple orgasms. Theoretically, if there is a great deal of tissue covering the clitoris, sexual stimulation of the clitoris could be blunted. Below the clitoris and between the labia minora one can find the urethral opening and below that the vagina opening. Just as it is important to listen to the patient who is coming to you for any aesthetic procedure and look with them in the mirror so that they can describe what bothers them and what they want to achieve with surgery, it is very important to let the patient tell you what specifically they do not like and how they would like to change it. It would be most embarrassing to trim or reduce the wrong area due to a miscommunication.

Descriptions of procedures

Labiaplasty:

Labia minora reduction: Reduction of the inner lips or labia minora is the most commonly requested procedure in female aesthetic genital surgery. There are two commonly used procedures which consist of trimming the excess labial tissue along the edge of the labia minora which is often actually a “Y” shaped incision line as frequently the excess labia minora extend toward the clitoral hood. This procedure is best for more complicated or extensive surgeries or in patients who have longer labia minora. For patients with shorter labia minora, there is another procedure which involves taking a V-shaped section out of the most prominent portion of the labia then suturing the incision closed. Both procedures are usually performed with absorbable sutures. Either general anesthesia, local anesthesia with sedation, or local anesthesia with topical anesthesia prior to injection can be used.

Labia majora reduction: Reduction of the outer lips or labia majora is less commonly requested but patients with this request often complain of an abnormal bulge in swimming suits or tight jeans due to overly large labia majora. Reduction of the labia majora can be performed using a wedge excision of the excess tissue with the incision along the length of the labia minora. Less commonly the enlarged labia majora can be reduced by suction lipectomy.

Labia majora enhancement: On occasion, the patient will request enhancement of the labia majora which can be accomplished with fat injection usually after removal of excess inner thigh fat and reinjection into the labia majora using a low pressure system such as the tumescent liposuction system.

Clitoral hood reduction: Reduction of the clitoral hood is usually performed for functional reasons with the goal to allow increased clitoral stimulation for sexual pleasure, or to improve the appearance of the genital area. It is a good idea to only reduce the outer hood and to do so in a fashion whereby scar contracture would not lead to problems near the clitoris. It is important for sexual functioning that the clitoris not be encumbered by thick or scarred tissue. It is also advisable to avoid scars close to the clitoris if possible.

Mons pubis reduction or liposuction: Reduction of the mons pubis is generally requested by patients who have massive weight reduction often after gastric bypass surgery. They have ptosis and excess tissue in this area which requires direct wedge excision usually in a transverse direction. For those without skin excess, liposuction of the mons pubis is effective. If the patient is undergoing an abdominoplasty, wedge resection of the fat pad through the lower abdominal incision is effective.

The Controversy

Traditional medical viewpoint: The traditional medical viewpoint currently on these procedures goes as follows: The woman expresses concern to her family practice physician or her OB/GYN physician, who says to her that there is no problem with her anatomy and there is no reason to have surgery.

Radical opposition: I discovered the radical opposition in a letter published in the British Medical Journal 2007; 334: 1335 from Marge Berer, editor of Reproductive Health Matters. She states “This procedure (labial reduction and female genital reshaping), which entails “the partial or total removal of the external female genital organs for cultural or other non-therapeutic reasons,” is a criminal offense in the UK under the Female Genital Mutilation Act.” So if may be wise to avoid practicing this surgery in the UK.

Plastic surgery perspective: Plastic surgeons, due to their extensive training in aesthetic surgery, have a different perspective. We are taught to weigh risks against benefits when considering surgical solutions for aesthetic problems. A plastic surgical principle is that a scar is preferable to a contour problem. As you can see from the pre-and postoperative photographs, the scar is minimal compared to the significant contour change. Nonetheless, many plastic surgeons prefer not to perform aesthetic external female genital surgery either because of lack of experience and training, or more commonly because of misconceptions regarding this patient population. Dr. James Apesos shared his early experience with us on the radio show. He said that several patients came to his office requesting this procedure. He was uncertain if he wanted to perform the surgery until he spoke with his wife who assured him that these women would not be in his office unless they felt they had a significant problem, and since he was well trained in transsexual surgery, this procedure should be very safe and simple. He found this to be the case, and is now the co-author of the book Vaginal Rejuvenation.

