Current Commentary Female Cosmetic Genital Surgery

Michael P. Goodman, MD

in the lexicon of appearance and functional Genital for women has come under scru- tiny and has been the topic of discussion in the news improvement. media, online, and in medical editorials. In the absence of As women become more comfortable with the measurable standards of care, lack of evidence-based idea of elective procedures on their faces, breasts, and outcome norms, and little standardization either in no- skin, designed to enhance their appearance and self- menclature or training requirements, concern has been confidence, it is not surprising that they may wish to raised by both ethicists and specialty organizations. alter, change, “rejuvenate,” or reconstruct even more Some women request alteration of their and intimate areas of their bodies. for reasons of cosmesis, increasing self-esteem, In 1984, Hodgekinson and Hait were the first to and improving sexual function. Patients must be assured discuss genital surgical alterations performed for their surgeon is properly trained and should understand purely esthetic reasons.1 Although there are no pub- that few validated long-term safety or outcome data are lished statistics from either the American Society of presently available in this relatively new field. Women Plastic Surgeons or the American College of Obste- also should be made aware that, although they may wish tricians and Gynecologists, it has become apparent in to cosmetically or physically alter their external genitalia, the lay press that esthetic surgery of the and this does not mean that they are developmentally or structurally “abnormal.” It is important that training is being performed with increasing frequency. guidelines for practitioners be established and that long- Keeping pace with women’s requests and in the absence term outcome, psychosexual, and safety data be pub- of official training programs, certification, and nomen- lished. The genital plastic surgeon must have sufficient clature, it is concerning that we are witnessing a prolif- training in to withhold these proce- eration of physicians, programs, and procedures touting, dures from women with , mental often without proof of validity, success of both improved impairment, or body dysmorphic disorder. In an atmo- appearance and sexual function. In the absence of sphere in which trademarked marketing terms are be- legitimacy and training, oversight, and commonly ac- coming part of the lexicon, a more descriptive terminol- cepted nomenclature, vividly descriptive terms such as ogy is suggested, incorporating the terms “,” “revirgination,” “designer laser ,” and “vag- “reduction of clitoral hood,” “,” “hymeno- inal rejuvenation,” thrive and multiply and may soon (if plasty,” and “vaginoplasty.” The term “female cosmetic not already) become part of the vernacular. genital surgery” is presented as a descriptive umbrella In his editorial in the May 2008 issue of encompassing these genital plastic procedures. & Gynecology,2 Douglas W. Laube, MD, MEd, ad- (Obstet Gynecol 2009;113:154–9) dresses but does not answer issues involving scope of practice, ethics, education, finances, and practice lective cosmetic surgical and nonsurgical proce- considerations. Edures have been with us for thousands of years; Esthetic surgery of the vulva and vagina has not the many forms of cosmesis have an established place been described as such nor sanctioned by specialty organizations. Some would go so far as to describe it as experimental. I disagree. The operations them- Corresponding author: Michael P. Goodman, MD, 635 Anderson Rd., Ste. 12B, Davis, CA 95616; e-mail: [email protected]. selves are not new; what is new is the concept that Financial Disclosure women may wish to alter their genitalia for reasons of Dr. Goodman’s medical practice encompasses the procedures discussed. He is the potential improvement of appearance or function. principal investigator of a multicenter outcome study on vulvovaginal aesthetic However, because any surgery has great potential for surgery, which is funded in part by an unrestricted grant from TriAxial Medical (Rockledge, FL). causing pain and distress if not performed properly, and especially because genital plastic surgery involves © 2008 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. concepts and procedures that are not yet fully re- ISSN: 0029-7844/09 searched nor understood, stringent guidelines for

