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Marci Bowers
Director, Division of Transgender Surgery
Mills-Peninsula Hospital
Burlingame, CA, USA
Linda Cardozo OBE, MD, FRCOG
Professor of Urogynaecology
King’s College Hospital
London, UK
Orawee Chinthakanan MD, MPH
International Urogynecology Associates of Atlanta and Beverly Hills
Vaginal Rejuvenation Center of Atlanta
Atlanta Medical Research, Inc.
Alpharetta (Atlanta), GA, USA
Andrew T. Goldstein MD, FACOG, IF
Director, the Centers for Vulvovaginal Disorders
Washington, DC; New York, NY;
Clinical Professor, Department of Obstetrics and Gynecology
The George Washington University School of Medicine
Washington, DC, USA
Pablo Gonzalez Isaza MD
Division of Urogynecology and Pelvic
Reconstructive Surgery
Department of Obstetrics and Gynecology Hospital Universitario San Jorge, Pereira, Colombia
Michael P. Goodman
Caring for Women Wellness Center, Davis, CA, USA
Sarah L. Jutrzonka PhD
Pacific Graduate School of Psychology
Palo Alto University, Palo Alto, CA, USA
Gustavo Leibaschoff MD
General Secretary, World Society of Cosmetic Gynecology
President, International Union of Lipoplasty
Dallas, TX, USA
David Matlock MD, MBA, FACOG
Medical Director
Laser Vaginal Rejuvenation Institute of America
Co-Medical Director, Laser Vaginal Rejuvenation Institute of Los Angeles, Los Angeles, CA, USA
John R. Miklos MD, FACOG, FACS, FPMRS
Director, Urogynecology
International Urogynecology Associates of Atlanta and Beverly Hills
Adjunct Professor of Obstetrics and Gynecology Emory University
Atlanta, GA, USA
Vaginal Rejuvenation Center of Atlanta
Atlanta Medical Research, Inc.
Alpharetta (Atlanta), GA, USA
Robert D. Moore DO, FACOG, FACS, FPMRS
Director, Advanced Pelvic Surgery
International Urogynecological Associates of Atlanta and Beverly Hills
Adjunct Professor of Obstetrics and Gynecology, Emory University
Atlanta, GA, USA
Vaginal Rejuvenation Center of Atlanta
Atlanta Medical Research, Inc.
Alpharetta (Atlanta), GA, USA
Otto J. Placik MD, FACS
Assistant Professor of Clinical Surgery (Plastic)
Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Principal Investigator, DeNova Research
Chicago, IL, USA
Dudley Robinson MD, FRCOG
Consultant Urogynaecologist and Honorary Senior Lecturer
Department of Urogynaecology
King’s College Hospital
London, UK
Alex Simopoulos
MD, FACOG
FPA Women’s Health
Los Angeles, CA, USA
Bernard H. Stern
MD, FACOG
Aesthetic Plastic Surgery International
Alexandria, VA, USA
Aventura Center for Cosmetic Surgery
Elite Plastic Surgery
Aventura FL, USA
Baftis Plastic Surgery
Jupiter, FL, USA
A women has the opportunity to request alteration of her vulva and/or vagina for a variety of reasons. Clinicians in the office hear of cosmetic and self-esteem rationale, as well as functional complaints. Regarding the vulva, distress with the appearance of “flaps” or “elephant ears” or other protrusions beyond the labia majora; self-consciousness; and distress over potential prominence or slippage of hypertrophic labia from beyond the confines of thong-type undergarments or swimwear predominate on websites, blogs, and office commentary. Discomfort (“chafing”) with sports, sexual, and other activities; discomfort with tight clothing; necessity to “re-arrange” the labia for sexual intimacy; and hygienic difficulties predominate functional complaints heard in the office. Redundant labia majora are described as “droopy,” or the patient dismays over the appearance of “camel toe.”
Sexual issues dominate pelvic floor complaints in women inquiring about a vaginal tightening procedure. They describe a “sensation of wide/smooth vagina” (a term popularized by Jack Pardo S. from Chile and Adam Ostrzenski from the United States) with secondary diminishment of friction, less sensation, and greater difficulty achieving orgasm, at times concomitant with displeasure regarding the visual appearance of the introitus.
