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Aesthetic Surgery of the Female Genitalia

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Aesthetic Surgery of the Female Genitalia Aesthetic Surgery of the Female Genitalia Julie M.L.C.L. Dobbeleir, M.D.,1 Koenraad Van Landuyt, M.D., Ph.D.,2 and Stan J. Monstrey, M.D., Ph.D.2 ABSTRACT Aesthetic genital surgery seems to have become a fashionable issue nowadays. Many procedures and techniques have been described these last years, but very few long- term results or follow up studies are available. The novelty of this aspect of plastic surgery and the lack of evidence-based interventions, have led to a comparison with female genital mutilation. In this article, the authors provide an overview of the possible surgical procedures as well as the general principles of aesthetic surgery of the female genitalia. KEYWORDS: Genital surgery, genital cutting, labioplasty, vaginal tightening Aesthetic surgery of the female genitalia is a rium, many questions have been raised, regarding tech- much discussed topic in the popular press as well as the nical issues, indications, and—not in the least–ethics, scientific journals. It seems to be fashionable for men but few scientific answers are available. and women of today’s world to have their genitals As for every new specialty, guidelines need to be altered. set up and long-term studies are a necessity. Complicat- Although it might strike as a new trend quickly ing the issue even more is the fact that genital beauty is arising in all layers of society, it has been around for ages. very culturally defined. The same template and indica- The genital ideal may differ historically and cross- tions cannot be used cross-culturally. culturally, yet in every society, social and cultural cus- For example, in Japan the so-called winged but- toms, often supported by medical rationale and health terfly appearance (Fig. 1) of the smaller labia is greatly explanations, seem to justify the need for particular admired and considered sexually desirable. In Western female genitalia. society, protruding inner labia are considered less attrac- Aesthetic female genital surgery involves surgery tive, whereas in parts of Africa, the inner labia are on normal female external genitalia; therefore, it falls deliberately stretched from a young age. The ritual is into the same category as liposuction, breast augmenta- known as Kudenga and is believed to optimize sexual tion, facial rejuvenation, cosmetic dental surgery, or any intercourse.2,3 other aesthetic surgery procedure to the body. It is designed to improve the appearance subjec- tively, and potentially provide psychological and func- ANATOMY AND PHYSIOLOGY tional improvement in sexual stimulation and Before understanding aesthetic genital surgery, one satisfaction.1 needs to have a thorough knowledge of the anatomy Ever since aesthetic genital surgery became a and the normal physiological changes occurring within more common part of the plastic surgeon’s armamenta- the anatomy. 1Department of General Surgery, University Hospital Leuven, Leuven, Guest Editors, Christopher J. Salgado, M.D., and Stan J. Monstrey, Belgium; 2Department of Plastic Surgery, University Hospital Gent, M.D., Ph.D. Gent, Belgium. Semin Plast Surg 2011;25:130–141. Copyright # 2011 by Thieme Address for correspondence and reprint requests: Stan J. Monstrey, Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, M.D., Ph.D., Department of Plastic Surgery, University Hospital USA. Tel: +1(212) 584-4662. Gent, De Pintelaan 185, 2K12C, B-9000 Gent, Belgium (e-mail: DOI: http://dx.doi.org/10.1055/s-0031-1281482. [email protected]). ISSN 1535-2188. Aesthetic and Functional Genital and Perineal Surgery: Female; 130 AESTHETIC SURGERY OF THE FEMALE GENITALIA/DOBBELEIR ET AL 131 importance of genetics versus environmental influences has not yet been elucidated.6,7 GENERAL PRINCIPLES The absence of guidelines and evidence about aesthetic genital surgery has led to a comparison with female genital mutilation. In most Western nations, irrelevant of age, ethnic background, and consent, female genital mutilation or cutting is illegal.8–10 The World Health Organization refers to female genital cutting as ‘‘all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious or non-therapeutic reasons.’’ Unfortunately, this definition does not distin- guish the traditional practice of female genital cutting Figure 1 Winged butterfly appearance. from elective vaginovulvar plastic surgery, thus giving rise to controversy.11 Female genital cutting originated in Arabic coun- It is here that the first problem arises: What tries as early as 450 BC. Although in some Arabic should we consider as normal vulvovaginal anatomy? countries, such as Sudan, the ritual is closely connected Female genital anatomy was first described in with the Islamic religion; female genital cutting actually 1899 by Waldeyer who reported that normotrophic labia predates Islam and is not condoned by that religion minora measure 2.5 to 3.5 cm.4 In a more recent study, because Islam forbids any harm inflicted on God’s Lloyd et al extensively measured the