2. Female Genital Cosmetic Surgery(FGCS)
Dr Mansooreh Yaraghi
Fellowship of pelvic floor
TEHRAN UNIVERSITY

3. The Rise of Consumer Demand in Gynecological Practice
• Increased access to information • Society becoming more egalitarian • Delivery of healthcare becoming partnership between patient-consumer’s ‘wishes’ and doctors ‘professional opinion’

4. The Rise of Consumer Demand in Gynecological Practice
• Most gynecological disorders are not lethal • Impact on Quality of Life • ‘Bothersomeness’ of a condition is perceived by patient within their own psychosocial context • May be different from ‘doctor-centered’ view of condition

5. Searches Professional vs Popular
‘designer vagina’
<100 items found
‘laser labiaplasty’
33 items found
>1,600,000 items found
376,000 items found

6. ‘Pornification’ drives rise in genital surgery
• Increased access to pornography • Altering perceptions as to ‘normality’ • Desire to emulate what is perceived as being ‘attractive’ • Consumer demand : Women or Men?
The Observer, March 2011

7. Factors That Influence the Decision to Undergo Labiaplasty
Women seeking to undergo labiaplasty (n = 35) were compared with women who were not (n = 30)
Standardized measures : media exposure (television, the Internet, advertising, pornography), relationship quality, and psychological well-being
The findings identified media exposure and relationship status as important factors that influence women’s decisions to undergo labiaplasty
Gemma Sharp, MSc; 2016

8. Evidence vs. Consumer Demand
• No reliable evidence on cosmetic gynecological surgery to guide management

9. Research Based Evidence on Pelvic Floor Dysfunction
• Observational not interventional • Subjective • No randomization • ‘doctor-orientated’ outcomes • Different grading systems used • ‘patient-centered’ Quality of life measures rarely assessed

10. Despite This, Public Interest in This Type of Surgery Is Increasing

11. The Rise of Consumer Demand in Gynaecological Practice
70% increase in the number of women requesting labiaplasty in NHS
404 procedures in 2006
1118 procedures in 2008
Liao et al, 2009
More than 5000 enquiries regarding cosmetic genital surgery in 2010
65% for labial reduction
35% for tightening and reshaping
Harley Medical Group

12. Why do women seek cosmetic surgery?
Retrospective review of 131 patients over 27 months
Aesthetic Reasons 37%
Functional Reasons 32%
Aesthetic and Functional Reasons 31%
Miklos and Moore 2008

13. Why Women Request Labiaplasty
Prospective 50 patient
Questionnaire assessing 11 physical and appearance related symptoms
Mean age 33.5 years (range, 17 to 51 years)
Most patients requesting labiaplasty experience both physical and appearance-related symptoms
Sarah C. Sorice 2017

14. What Is The “Normal” Anatomy of the Vagina and Vulva?
• 50 nulliparous premenopausal women having
procedure not involving the external genitalia
• Measured :
Clitoral size
Labial length / width
Color
Rugosity
TVL
Perineal length
• Found enormous natural variation in topographical features
Lloyd et al 2005

15. Wide natural variation in all these features
Range Mean
Clitoral length (mm)
Clitoris to urethra (mm)
Labia minora length (mm)
Labia minora width (mm)
Perineum length (mm)
Vaginal length (cm)
Rugosity of labia(n) Smooth 14
Moderate 34
Marked 2
Lloyd et al 2005

16. The Great Wall of Vagina – Jamie McCartney 2010

17. shape of the vagina
• 3 studies explore the shape of the vagina when filled with dental putty • 5 distinct vaginal shapes:“Parallel sides”, “conical”, “heart shape”, “pumpkin seed ” , and “slug” • Again found wide variation in length and width • Comparing women with and without children: much larger variation between individuals than between groups
Pendergrass et al 1996, 2000, 2003

