Female Genital Cosmetic Surgery: a Review of Techniques and Outcomes
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Int Urogynecol J (2013) 24:1997–2009 DOI 10.1007/s00192-013-2117-8 REVIEW ARTICLE Female genital cosmetic surgery: a review of techniques and outcomes Cheryl B. Iglesia & Ladin Yurteri-Kaplan & Red Alinsod Received: 15 April 2013 /Accepted: 18 April 2013 /Published online: 22 May 2013 # The International Urogynecological Association 2013 Abstract The aesthetic and functional procedures that com- Keyword Female genital cosmetic surgery . Cosmetic prise female genital cosmetic surgery (FGCS) include tradi- gynecology . Vaginal rejuvenation . Labiaplasty . tional vaginal prolapse procedures as well as cosmetic Vaginoplasty vulvar and labial procedures. The line between cosmetic and medically indicated surgical procedures is blurred, and today many operations are performed for both purposes. The Introduction contributions of gynecologists and reconstructive pelvic surgeons are crucial in this debate. Aesthetic vaginal sur- Consumer marketing and media hype have spawned the con- geons may unintentionally blur legitimate female pelvic siderable controversy over female genital cosmetic surgery floor disorders with other aesthetic conditions. In the ab- (FGCS). FGCS articles first appeared in North American sence of quality outcome data, the value of FGCS in im- journals in 1978, and the first technical article appeared in proving sexual function remains uncertain. Women seeking 1984 [1, 2]. This review describes the techniques and outcome FGCS need to be educated about the range and variation of data of labiaplasty, vaginoplasty, and other cosmetic gyneco- labia widths and genital appearance, and should be evaluat- logical procedures. ed for true pelvic support disorders such as pelvic organ prolapse and stress urinary incontinence. Women seeking FGCS should also be screened for psychological conditions Female genital perceptions and should act autonomously without coercion from part- ners or surgeons with proprietary conflicts of interest. Women seek FGCS for both aesthetic and functional reasons including pain with intercourse or sports, vulvar irritation, chaf- ing, and discomfort with underwear or clothing [3]. Younger C. B. Iglesia generation X women (ages 18–44) prefer pubic hair removal, Section of Female Pelvic Medicine and Reconstructive Surgery, MedStar Washington Hospital Center, Washington, DC, USA which allows for easier vulvar visualization compared with older women [4]. Konig et al. found that 78 % of 482 women C. B. Iglesia (*) learned about labia minora reduction via the media and 14 % Departments of ObGyn and Urology, Georgetown University thought their own labia minora looked abnormal [5]. Indeed, School of Medicine, 106 Irving Street, NW Suite 405 South, Washington, DC 20010, USA many women undergoing labia minora reduction perceive their e-mail: [email protected] own genitalia as abnormal [6]. Feelings of embarrassment with sexual function including a strong desire to improve strained L. Yurteri-Kaplan relationships are also commonly cited as reasons for FGCS [7]. Section of Female Pelvic Medicine and Reconstructive Surgery, MedStar Washington Hospital Center, Georgetown University Issues of vulvar dissatisfaction can start in early adolescence School of Medicine, 106 Irving Street, NW Suite 405 South, and have been reported in girls less than 10 [8, 9]. Michala et al. Washington, DC 20010, USA evaluated 16 girls with a mean age of 14.5 years who presented for labia minora reduction [8]. Six girls were bothered by labia R. Alinsod South Coast Urogynecology, Inc, 31852 Coast Highway Suite 200, minora asymmetry while 10 complained of labia minora pro- Laguna Beach, CA 92651, USA trusion, despite having normal labial width. 1998 Int Urogynecol J (2013) 24:1997–2009 Western perception of ideal female external genitalia cutting and treatment for labial hypertrophy or asymmetry differs from other countries. In Rwanda and Mozambique secondary to congenital conditions, chronic irritation, or ex- elongated labia minora are considered attractive [10, 11]. cessive androgenic hormones [17]. Elongated labia minora are seen as a sign of modesty in Surgeons focused on vulvar aesthetics also cite vaginal Mozambique, and the butterfly appearance of the labia relaxation, feeling loose or lacking friction during intercourse, minora is considered desirable in Japan [11, 13]. and enhancement of a partner’s sexual experience as additional reasons to pursue FGCS [18]. In one multicenter retrospective study, 76 % of 258 women underwent surgery for functional Cosmetic gynecological surgery versus female genital reasons; 53 % percent had surgery for cosmetic reasons and mutilation 33 % to enhance self-esteem. Fifty-four percent of women who underwent vaginoplasty