10/27/2016 Aesthetic Surgery of Female Genitalia: A Plastic Surgery Perspective Maura Reinblatt, MD, FACS Assistant Professor of Surgery Division Plastic & Reconstructive Surgery Icahn School of Medicine at Mount Sinai DISCLOSURES No relevant financial relationships with a commercial interest 1 10/27/2016 WHO AM I? . Board Certified by American Board of Surgery . Board Certified by American Board of Plastic Surgery . Member of ASPS . Member ASAPS . Former faculty at Johns Hopkins School of Medicine . Practicing 9 years SPECIALTIES WORKING TOGETHER What we do What we do NOT do 2 10/27/2016 WHY? . Styles & fashion . Popularity of waxing & hairless trend . Primarily cosmetic in nature “meat curtains” . Complaints of rubbing with cycling & running . Complaints of feeling “bulky” in yoga clothes . How a woman perceives her genitals may have a positive effect on sexual function . Possible insurance with preapproval CPT 56620 . Congenital, puberty, pregnancy, age Hamori CA. Postoperative clitoral hood deformity after labiaplasty. Aesthet Surg J. 2013 Sep 1;33(7):1030-6. “Vaginas Under Attack”? . Cosmopolitan Magazine Cover July 2010 . Vaginas Under Attack: Don’t Let a Greedy Gyno Talk You into This Horrible Mistake . Perception doctors are encouraging patients . Women are actively seeking this procedure . Ethics of safety & marketing of cosmetic vaginal surgery has been raised . Reports of cosmetic procedures on external genitals in both plastics & gynecology date to 70’s-80’s -Hamori CA. Aesthet Surg J. 2013 Sep 1;33(7):1030-6. -Hardwick-Smith S. Examining the controversy in aesthetic vaginal surgery. Am J Cosmet Surg. 2011;28:106–113. 3 10/27/2016 PLASTICS LEADERS & MENTORS Dr. Gary Alter: Board Certified Urology & Plastics Beverly Hills, NYC Dr. Christine Hamori: Board Certified Plastics Duxbury MA Dr. Frank Lista: Board Certified Plastics Ontario Canada & USA Dr. Lina Triana: Board Certified Plastics Cali Colombia WHO ARE THE PATIENTS? . Not strippers or porn stars . Ranging from professional women to students . Wide age range, 20-50 . Wait until sexual maturation & work with gynecologist . Most patients very thoughtful & weren’t aware this was an option until they researched it or friend told them 4 10/27/2016 PROCEDURES: . Labiaplasty: labia minora reduction . Labia majora deflation . Labia majora excision . Clitoral hood reduction . Vaginal tightening . Hymenoplasty . Perineoplasty . Fourchette area . Laser treatment PROCEDURES: . Labiaplasty: labia minora reduction . Labia majora deflation: fat grafting, filler . Labia majora excision: massive weight loss . Clitoral hood reduction . Vaginal tightening . Hymenoplasty . Perineoplasty . Fourchette area . Laser treatment 5 10/27/2016 LABIAPLASTY: Labia Minora Reduction Patient Presentations Hamori CA. Aesthetic surgery of the female genitalia: labiaplasty and beyond Plast Reconstr Surg. 2014 Oct;134(4):661-73 LABIAPLASTY: Labia Minora Reduction . Wedge Excision: -Avoids scar along edge -More technical/challenging -Less scalloping -Possible mismatched pigmentation -remove protuberant portion . Extension to clitoral hood (Alter) . Extension laterally to interlabial groove (Hamori) 6 10/27/2016 LABIAPLASTY: Extension to clitoral hood •Alter GJ. Aesthetic labia minora and clitoral hood reduction using extended central wedge resection. Plast Reconstr Surg. 2008;122(6):1780-1789. LABIAPLASTY: Extension to Interlabial groove Hamori CA. Postoperative clitoral hood deformity after labiaplasty. Aesthet Surg J. 2013 Sep 1;33(7):1030-6. 