Size-reducing labia minoraplasty and/or majoraplasty (LP-m; LP-M), size reduction of redundant clitoral hood folds (RCH), posterior colporrhaphy/perineoplasty (PP), and anterior colporrhaphy/vaginoplasty (VP), the latter two colloquially termed “vaginal rejuvenation” (VRJ), are increasingly common women’s cosmetic genital surgical procedures and have been subject to scrutiny both in the press and by investigators and editorialists. Another genital plastic procedure, hymenoplasty (HP), is usually performed for religious and cultural reasons, although occasionally requested as a “gift” for one’s sexual partner.
In this text, the first to concentrate on plastic and cosmetic procedures specifically designed for elective comfort, self-esteem, and sexuality reasons, the procedures themselves, their rationale and risks, what is presently known regarding outcome, ethical considerations, and psychosexual considerations are discussed. The importance of proper and adequate surgical and sexual medicine training for surgeons is emphasized, along with the specific anatomic adjustments and psychosexual outcomes produced by these procedures.
The specific surgical procedures are defined and described. The importance of proper patient selection and preparation and adequate patient protection are reviewed, along with reminders of the intensely sexual nature of this work and the importance of counseling patients regarding their personal normality, while at the same time acknowledging their right to seek reconstruction.
Above all, this text hopes to familiarize the gynecologic, the plastic and reconstructive, and the cosmetic surgeon with a crucially important area of a woman’s body, the intensity of her concentration and concern about the appearance and function of the area, and the availability and potential pitfalls of methods, predominantly surgical at this time, designed to meet her stated goals. We, your editor, associate editors, and contributors, intend to help raise your awareness of the issue and begin to explore the territories entered with an understanding of women’s body image, feelings about their genitalia, and surgical and non-surgical options to safely and effectively achieve personal goals.
First and foremost, I wish to acknowledge Drs. Marco Pelosi II and III and Dr. Red Alinsod. The vision, perseverance, and educational efforts of these friends have resulted in the education and training of hundreds of genital plastic and cosmetic surgeons who are far more likely to accomplish success rather than failure for their patients. They are fine surgeons and educators.
Of course I am indebted to each and every one of the authors and associate editors (especially my friend Dr. Otto Placik) who have worked their behinds off on this project, and without whose efforts this unique book would not be before you. I am personally indebted to Dr. Gary Alter, from whose 1998 publication I initially learned the labiaplasty technique of modified V-wedge, and Dr. David Matlock, from whom a few years later I learned proper technique for curvilinear resection, and who has carefully trained hundreds of genital plastic/cosmetic surgeons. They are pioneers in the field.
Martin Sugden, publisher of the Scientific Textbook Division at Wiley, is my mentor in this book, Pri Gibbons and Jasmine Chang is my editor and Radjan Lourde Selvanadin is the project manager. They both have worked “above and beyond.” An author could not ask for a more knowledgeable, flexible, and easy to work with pair of professionals.
I offer my thanks to my family, my friends, especially my son, Sam, from whom I was aloof during the full-term gestation of this project. They all hope this is the termination of my writing—at least for a while!
I thank my professional, empathetic, kind, and flexible office staff. Nicole Sanders is our patient care coordinator, office manager, and first assistant. Raechel Davis is our receptionist and first assistant. Elise Eisele and Heather Kochner were our surgical nurses during this text’s gestation. There is absolutely no way I could practice genital plastic surgery without this crew!
And last, but certainly not least, I wish to thank my patients. These intrepid and trusting (!!) souls, women on a mission, wonderfully weave through this text, which would not exist without them.
Michael P. Goodman
Caring for Women Wellness Center, Davis, CA, USA
The time is the time. After the time is sometimes the time. Before the time is never the time.
Francois Sagan
Female genital plastic/cosmetic surgery (FGPS), aka female cosmetic genital surgery (FCGS), vulvovaginal aesthetic surgery (VVAS), aesthetic (vulvo)vaginal surgery (AVS), or cosmeto-plastic gynecology (CPG), has mounted the stage of twentieth-century cosmesis. Adding in the promise of improvement in sexual function makes for an intriguing debut.
As this elective plastic/cosmetic surgical discipline, like many novel surgical and medical disciplines, traces its genesis to a community rather than academic setting, the succession of different but related names have mirrored the semantic directions of individuals and subspecialty organizations. Although any of the terms noted above will do, for the purposes of this textbook the quite descriptive term FGPS will be utilized.