Patient Goals and Motivations:
More research is needed to determine what patient goals and motivations entail. Our practice is currently asking patients to fill out a simple questionnaire regarding preoperative goals and expectations and compare them to postoperative results. The preliminary results of this survey shows that over 80% of the patients are very satisfied and had no change in sensation of the clitoris unless a clitoral hood procedure was performed, in which case the sensation is increased as expected. One patient reported that she had prolonged swelling and tenderness and reported being satisfied with the procedure. The majority of patients reported that discomfort with activity including sexual activity, is the primary reason for having the surgery and that surgery was successful in treating this symptom.

Vulvar Rejuvenation

Typical Patient Requests:

Cosmetic: Patients request most frequently trimming of enlarged or asymmetrical labia minora followed by excess clitoral hood reduction which can be either unilateral or bilateral. The goal is usually to obtain a more symmetrical and neatly trimmed area with the labia minora tucked between the labia majora. Many of these women also keep their pubic hair well trimmed and are otherwise meticulous in their grooming.

Functional:

Labial discomfort: The most frequent complaint in my practice is discomfort during sexual activity. The majority of patients have had a long-standing problem but report the problem has been exacerbated by childbirth. Other problems include discomfort with sports activity including horseback riding.

Skin irritation from tissue folds: Teenagers and young adults with excess labial tissue often report local irritation as well as infections (both fungal and bacterial) in the area. Surgery is very successful at relieving the symptoms.

Problems with orgasm: Patients with excessive clitoral hoods may experience problems with orgasm due to lack of clitoral stimulation. The unhooding procedure by removing excess tissue of the outer hood is usually successful in increasing clitoral stimulation.

Comparison to facial or breast rejuvenation:

Given that the results of female genital surgery are not frequently seen publicly unless the patient is in the profession that typically exposes this area of the body, minor asymmetries or contour irregularities are not generally problematic. This is not necessarily the case for facial rejuvenation surgery where these problems are almost always noticed by the patient as well as her friends and not well tolerated. The breasts, being a secondary sexual appendage, is also usually covered although some asymmetries of the breast are very noticeable even under clothing. Fortunately, this area (the labia and the clitoral hood) of the body enjoys a good vascular supply and this area usually heals easily and rapidly with few complications.

Ability of surgery to meet patient goals:

From our surveys that have been returned, it appears that patient goals are readily achieved with very little surgical risk. Further clinical research in this area is ongoing.

Problems and complications of surgery:

The most frequent problem encountered in my practice is prolonged swelling and discomfort and is usually due to excessive activity in the postoperative period. Patients often do not realize that they must limit their activity for several weeks postoperatively. If they do not, these labia, similar to the lips on the face, have the capability of swelling and being uncomfortable. Three patients had sexual intercourse during the third week postoperatively and experienced small tears below the vaginal opening which healed without difficulty. I have since changed my postoperative instructions to avoid sexual intercourse for six weeks rather than four weeks. Another common problem is minor asymmetries. This problem may be reduced by using general laryngeal mask anesthesia without injection of local anesthetic until the end of the procedure so as to avoid distortion of the labia. There has been very little problem with excessive scarring if postoperative instructions are followed. On one occasion, two procedures to reduce a very large clitoral hood were needed because if only one procedure had been done, the length of the incisions would be excessive and could possibly result in scar contracture. As this was determined preoperatively the patient was informed and accepted that two procedures would be needed. In my patients there have been no infections and two postoperative bleeds. Since we have stopped using local anesthesia with epinephrine, no more bleeding has occurred. A common problem we have is in obtaining postoperative photographs. Patients are generally happy with the procedure, they rarely return for follow-up past the first post-operative visit. Over half my patients are not local so follow-up is inconvenient.