7 10/27/2016 LABIAPLASTY: Extension to Interlabial groove LABIAPLASTY: Extension to Interlabial groove 8 10/27/2016 LABIAPLASTY: Extension to Interlabial groove LABIAPLASTY: Extension to Interlabial groove 9 10/27/2016 LABIAPLASTY: Labia Minora Reduction . Edge resection or “trim”: -Pigmentation concerns -Faster procedure -No dog ear -Scalloped edges LABIAPLASTY: Labia Minora Reduction •Lista F, Mistry BD, Singh Y, Ahmad J. The Safety of Aesthetic Labiaplasty: A Plastic Surgery Experience. Aesthet Surg J. 2015;35(6):689-695. 10 10/27/2016 LABIAPLASTY: Labia Minora Reduction . Many different techniques . Complications, revisions!!! . High patient satisfaction (92%) . Improved confidence, sex life . Recovery . Controversial issues . Teenagers . ACOG Committee Opinion 5/2016 . Education of anatomy & puberty, assess maturity, screen BDD, discuss non surgical options LABIA MAJORA . Labia majora deflation: fat grafting, filler? Hamori CA. Aesthetic surgery of the female genitalia: labiaplasty and beyond Plast Reconstr Surg. 2014 Oct;134(4):661-73 11 10/27/2016 LABIA MAJORA . Labia majora excision: massive weight loss Hamori CA. Plast Reconstr Surg. 2014 Oct;134(4):661-73 ASSOCIATED PLASTICS PROCEDURES . Pubic lift for ptosis . Liposuction of the mons pubis . Often performed with abdominoplasty and/or liposuction 12 10/27/2016 CONCLUSIONS . Aesthetics of female genitalia has become an area of increasing concern to women . Women seem to prefer: hairless, neat, no labial show past labia majora . Labiaplasty is most common procedure in aesthetic vaginal surgery . Labiaplasty may be performed via wedge excision or edge trim . Proper technique is critical CONCLUSIONS . Excess clitoral hood may be addressed with extension of wedge excision . Labia majora may be enhanced with fat injection, filler/off label (minimal skin excess but deflated) . Sometimes excess labia majora skin may be excised (massive weight loss patients) 13 10/27/2016 CONCLUSIONS . Cosmetic vaginal surgery often results in significant patient satisfaction . Changes in patient confidence . Some of my most grateful patients IMPORTANT REFERENCES • Alter GJ. Aesthetic labia minora and clitoral hood reduction using extended central wedge resection. Plast Reconstr Surg. 2008;122(6):1780-1789. •Aesthetic surgery of the female genitalia: labiaplasty and beyond. Hamori CA. Plast Reconstr Surg. 2014 Oct;134(4):661-73. doi: 10.1097/PRS.0000000000000516. PMID: 25357028 •Lista F, Mistry BD, Singh Y, Ahmad J. The Safety of Aesthetic Labiaplasty: A Plastic Surgery Experience. Aesthet Surg J. 2015;35(6):689-695. Goodman MP, Placik OJ, Benson RH III, et al. A large multicenter outcome study of female genital plastic surgery. J Sex Med. 2010;7(4 Pt 1):1565-1577. 14 10/27/2016 IMPORTANT REFERENCES •Cosmetic Surgery National Data Bank Statistics. Aesthet Surg J. 2015;35(suppl 2):1-24. •Committee Opinion No. 662: Breast and labial surgery in adolescents. Obstet Gynecol. 2016;127(5):e138-e140. •Factors That Influence the Decision to Undergo Labiaplasty: Media, Relationships, and Psychological Well-Being. Sharp G, Tiggemann M, Mattiske J. Aesthet Surg J. 2016 Apr;36(4):469-78. doi: 10.1093/asj/sjv270. Epub 2016 Feb 18. •Triana L, Robledo AM. Refreshing labioplasty techniques for plastic surgeons. Aesthet Plast Surg. 2012;36:1078-1086. •Postoperative clitoral hood deformity after labiaplasty. Hamori CA. Aesthet Surg J. 2013 Sep 1;33(7):1030-6. doi: 10.1177/1090820X13502202. Epub 2013 Sep 4. PMID: 24005612 IMPORTANT REFERENCES •Hardwick-Smith S. Examining the controversy in aesthetic vaginal surgery. Am J Cosmet Surg. 2011;28:106–113. 15 10/27/2016 DISCUSSION & MANY THANKS! . Debate . Confluence of different specialties, techniques, opinions 16.