external and inter- creation.10,12 nal female genitalia and also studied color changes and Even in the United States and Great Britain from texture, thereby mapping the female genitalia in a whole the early 1800s to the mid-1950s clitoridectomy and new way.5Their study found that there is a much larger hysterectomy were believed to treat diverse disorders variation than first assumed: They reported a mean (labia such as masturbation, lesbianism, hysteria, debility, minora) width of 2 cm, but found a natural variation nymphomania, etc. Sigmund Freud once opined that between 7 mm and 5 cm.5 ‘‘elimination of clitoral sexuality is a necessary precondi- It cannot be denied that as women age, physio- tion for the development of femininity, since it is logic changes in their genital area occur. Because pro- immature and masculine in its nature.’’12 creation is often seen as the primary function of female In Arabic culture, female genital cutting is called genitalia, it is only natural that they are at their best Khafd (reduction) or Tahara (purification). Its purpose is during fertile age. to remove all male qualities so that a woman is fit for In an aging vagina, there is loss of tone and marriage.13,14 tightness due to slackness in the pelvic floor and of According to the WHO, there are four types of vaginal muscles after childbirth. This might result in a female genital cutting: feeling of wideness and less sexual sensitivity for both women and their partners. The mons pubis progressively Type 1: excision of prepuce with/without excision enlarges through fat deposits and sagging. In contrast to part/all clitoris the mons pubis, there is volume loss in the labia majora, Type 2: excision of clitoris with partial/total excision increasing the optical sagging even more. labia minora With growing age hypertrophy of the labia mi- Type 3: excision of part/all external genitalia and nora occurs, although this is not the only cause of narrowing vaginal opening (infibulation) hypertrophy. Labia minora hypertrophy can also be Type 4: piercing, incising or stretching clitoris and/or secondary to mechanical irritation by intercourse or labia, cauterization by burning of the clitoris and masturbation, childbirth, lymph statis, myelodysplastic surrounding tissue disease, chronic irritation from dermatitis or urinary incontinence. It is multifactorially defined, meaning Immediate complications of female genital cut- that also hereditary factors play a certain role. The ting include severe pain, cellulitis, sepsis, urinary 132 SEMINARS IN PLASTIC SURGERY/VOLUME 25, NUMBER 2 2011 retention, hemorrhage, shock, and even death. Long- patients, the indication is partially reconstructive (for a term complications include cysts, abscesses, keloids, functional or medical indication) as well as aesthetic (for recurrent infections, dyspareunia, and dysmenorrhea. cosmetic reasons). This is illustrated by M. Goodman Neuromata and infertility are seen, but are rare. who attempted to pull genital surgery out of the dark Decreased sexual responsiveness, psychological seque- with his proposal for indications and guidelines.16 lae, or even posttraumatic stress syndrome, are under- Indications: standably common. Aesthetic procedures in the genital area can re- 1. Perceived genital hypertrophy or significant discrep- semble female cutting in terms of technique and final ancy result, but the fundamental difference lies in the inten- 2. Discomfort with sports activities or clothing, or tion and the purpose never to harm the functionality of vaginal entrapment with coitus the female genitals with this surgery.9,15 3. Genital changes due to childbearing or obstetrical Obviously, patients should be aware that this injury affecting beauty or gripability and pleasurable surgery carries inherent risks and complications that coital sensation. eventually can result in a diminished function.3 For plastic surgeons performing aesthetic genital surgery, four ethical principles mark the difference with LABIOPLASTY genital cutting practices11: Labioplasty refers to reduction of the labia minora (mostly) or majora, as well as to augmentation through 1. Autonomy of the patient: Patients should be over injection of bulking agents or autologous fat transfer.1 18 years old, psychologically stable, and fully in- The function of the labia minora is to protect the formed on the risks and expected results, so that the vagina from drying out and the labia play a significant decision in full knowledge of the issue is theirs only. role in the process of micturition by funneling the urine An informed consent should always be obtained. stream, therefore the minimal labial width should be 2. Nonmaleficence: The ‘‘first of all to do no harm’’ 1cm.2,13 principle of Hippocrates specifically applies in gen- ital surgery, which should never result in genital or sexual dysfunction. Reduction of Labia Minora 3. Beneficence: Literally this means ‘‘to do good,’’ which Reduction labioplasty has been reported in the peer- translates to performing high-quality surgery, pro- reviewed medical literature since 1971.
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