As women become more comfortable with the idea of elective procedures on their faces, breasts, skin, and so forth designed to enhance their appearance and self-confidence, it is not surprising that they may wish to alter, change, “rejuvenate,” or reconstruct even more intimate areas of their bodies [1].
Although surgeons for years have unofficially performed surgical procedures resulting in alterations in genital size, appearance, and function (labial size alteration, perineorrhaphy, anterior/posterior colporrhaphy, intersex and transsexual surgical procedures, and alterations on children and adolescents for benign enlargements of the labia minora), Honore and O’Hara in 1978 [2], Hodgekinson and Hait in 1984 [3], and Chavis, LaFeria, and Niccolini in 1989 [4] were the first to discuss genital surgical alterations performed on adults for purely aesthetic reasons. While there are at present no accurate and ongoing published statistics from either the American Society of Plastic Surgeons, American Academy of Cosmetic Surgeons, or American College of Obstetricians and Gynecologists, it has become apparent in the lay press that aesthetic surgery of the vulva and vagina is gaining significantly in popularity. As far back as 2004, Dr. V. Leroy Young, chair of the emerging trends task force of the Arlington Heights, Illinois, American Society of Plastic Surgeons, commented in a personal communication that he felt that “labiaplasty and vaginal cosmetic surgery are the fastest growing emerging growth trend in cosmetic plastic surgery.”
Aesthetic surgery of the vulva and vagina has heretofore not been officially described as such, nor “sanctioned” by specialty organizations, as they are community rather than university or academically driven. The operations themselves, however, are really not new; the only new thing is the concept that women may individually wish to alter their external genitalia for appearance or functional reasons, or tighten the vaginal barrel to enhance their sexual pleasure. However, since any surgery has potential for causing morbidity including pain and distress (both physical and psychological) if not performed properly, and especially since FGPS involves concepts and procedures that are not yet fully researched nor understood, guidelines for training, surgical technique, and patient selection should be discussed.
This textbook will give an overview of the most commonly performed procedures: labiaplasty of the minora and majora (LP-m; LP-M), size reduction of redundant clitoral hood epithelium (RCH), clitoral hood exposure for symptomatic phimosis (RCH-p), perineoplasty (PP), vaginoplasty (VP), colpoperineoplasty (CP; a combination of VP and PP), and hymenoplasty (HP), and will discuss rationale for surgery, ethical issues, patient expectations, patient selection and patient protection, complications, training issues, psychosexual issues, the procedures themselves, and all presently available outcome data. “Vaginal rejuvenation” (VRJ), a slippery and colloquial—although frequently used—term used to mean elective VP, PP, and/or CP (and for some, even LP) will be discussed.
First performed by community gynecologists or plastic surgeons in response to occasional patient requests in the mid-/late 1990s and early 2000s, by the mid-2000s the alternative of surgical alteration or reconstruction for “enlarged” labia/clitoral hood, and vaginal operations geared primarily to a goal of tightening for reasons of enhancement of sexual satisfaction, became more widely available and a subject of comment, blog, search, and consultation.
Although certainly the vulva and vagina are areas under the purview of gynecology and gynecologic training, virtually no training is offered in OB/GYN residencies in plastic technique, cosmetic labiaplasty, or pelvic floor surgery designed specifically for enhancement of female sexual pleasure (see Chapter 21). With the subject adequately addressed by only a portion of plastic surgery residencies (and in these, usually LP/RCH only), an individual patient finds herself on her own when endeavoring to navigate a path to successful reconstruction. With little guidance from specialty or regulatory agencies, “caveat emptor” became the rule, and un- or undertrained surgeons began performing these plastic procedures, frequently with less-than-optimal, and occasionally disastrous, results.
A textbook cannot substitute for a teaching program, observation of proper technique, and actual performance of procedures with expert proctoring. However, this text will point the way and provide guidance toward those ends. It is designed to be a complete teaching guide to be used concomitantly with a hands-on teaching program, designed to develop competency leading to proficiency for female patients putting their trust in the hands of their gynecologic, plastic, or cosmetic surgeon. It is intended to educate the uninitiated and point the way toward the goal of comfort working with—psychologically, sexually, physiologically, and surgically—women who desire a guide to help them achieve their cosmetic, functional, sexual, and psychological goals.