154 VOL. 113, NO. 1, JANUARY 2009 OBSTETRICS & GYNECOLOGY training, anesthesia, surgical technique, and postop- AUTONOMY erative monitoring, among others, should be The principle of autonomy is used commonly to established. justify cosmetic surgical procedures. Although auton- The goal of this article is to endeavor to bring some omy may be used to justify female cosmetic genital cohesion to this emerging and essentially unregulated procedures, the surgeon must be convinced that the area of women’s health care. Its purpose is to: 1) patient is acting completely autonomously. She must recognize the right of women to seek cosmetic and have no mental impairment, no evidence of depres- functional alteration of their external genitalia and vagi- sion, anxiety, or body dysmorphic disorder. She must nas, 2) frankly discuss ethical considerations and patient be free of any outside coercive influences (eg, from a evaluation requirements, 3) suggest safeguards to protect sexual partner) and must be completely aware of the patients from unrealistic expectations and unethical or risks of surgery and free of any influence, covert or poorly trained practitioners, 4) suggest training require- overt, from the surgeon. Provider coercion can begin ments for professionals, and 5) begin to define and even before the patient’s first visit via marketing that establish a legitimate nomenclature. promises a “designer vagina” or appearance “like a Playboy model” and touts the surgeon as “world RECOGNITION famous” or “a pioneer” or uses misleading proprietary terms. Cosmetic surgery is theoretically an opportunity to It is the obligation of the surgeon to inform the make a physical change in one’s appearance to cor- patient fully regarding treatment options and the rect a (sometimes self-perceived) defect or physical potential risks and benefits of these options. Once problem, enhance self-esteem, look better in clothes, the physician is satisfied that the patient fully compre- and improve personal assessment of one’s sexual hends the options, the patient’s autonomous decision functioning, among other reasons.3–6 ordinarily should be respected and supported. Cosmetic procedures designed to alter body shape and contour are a fact of life. It can be argued that NONMALEFICENCE female genital reshaping falls into the same category as Any procedure that has a greater chance of causing liposuction, rhinoplasty, breast augmentation, abdomi- harm than good (primum non nocere) is unethical. noplasty, and other cosmetic alterations.3 Toward this end, it is important to note that there are There has been an avalanche of publicity about very few long-term, peer-reviewed data regarding safety labiaplasty and other vulvovaginal esthetic surgical and cosmetic, functional, and psychosexual outcomes of procedures. Some call it labial or vaginal rejuvena- genital cosmetic procedures. The few reports available tion, female cosmetic genital surgery, or vulvovaginal to date list no serious complications,4,10–14 but most refer esthetic surgery. These procedures and their credibil- only to labiaplasty. These reports equivocate when it ity have touched a nerve in the medical community. comes to questions of adequate explanation and under- Indeed, at a more basic level, the medicalization (and, standing of outcome and sidestep definitions of “normal- by extension, the surgicalization) of sexual behavior, ity” when it comes to potential clients, who pay signifi- where surgery and drugs are used to enhance sexual cant monetary sums for their procedures. pleasure, has been decried.7 Indeed, the professional- It is important for those in the medical community ism of the physicians performing these procedures performing these procedures to follow established and the ethics and propriety of the procedures them- guidelines to theoretically ensure proper guidance, selves have been called into question.8 informed consent, psychosexual screening and coun- seling, and safe performance of the procedure. It is the surgeon’s responsibility to make sure that his or ETHICAL CONSIDERATIONS her patient is psychologically stable and not being To answer the question whether elective vulvar cos- coerced, that she fully understands the procedures, metic surgery is ever warranted, it is necessary to risks, recovery times, and restrictions, and that she examine these procedures through the lens of estab- understands that outcomes may not be exactly up to lished and accepted principles of biomedical ethics: her expectations and that she has the opportunity and respect for autonomy, beneficence, nonmaleficence, time to make a truly informed decision. Additionally, justice, and veracity.9 This has been done well by the surgeon should inform the patient about presently Andrew T. Goldstein, MD, and Gail R. Goldstein, limited outcome data regarding the safety and efficacy MD,3 and many of their ideas follow. of these procedures.