Societal and psychological consideration:

Feminist perspective versus the return of the Goddess:
In the early 1990’s, I was asked to debate a feminist leader regarding the controversial subject of breast augmentation on CNN. Her position was that no woman should get breast augmentation because we were being influenced by a society that degraded women. She felt women were motivated to seek out this surgery in order to please men and that they should be happy with whatever breast size they had. I replied that I had been spiritually guided during a meditation to get breast implants. She replied that that was fine but nobody else should get breast implants. It was a very odd interview but it does portray the two extreme views on the subject. Are women sexually controlled by men and a society that convinces women that to be valuable they need to have a certain breast size and appearance of the female external genitalia, or are women having these surgeries for themselves, in order to achieve what they want to look like regardless of the opinions of others. In my world, the women are deciding to have the procedures in order to create what they want. The men in their lives are frequently surprised and amused that their partners are having the surgery but make it clear that the women are doing it for themselves and not to save the marriage or relationship. I am sure that there are other scenarios that exist but as “like attracts like”, these women who are dominated by men rarely walk through my door. It is likely that a decade from now, female aesthetic genital surgery will be as common as surgery to change the shape or size of the breast is today. And I predict, if any of these surgeries are found to enhance sexual pleasure, they may surpass all aesthetic surgery currently being done on women. We just will need to convince insurance companies to pay for the procedures, like they pay for Viagra.

Body images issues:
The history of body image is very interesting. Anthropologists studying this issue speculate that the reason men are attracted to women with significant curvature of the hips and breasts, is because these women are more likely to conceive than women who are thin with little shape. Curvature results from estrogen so this theory may have some merit. Long-distance runners with little subcutaneous fat, are more likely to be infertile. What catches the man's eye may be more related to his DNA being able to successfully reproduce, than anything else. A study of history of art also indicates that in previous times other cultures valued women with significant subcutaneous fat. In the late 20th century, there was a trend toward seeking out supermodels that were very tall and thin, so some women adopted this body image as ideal. As we learn from the movie “Silence of the Lambs”, we covet what we see, so it is possible that some women seek out this surgery based on what they have seen in the popular media. The question is do they do this for themselves or for their partners?

Trends in interest in aesthetic female genital surgery:
It is clear from the statistics presented earlier in this presentation showing a five-fold increase in visitors monthly to between 2002 and 2007, that patient interest in this procedure is significantly on the rise. The American Society of Plastic Surgeons reports a 30% increase in plastic surgery statistics for labiaplasty between 2005 and 2006. Articles in the popular press as well as the plastic surgery professional press emphasize that these procedures are becoming a mainstay in plastic surgery as they are very safe and very effective at achieving their goals. Other specialties such as gynecology, general surgery, and dermatology are not as frequently involved with this area, unless they specialize in vaginal and vulvar rejuvenation. Gynecologists often also offer vaginal tightening procedures as well as procedures for prolapse and incontinence.

The Future Predicted:

The future of female aesthetic genital surgery will be influenced by economic factors as well as society’s trends regarding body image. If more specialties become comfortable performing the surgery, it is likely that surgical fees will become more competitive. Women use disposable income for this procedure which is usually priced from $2000 to $5000 depending on the level of the surgeon’s expertise, the type of facility and anesthesia used, and the geographical area. Of course, the condition of the general economy may also play a role. There may be a trend especially with more female medical directors of insurance companies, to have functional problems in the area covered under the insurance plans. I have been successful in having several women with significant symptoms pre-authorized for this procedure. Body image issues as influenced by popular cultural venues especially media related, will undoubtedly drive the market as well.

Conclusions:

Aesthetic female genital surgery is likely here to stay given that women still have disposable income. Functional female genital surgery may actually increase, given that insurance companies do not exclude the procedure.
So if you are interested in this type of surgery, find a surgeon that will listen to your concerns and who has expertise in this area of surgery.

 

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