18. Female Sexual Function
Desire may be early stage of arousal, triggered by sexual stimulus, modified by situational variables
Sexual
desire
Emotional
intimacy
Sexual response cycle
(Positive Reinforcement)
Emotional
and physical
satisfaction
Sexual
arousal
Sexual
stimuli
Janssen et al 2000

19. Vaginal Anatomy and Sexual Function
• 104 women
routine gynecological check-up, average age 55.8
• Sexual function questionnaire and measurement of vaginal length and caliber
73/104 sexually active
• Vaginal anatomy no different between women
not sexually active, active with no sexual
difficulties, active with sexual difficulties
Weber et al. 1997

20. Cosmetic Vaginal Surgery
LASER VAGINAL REJUVENATION®
Laser Vaginal Rejuvenation:
Enhancement of sexual gratification
Correction of stress urinary incontinence

21. Cosmetic Vaginal Surgery
DESIGNER VAGINOPLASTY
Reduction Labiaplasty
Aesthetic Reconstruction and Enhancement of the Vulvar structures
Perineoplasty
Hymenoplasty
Aesthetic Augmentation Labioplasty
Liposculpturing

22. Claims Made for Cosmetic Vaginal Surgery
Enhanced aesthetic appearance(Aesthetic Genital Surgery): Possibly
Increased sexual gratification : ????????

23. Labioplasty • first described in 3 case reports
Hodgkinson and Hait, 1984
• Series of 163 labioplasties reported (12-67 yrs)
89% satisfied with aesthetic result
93% satisfied with functional outcome
Rouzier et al, 2000
• 55 Laser Labioplasty described (10 – 55yrs)
91% very satisfied 9% satisfied
Pardo et al, 2006

24. labial surgery
• Review of labial surgery for well women • 1950 – 2009 • 40 published articles; 18 including patient data • No prospective randomized or controlled trials • All claimed high success and patient satisfaction • No data on clinical effectiveness
Liao et al, 2009

25. The Safety of Aesthetic Labiaplasty
Retrospective chart review
Edge excision technique
August 2007 to April 2014
113 patients
15 patients (13.3%) reported transient symptoms, including swelling, bruising, and pain
No major complications
A very low complication rate
Frank Lista 2015

26. Psychological Outcomes of Labiaplasty
Retrospective,48 adult women
3 and 204 months prior
Most women were very satisfied with their labial appearance and function after surgery at the time of completing the questionnaire compared to their recalled levels prior to surgery
Statistically significant increases in their:
Genital appearance satisfaction
Sexual satisfaction
Psychological well-being

27. The Impact of Labiaplasty on Sexuality
24 consecutive sexually active patients
divided into two groups of 12 patients each
No significant differences in Rosenberg Self-Esteem scale or Medical Outcomes Study 36-Item Short Form Health Survey score were found in either group
Significant improvement was found in the Female Sexual Function Questionnaire total score in the pain and enjoyment domains
Labiaplasty had a positive impact on sexual functioning
Tatiana Turini,2018

28. Evaluation of Body Image and Sexual Satisfaction
Prospective cohort case-controlled study of 120 subjects
Evaluated at baseline, 6, 12, and 24 months postoperative, paired with a demographically similar control group
Interventions :
labiaplasty, clitoral hood reduction, and/or aesthetic vaginal tightening, dened as perineoplasty + “vaginoplasty”
Outcome :
body image, genital self-image, sexual satisfaction, and body esteem
FGPS appears to provide sexual and genital self-image improvement
Michael P. Goodman, 2016

29. Labia minora reduction techniques
literature review
The search returned 247 articles(19 articles were selected)
1949 patients
Seven different surgical techniques were used for labiaplasty
Patient satisfaction rates for each technique ranged from 94 to 100 %
Most common postoperative complication for all techniques was wound dehiscence (4.7 %)
Labiaplasty is safe and carries a high satisfaction rate
ORANGES CM 2015