VOL. 113, NO. 1, JANUARY 2009 Goodman Female Cosmetic Genital Surgery 155 BENEFICENCE ence with the proposed treatment or knowledge regard- The principle of beneficence refers to the ethical ing potential long-term outcomes. obligation of the physician to promote the health and welfare of the patient. For the surgeon to benefit her PATIENT PROTECTION or his patient, the patient must receive the functional At the present time, the field of female cosmetic and cosmetic results she expects. genital surgery is like the old Wild, Wild West: wide The literature3–6 as well as anecdotal experience open and unregulated. In this environment, the pa- from many genital plastic surgeons suggest that women tient is afforded little protection when there exists no undergo these procedures for purely cosmetic reasons, specialized training or experience requirements.2 because of discomfort in clothing or when taking part in Outcome studies (physical, functional, social, sexual, sports, because of invagination of excess labial tissue and psychological) to guide both surgeon and pro- during coital penetration, and because of lack of sensa- spective patient are few in number and small in size tion, “gripability,” and “feeling loose,” with resultant and generally do not discuss psychological and sexual diminished pleasure during lovemaking. ramifications.4,11–14 The surgeon must know the proper surgical tech- American College of Obstetricians and Gynecol- niques and have sufficient experience with the proce- ogists Committee members, as evidenced in their dure to adequately reassure a prospective patient that Committee Report No. 378,8 take issue with what her results will meet reasonable expectations. To be they see as unsubstantiated claims inherent in the reassured, the patient must reasonably expect that her promises of enhanced sexual gratification with proce- surgeon has been adequately trained and supervised dures such as “vaginal rejuvenation” and “designer and has had experience adequate to perform the laser vaginoplasty” in the absence of adequately pow- specific procedure she will be undergoing. ered outcome data. For patient protection in addition to expecting JUSTICE the application of the ethical principles previously discussed, patients have the right to expect that their The ethical principle of justice implies that the resources surgeons have had a proper level of training and of society are used to the greater good of society. In experience to perform the agreed-on procedure. They medical ethics, this suggests that everyone is entitled to should know the expected outcomes of their proce- a decent minimum of health care. Because the costs for dures, alternative surgical techniques available, ex- elective cosmetic surgery are borne solely by the patient, pected complications, and rates of (mal)occurrence, so the issue of justice is not especially applicable. However, as to be able to choose what they wish done based on a in a situation in which medical resources are rationed knowledge of the procedure and known and resources needed for the greater good are directed rates. to cosmetic/comfort surgery, the principle of justice Some risks (eg, overtightening of the introitus theoretically does apply. Importantly, the principle of through perineoplasty, risks of bowel or bladder entry justice should prevent any physician from suggest- or risk of producing incontinence by alterations of the ing to a third-party payer that there is a medical anterior or posterior compartments in vaginoplasty, indication to obtain monetary coverage in situations infection, poor wound healing) are known and must in which esthetic concerns are the main motivation of be discussed with the patient. the patient. Because these procedures are relatively new and the literature investigating outcomes and risks rela- VERACITY tively sparse, the possibility of other untoward out- Veracity, or truth telling, is important in surgical comes must be discussed candidly. In my experience, counseling and decision making. The surgeon must patients look on this surgery as relatively risk-free and not represent his or her patient’s anatomy as abnor- do not expect much discomfort nor a difficult recov- mal. These procedures must not promote a more ery. The fact that these are serious surgical proce- normal appearance. There is no “normal,” and sur- dures, that recovery may be protracted, and that the geons must emphasize this and must be clear regard- risks are potentially significant must be shared. ing the present lack of scientific evidence and safety This is admittedly difficult given the paucity of data regarding these procedures. evidence-based outcome data available. However, The surgeon must be honest regarding potential patients are requesting these procedures, and they are outcome, effects on sexuality, and potential compli- being performed. Presently, in the absence of ade- cations and should not misrepresent his or her experi- quately powered multicenter data, all that can be ex-

