Vaginal rejuvenation, Laser Vaginal Rejuvenation, the “Mommy Makeover”, “Designer Vaginas”, reduction labiaplasty and vaginal tightening are among the many terms used to describe operations focused on female genital enhancement. This is the fastest growing area of cosmetic surgery as women and surgeons become more aware that the nonmedical genital effects of childbirth, weight fluctuations, tissue laxity and anatomic idiosyncrasies can be addressed by a variety of procedures. The leaders and pioneers in this type of surgery are all members of the International Society of Cosmetogynecology.
Although cosmetic vaginal surgery is the general term, external or vulvar structures are also commonly treated. These include the mons pubis, the labia majora and the labia minora including the clitoral hood or prepuce. The perineum which forms the muscular bridge of tissue between the anus and the vagina, and the lower third of the posterior vaginal wall are the areas typically operated in vaginal tightening procedures. The anterior vaginal wall plays a lesser role in vaginal tightening, but a far greater role in the surgical treatment of urinary incontinence. Hymenoplasty, sometimes referred to as “revirgination” is typically performed when a request is made for cultural reasons.
Prior to embarking upon cosmetic vaginal surgery, a thorough gynecologic evaluation should be performed to screen for pre-existing gynecologic, urogynecologic or urologic conditions which might alter the timing of the procedure or influence the surgical plan. Failure to do so may result in patient dissatisfaction with the cosmetic procedure or, worse, aggravation of the medical problem. Therapeutic and cosmetic surgeries can be performed under the same anesthesia in some instances. Another issue which must always be kept in mind is the potential effects of future vaginal childbirth on the cosmetic procedure and that a cesarean delivery by patient request may not always be available.
Cosmetic vaginal surgery can be performed with general anesthesia, epidural anesthesia, spinal anesthesia or intravenous sedation with local infiltration and pudendal block. Prophylactic antibiotics are routinely administered. Patients are typically positioned in dorsal lithotomy with boot-type stirrups, mild knee flexion and routine Intermittent pneumatic compression stockings to prevent deep venous thrombosis. Indwelling bladder catheterization and vaginal packing are employed during some operations.
Either mons pubis liposuction or mons pubis lifting will alter the appearance of the appearance of this region. Mons pubis liposuction is typically performed in the supine position at the time of general abdominal liposuction. The endpoint of mons pubis liposuction is an even thickness of the fat contours between the areas cephalad and caudad to the pubic bone without skeletonizing the latter. Mons pubis liposuction is also integral to abdominoplasty when the lower incision edge is thicker than the upper edge.
The mons pubis lift is an effective aesthetic option for women with significant laxity in the mons pubis region and sagging of the labia majora as viewed in the standing position. It is achieved by precise alignment of the central tension vectors at the time of abdominoplasty. The pubic lift integrates well with mons pubis liposuction and yields a more complete and balanced aesthetic solution for the abdominal wall.
The Clitoral Region
Cosmetic alterations in this region are focused on the excision of loose, redundant folds of skin from the prepuce. When planning surgery of this type in combination with a mons pubis lift, the lift is done first because it frequently produces a tightening of the prepuce in the vertical axis when the mons pubis is placed on cephalad traction.
Inferior to the prepuce, the trifurcation of the posterolateral portion or the prepuce, the frenulum and the labium minus must be addressed when prepuce alterations and reduction of the labia minora are requested by the patient.
The Labia Minora
Reduction labiaplasty is the most common treatment for patients dissatisfied with elongated, asymmetric or hyperpigmented labial tissue. When examining the labia minora, it is necessary to splay them laterally onto the labia majora to determine the degrees of hypertrophy, hyperpigmentation and asymmetry which may be present. When combined reduction labialplasty and vaginal tightening procedures are performed, vaginal tightening is performed first because it involves the resection of the fourchette with subsequent reconstruction in a more anterior position.
The Labia Majora
Three procedures are available for cosmetic alteration of the labia majora: augmentation by autologous fat transfer, skin tightening by resection of loose skin, and sclerotherapy. The labia majora frequently lose volume with both age and weight loss producing a deflated appearance with looseness and wrinkling of the overlying skin. In most patients, these changes can be addressed effectively with autologous fat transfer. Similar to fat grafting in facial applications, an sufficient amount of fat is harvested from a suitable site, prepared according the surgeon’s preferred technique then injected into the subcutaneous fat layer. Deep injections are avoided as they may disrupt the structures of the vestibule.
When a greater degree of skin laxity and sagging are present, an ellipsoid full thickness skin resection in the long axis of the labia majora either alone or in conjuction with autologous fat transfer will provide an effective cosmetic solution.
Varicose veins of the vulvar region respond to sclerotherapy in much the same manner as those of the lower extremity. Not infrequently, these varicosities are a source of pelvic pain and a gynecologic workup for pain should rule out other etiologies prior to treatment. The veins are targeted in the standing position and injected in the supine position. The technique is identical to sclerotherapy of the leg varicosities working from proximal to distal veins. A pelvic compression garment is worn for the first seven days.
Commonly known as vaginal rejuvenation, procedures for tightening the vaginal dimensions originate from a class of gynecologic operations referred to as vaginoplasties or colporrhapies initially developed for the treatment of prolapse of the bladder (cystocele) and of the posterior vaginal wall (rectocele). Mild to moderate degrees of vaginal laxity can be corrected quite adequately by targeting the lower third of the posterior vaginal wall and the perineal body for this type of surgery.
Experience with the management of complex pelvic surgical conditions is mandatory for surgeons embarking upon vaginal tightening procedures because of the frequency with which anatomic distortion from childbirth-related scarring is encountered in this region and also because of the close proximity to the bladder and rectum. Also, gauging the degree of tightening can be tricky in inexperienced hands and those considering offering these surgeries to their patients are well advised to seek specific training in these operations from experts.