and perineoplasty and 24 % of those Critics of FGCS note parallels with female genital mutila- who had a combined vaginoplasty, perineoplasty, labiaplasty, tion surgery (FGMS) [13]. According to the World Health and clitoral hood reduction did so to enhance their male Organization, female genital mutilation comprises all pro- partner’s sexual experience. Only 5 % of participants cedures that involve partial or total removal of external underwent surgery because they were urged by their partner female genitalia, or other injury to female genital organs [18]. In another retrospective study on labiaplasty, 94 % for non-medical reasons [14]. There is legislation and call (503 women) felt that their labia minora protruded beyond for reform in some European and Western countries based the edge of the labia majora, 46 % felt that their labia on this definition [15]. Clearly, opponents of FGCS are minora were enlarged, and 71 % felt that the edges were motivated by a desire to protect women from the potential dark [19]. Fifty-two percent wanted the labia minora edge dangers of elective genital surgery and the societal pressures below the labia majora [19]. some girls and women may feel about the appearance of their own genitalia. While FGMS should be prosecuted, FGCS is a matter of debate. The decision to operate should Types of cosmetic surgery account for the physical and mental health of each patient, including assessment for body dysmorphic disorder. The types of cosmetic surgery are detailed in Tables 1–3. Informed consent of the potential benefits, risks, and limited outcome data should be reviewed and consideration for Vaginoplasty/vaginal rejuvenation/vaginal tightening additional evaluation by a clinical psychologist or psychia- trist may prove useful. Vaginoplasty refers to plastic surgery of the vaginal opening, vaginal canal, and vaginal epithelium. Perineoplasty is the surgical reconstruction of the vaginal introitus and is often Surgeons performing FGCS part of a complete vaginoplasty repair. Vaginoplasty is not intended to correct pelvic floor defects; however, these repairs Traditionally, gynecologists are most comfortable with vag- are modifications of traditional colporrhaphy and are frequent- inal and vulvar surgery. However, more plastic surgeons ly performed in conjunction with reconstructive procedures have been performing FGCS, and have added modifications for prolapse [20]. such as fat grafting. A survey of the American Society of “Laser vaginal rejuvenation” is a trade-marked term and Plastic Surgeons revealed that more than half (51 % of the most commonly refers to traditional posterior and anterior 750 respondents) offer labiaplasty [16]. Only 31.5 % had colporrhaphies carried out to treat a “wide” vagina [8, 18, formal training for this procedure. Case volume over 21, 22]. These procedures involve vaginal reconstructive tech- 24 months ranged from 0 to 300 procedures with a mean niques to anatomically modify the vaginal caliber by decreas- of 7.37 procedures. Gynecologists, urogynecologists, and ing the diameter of the lower third of the vagina while urologists also perform FGCS. While no formal training reconstructing the perineal body [21, 23–26]. A “full-length programs exist, several marketing and franchised training vaginoplasty” consists of decreasing the vaginal caliber of the programs have been developed in the USA and abroad. lower two thirds of the vagina as far up as the ischial spines [26]. The desired surgical outcomes of these procedures in- clude improvement in both aesthetic external appearance and Indications for cosmetic gynecological surgery an increase in frictional forces during intercourse; however, loss of sexual pleasure due to vaginal laxity has not been In general, cosmetic surgery does not require a medical indi- established [24], and no currently published FGCS studies cation. According to a 2007 ACOG committee opinion, in- adequately address the complex psychological components dications for FGCS include reversal or repair of female genital involved with sexual function and response. No comparative Int Urogynecol J (2013) 24:1997 Table 1 Labiaplasty studies Author n Hypothesis Results Follow-up Complications Study type Grade (months) Triana and Robledo [63] 74 Labia minora excision with or 92 % satisfaction 6 Infection 2 Retrospective Very low without clitoral hood molding and Wound dehiscence 1 cohort management of the labia majora 8 % dissatisfaction (6 % asymmetry, 2 % fat Fatty cyst in the labia majora 6 reabsorb into the labia majora) Goodman et al. [18] 258 Evaluation satisfaction for labiaplasty 91.2 % satisfaction 6–42 Dyspareunia 5 Retrospective Low Clitoral hood reduction 83 % satisfaction for vaginoplasty Skin burn 1 Cross-section Vaginoplasty and perineoplasty Introitus narrow 1 – 2009 Perineoplasty Rectal