30. Vaginal Laxity Common Complaints
• Discomfort and symptoms of prolapsed • Tampons fall out • Lack of friction during intercourse • Penis falls out during intercourse • Vaginal wind • Bathwater entrapment

31. Vaginal Laxity How should It Be Managed ?
• Evaluate symptoms – patient perspective
• Consider function of all 3 pelvic compartments
• Sexual dysfunction ?
• QoL
• Hormonal status
• Family complete?
• Examination with prolapsed grading
• life-style
• General Aims
Relieve symptoms
Maintain or restore bladder/bowel function
Maintain (or improve) sexual function

32. Urogenital Prolapse Surgical Approach
Should only be considered after failure of conservative measures
After full discussion and counseling
when family is complete
Limitations and benefits of surgery should be
discussed
Risk of dyspareunia

33. Genital Plastic Surgery
• Retrospective cross-sectional North American
• 12 centers ; 258 women; 341 procedures
104 labial reductions
34 clitoral hood reductions
49 combined labial/clitoral hood reductions
47 vaginoplasties / perineoplasties
34 combined procedures
• Reasons for procedure(functional or to look better)
• Sexual function
• Satisfaction rates (83-97%)
Goodman et al, 2009

34. Conclusions Vaginal rejuvenation", "designer vaginoplasty",
"revirgination", and "G-spot amplification" are vaginal
surgical procedures offered by some practitioners
• These procedures are not medically indicated, and the safety and effectiveness of these procedures has not been documented
ACOG Committee Opinion, 2007

35. Conclusions
• Women should be informed about the lack of data and their potential complications
Evaluate for sexual dysfunction all women requesting FGCS to improve sexual functioning and consider other non-surgical interventions
Consider ethical issues associated with the marketing and franchising of FGCS
ACOG Committee Opinion, 2007

36. ACOG Committee Opinion, 2016
Conclusions
Recommendations regarding labial surgery in adolescents:
The obstetrician–gynecologist caring for adolescents should have good working knowledge of nonsurgical alternatives for comfort and appearance as well as knowledge of indications and timing of surgical intervention and referral
When adolescents seek medical treatment, the first step is often education and reassurance regarding normal variation in anatomy, growth, and development.
ACOG Committee Opinion, 2016

37. ACOG Committee Opinion, 2016
Conclusions
Appropriate patient counseling and assessment of the adolescent’s physical maturity and emotional readiness are necessary before surgical management or referral.
Individuals should be screened for body dysmorphic disorder. If an obstetrician–gynecologist suspects an adolescent has body dysmorphic disorder, referral to a mental health professional is appropriate..
ACOG Committee Opinion, 2016

38. Aesthetic Surgery Journal
Conclusions
Emphasize the importance of education, counseling, and appropriate surgical decision making with adolescent patients interested in genital cosmetic surgery
Christine A. Hamori, MD
Aesthetic Surgery Journal
2016

39. Aesthetic Surgery Journal
Conclusions
It is disappointing that the committee did not include more recent literature regarding safety and patient satisfaction with labiaplasty.
It is important that we as plastic surgeons consider these guidelines in order to safely evaluate and treat labia minora hypertrophy in this impressionable age group
Christine A. Hamori, MD
Aesthetic Surgery Journal
2016

40. Conclusions
Term “deformity” as a description of the labial length should perhaps be replaced with length variation
There already exists pressure from the media for women to achieve a prepubescent appearance with little or no labia minora
Variable labial length and asymmetry is normal female anatomy
we must be careful not to create a “gold standard” of ideal labial length and vulvar appearance

41. Conclusions
• Underlying desire for cosmetic genital surgery needs to be explored – it may be quite reasonable • Labiaplasty is the most commonly performed procedure • Main indications are functional and cosmetic • Important to recognize sexual problems as surgery may make them worse • There is little evidence to support surgical techniques and outcomes • Further research is required into all aspects of this type of surgery