156 Goodman Female Cosmetic Genital Surgery OBSTETRICS & GYNECOLOGY pected is that surgeons collate their results, take note of surgeon, it is important for these physicians to be the results of the small, single-practice studies available, adequately trained in vulvar and vaginal anatomy and and refer to these procedures as relatively new and the intended surgical procedure(s), and patients should untested. understand their surgeons’ professional training and Many patients seeking cosmetic genital surgery background. perceive themselves as abnormal, unattractive, or In either case, a surgeon embarking on a procedure deformed. Clear and direct information must be should have specific expertise in the procedure he or she provided to each patient regarding the wide range of will perform, either secondary to previous performance anatomic normality and that they fall within this of an adequate number of cases or through completion range. Given this, patients still may reasonably wish of an approved training course followed by proctoring. to alter their appearance. The makeup of these courses, the number of hours Each patient seeking a cosmetic genital proce- required, and course content are not something we as a dure should be evaluated, either by the use of an profession necessarily can legislate, but it is the goal of approved instrument (eg, the Arizona Sexual Experi- this article to stimulate formation of a group of peers to ence Questionnaire, Female Sexual Function Index) agree on acceptable standards of care and training or by a general set of uncovering questions. Patients requirements. I anticipate that such requirements will with sexual dysfunction should be further evaluated, specifically include sexual medicine training sufficient to either by the operating surgeon if she or he is trained enable the cosmetic genital surgical practitioner to eval- in this evaluation or through referral to a qualified uate the sexual health of his or her patient and to be able sexual medicine practitioner for resolution before to uncover sexual dysfunction that may masquerade as surgery. Patients with serious sexual dysfunction a surgical request. should not undergo these procedures. The patient should be made aware that the proce- DEFINITIONS AND NOMENCLATURE dure she is to undergo is basically for cosmetic and An acute need exists to develop a reasonable nomen- self-esteem reasons. Although it may be reasonable to clature to replace proprietary terms such as “vaginal expect that there may be positive effects on sexual rejuvenation,” “designer laser vaginoplasty,” “revirgin- function, this result should not be touted or guaranteed. ation,” and “G-shot” before they become entrenched A consent form should be part of the preoperative in the rubric of medical and lay terminology. No specific process and should include information about the pro- term is accepted to describe these procedures, although cedure, short-term and long-term recovery, known and genital plastic surgery, cosmetic surgery of the vulva, potential complications, and inability to guarantee the and other terms have been used. I suggest “vulvovaginal expected outcome, as well as a disclaimer regarding esthetic surgery” as an easily stated and descriptive inability to guarantee beneficial effects on sexual func- terminology. tioning and enjoyment. It is accepted that, as in other surgical disciplines, It is anticipated that minimum standards of com- various techniques and instrumentation are used in petence and training will be established and that the performing these procedures.10–14 It is not the purpose medical professionals who perform these procedures of this article to comment on the superiority of one will publish their outcome statistics. Surgeons should method or technique over another. Surgeons, the not give the impression that these procedures are marketplace, and, ideally, evidence-based outcome universally accepted or routine and should approach data will determine which procedures will survive the them with the same respect and caution as any other test of time. surgical procedure on the female genitalia. Female cosmetic genital surgery (genital plastic TRAINING GUIDELINES surgery or vulvovaginal esthetic surgery) involves sur- gery on the female external genitalia, vagina, and sur- As previously noted, patients have the right to expect rounding structures and is designed to improve appear- that their surgeons have a known minimal level of ance subjectively, potentially provide psychological and training and experience. Patients reasonably can ex- functional improvement, or both, in sexual stimulation pect, if their surgeon has completed an approved and satisfaction. obstetrical–gynecological residency program, that she or he is experienced in vaginal and perineal repairs and fully understands the anatomy of the pelvis. If the LABIAPLASTY surgeon has not completed an obstetrical–gynecological Labiaplasty refers to surgical alteration, usually residency, whether a general, urological, or plastic through reduction of the size of the labia. Although

VOL. 113, NO. 1, JANUARY 2009 Goodman Female Cosmetic Genital Surgery 157 this usually involves reduction of the labia minora or vaginal mucosa, or a combination of the above, all majora, occasionally labiaplasty involves reconstruc- designed to surgically “tighten” the upper vagina. tion after obstetrical injury or enlargement via injec- tion of bulking agents or autologous transfer. The HYMENOPLASTY procedure usually is performed by modified wedge Hymenoplasty is a surgical procedure whereby the resection, linear removal, and “sculpting,” or by a hymeneal ring is surgically altered via small, tighten- modified z-plasty technique. ing revisions to produce size minimization of the vaginal aperture. REDUCTION OF THE CLITORAL HOOD A valid nomenclature very well may include (“CLITORAL UNHOODING”) subgroups as suggested by Miklos and Moore15 based Reduction of the clitoral hood is a surgical separation on cosmetic, functional, or sexual reasons for surgery of the female clitoral prepuce designed to produce (or combinations of these). more “exposure” of the clitoral body, theoretically Establishing a descriptive, officially recognized, providing improved sexual stimulation, cosmetic size standardized nomenclature will suppress the validity reduction of redundant prepuce or frenular folds, or of marketing terms that, in some eyes, discredit the both, for cosmetic reasons. legitimacy of patients’ requests for reasonable cosmet- ic-enhancement procedures. VAGINAL REJUVENATION Vaginal rejuvenation is a proprietary term meant to SUMMARY encompass perineoplasty and/or vaginoplasty as a Patients must be adequately screened, taking note technique to “tighten” the vaginal barrel and elevate of the ethical principles of autonomy, nonmalefi- and strengthen the perineal body. Unfortunately, cence, beneficence, justice, and veracity. Patients neither patients nor medical professionals know ex- should be adequately protected and guided to actly what is meant by this term. I suggest the use of develop reasonable expectations and understand more standard medical terminology to specifically that their genitalia are not abnormal. Surgeons describe the surgery performed. should be adequately trained and experienced and should use universally accepted, accurate, and de- PERINEOPLASTY scriptive terminology. The procedures should be Perineoplasty involves surgical reconstruction of adequately described to patients, and risks and the vaginal introitus. This sometimes is performed expected outcomes should be fully explained. along with a minor low-posterior compartment repair with dissection and reapproximation in the REFERENCES midline of the musculature, whereby a 1. Hodgkinson DJ, Hait G. Aesthetic vaginal labiaplasty. Plast diamond-shaped wedge of tissue is removed with Reconstr Surg 1984;74:414–6. 2. Laube DW. Cosmetic therapies in obstetrics and gynecology the incisional apex in the posterior lower one third practice: putting a toe in the water? Obstet Gynecol 2008;111: of the vagina and the incisional nadir on the 1034–6. perineum superior to the anus. The “wings” of the 3. Goodman MP, Bachmann G, Johnson C, Fourcroy JL, Gold- diamond extend laterally to the hymeneal ring. stein A, Goldstein G, et al. Is elective vulvar plastic surgery ever warranted, and what screening should be conducted Skin, mucosa, and fibrotic scar tissue are excised, preoperatively? J Sex Med 2007;4:269–76. and the resultant defect is repaired vertically, reap- 4. Miklos JR, Moore RD. Labiaplasty of the labia minora: proximating the levator muscles and resulting in an patients’ indications for pursuing surgery. J Sex Med 2008;5: elevated perineum, attenuated vaginal orifice, strength- 1492–5. ened perineal body, and altered visual appearance and, 5. Di Saia JP. An unusual staged labial rejuvenation. J Sex Med potentially, sexual function. 2008;5:1263–7. 6. Bramwell R, Morland C, Garden AS. Expectations and expe- rience of labial reduction: a qualitative study. BJOG 2007;114: VAGINOPLASTY 1493–9. In vaginoplasty, portions of mucosa are excised 7. Hart G, Wellings K. Sexual behaviour and its medicalisation: from the vaginal fornices via scalpel, needle elec- in sickness and in health. BMJ 2002;324:896–900. trode, or laser. Unfortunately, there presently exists 8. Vaginal “rejuvenation” and cosmetic procedures. ACOG Com- mittee Opinion No. 378. American College of Obstetricians and no standardization of the procedures performed, Gynecologists. Obstet Gynecol 2007;110:737–8. and they may consist of anterior colporrhaphy, 9. Beauchamp T, Childress JF. Principles of biomedical ethics. high-posterior colporrhaphy, excision of lateral 3rd ed. New York (NY): Oxford University Press; 1989.

158 Goodman Female Cosmetic Genital Surgery OBSTETRICS & GYNECOLOGY 10. Giraldo F, Gonzalez C, de Haro F. Central wedge nymphec- 13. Rouzier R, Louis-Sylvestre C, Paniel BJ, Haddad B. Hypertro- tomy with a 90-degree Z-plasty for aesthetic reduction of the phy of labia minora: experience with 163 reductions. Am J labia minora. Plast Reconstr Surg 2004;113:1820–5. Obstet Gynecol 2007;182:35–40. 11. Pardo J, Sola V, Ricci P, Guilloff E. Laser labioplasty of the 14. Pardo JS, Sola VD, Ricci PA, Guiloff EF, FreundlichOK, labia minora. Int J Gynaecol Obstet 2006;93:38–43. Colpoperineoplasty in women with a sensation of a wide 12. Munhoz AM, Filassi JR, Ricci MD, Aldrighi C, Correia LD, vagina. Acta Obstet Gynecol Scand 2006;85:1125–7. Aldrighi JM, et al. Aesthetic labia minora reduction with 15. Surgery and patient choice. ACOG Committee Opinion No. 395. inferior wedge resection and superior pedicle flap recon- American College of Obstetricians and Gynecologists. Obstet struction. Plast Reconstr Surg 2006;118:1237–47. Gynecol 2008;111:243–7.

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