The feminine mystique

Dr. ShambanEvolving attitudes about aesthetic treatment of the vulvar area are driving increased interest in female rejuvenative procedures, said experts who spoke at Cosmetic Boot Camp, held here.

The United States' first breast implant occurred in 1963, said Daniel L. Kapp, M.D., a plastic surgeon based in West Palm Beach, Florida. In 1966, the first American transgender operation – performed by his mentor's mentor, plastic surgeon Milton Edgerton Jr., M.D. – followed.

"So if you think you operating on genitalia is new in plastic surgery, it's actually one of the oldest things in plastic surgery," says Dr. Kapp.

Form and function

The reasons why plastic surgeons perform any aesthetic procedure is more basic than improving someone's appearance and self-esteem, he said.

"We're bringing self-esteem to our patients and improving their sexuality, so they'll be more successful in reproducing. It's a basic biologic function."

The first aesthetic labiaplasty publication appeared in 1984.¹ In 2007, the American College of Obstetricians and Gynecologists advocated against labiaplasty unless medically necessary. "They reiterated this position in 2008, 2012 and 2014,"² said Dr. Kapp. So when patients go to their OB/GYN with aesthetic concerns, he said, "They are told, 'we just operate on the vagina for medical problems.' They have nowhere else to turn," except for core aesthetic specialists.

In dermatology, said Beverly Hills-based dermatologist Ava Shamban, M.D., "There's been a big debate. Is this within the scope of our practice? Should this be the gynecologists' area? But it is tied up with self-esteem and skin health. It used to be dicey to talk about menopause. We've moved way beyond that in our culture – no area is out of bounds" for aesthetic or functional enhancement.

When the ThermiVa radiofrequency (RF) device (ThermiAesthetics) debuted, she said, "I wasn't going to go there." But talking – and especially listening – to her patients convinced her that such procedures are appropriate for dermatologists, said Dr. Shamban, whose patients must get clearance from their gynecologist before they can undergo treatment.

Her patients' concerns include loosening of the vaginal mucosa, loss of sensation, vaginal atrophy and dryness. Patients who have been treated for cancer cannot take estrogens, she said, and atrophy and dryness can make sex very uncomfortable for them. Patients also may suffer from stress incontinence or pelvic floor prolapse, she added.

Over the last three years, said Dr. Kapp, the number of labiaplasty procedures performed in the United States has increased fivefold. Driving factors range from advancements in facial aesthetics and body contouring to the near-ubiquity of pornography, he said.

"And the truth is, in plastic surgery, we've been doing vaginal surgery for a long time. Almost every time we do a tummy tuck, we do a monsplasty, elevating the mons to a normal anatomic location. Doing surgery such as labiaplasty is a natural progression."

Female genital surgery can involve repositioning or performing suction lipectomy on the mons.

"These are things we've always done,” says Dr. Kapp. “We move down below the Mons and look at the labia and clitoris. We can improve the exposure of the clitoris by reducing the clitoral hood, and tailoring the labia minora to get the 'Barbie' look."

Regarding the labia majora, he said, "As we get older, women lose fat in the labia majora. So we do fat grafting, or infrequently, resection of the labia majora. Vaginal tightening, perineoplasty, urinary incontinence – I leave that to my GYN colleagues."

A black patient in her mid-40s treated by Dr. Kapp told him in consultation that she and her husband disliked the appearance of her labia minora. From a surgeon's perspective, said Dr. Kapp, "The labia minora is like any other lip with any other dog ear – for a good outcome, resect and respect the vermilion border so it's a natural appearing vagina." For the patient in question, "We resected her excess labia minora and gave her a look she was very happy with. She felt good about herself. And by feeling good about herself, she felt good about her relationship with her husband. And that is why I do this operation – it's all about fulfilling our destiny." The procedure's over 90% satisfaction rate doesn't hurt either, he said.

Next: Nonsurgical treatments

Nonsurgical treatments

Nonsurgical options for vaginal reconstructive procedures include RF and laser devices. Although RF-based treatments have existed for decades, said Dr. Shamban, "Radiofrequency probably works best in the vaginal mucosa." RF devices for vaginal rejuvenation use the same operating range – raising the tissue temperature between 35° and 47°C – as RF equipment designed for use elsewhere. "And the ThermiVa is designed specifically for the area."

As on the face, Dr. Shamban said, heating vaginal tissue produces immediate collagen contraction and collagen remodeling, plus long-term stimulation of new collagen. The treatment also increases blood flow, she said.

Sexual arousal involves the same anatomy in men and women, said Dr. Shamban. While males get an erection, "Women literally sweat as increased blood and plasma flow sweats through the wall of the vagina." With ThermiVa, "You can get effective restoration of normal sexual function."

In photos from the device's pilot study, "You can see dramatic tightening of not only the labia minora, but also the labia majora. The super-Brazilian or no-hair look is in, so now those lips are visible too."

As with any radiofrequency treatment, "I do a series of three to six treatments and tell patients they must come in for maintenance two or three times yearly. No treatment that we do is 'one and done,' or even 'one series and you're done.'"

While RF treatment does not disrupt the vaginal tissue, said Dr. Shamban, fractionated laser treatment does, producing all the improvements one would expect based on the performance of other fractional ablative lasers: vaginal tightening, through ablation and a photothermolytic effect. Vaginal laser treatments also can improve vulvar pigment problems, she said, and address urinary incontinence very effectively.

The diVa laser (Sciton) combines 2940 nm erbium:YAG and 1470 nm diode lasers, which together both ablate and coagulate the vaginal mucosa, Dr. Shamban said. Placing a disposable cone-shaped protective shield (called a Strengthened Quartz Dilator) over the laser handpiece means that users need not clean or dispose of the device head after each application, as is the case with the ThermiVa device, she added.

"The laser is inserted all the way to the end of the introitus. Insert it all the way up to the cervix, and fire it as you withdraw the device," rotating the applicator while also monitoring the position of markings on the applicator to indicate where to stop firing the laser. "You stop firing the device close to the introitus. The protective shield is left in place. It's very precise."

Treating the entire introitus, including the G spot, as well as trying to lift up the urethra for people who have had multiple vaginal births, tightens the entire area safely, she said. "The nice thing is, you can't get too tight, which is one of the problems with surgical vaginal restoration (but not with the external labia minora treatments Dr. Kapp discussed)."

With the Petit Lady procedure, performed with the Action II fractional erbium:YAG laser (Lutronic), Dr. Shamban said, treating the external labia minora and majora requires a different treatment head than treating intravaginally. For external treatment, "You treat the entire area. And as you can imagine, this tissue is very sensitive to it." About two months after treatment, she said, patients experience visible thickening of the labia minora and majora.

Disclosures: Drs. Shamban and Kappa report no relevant financial interests.

References

1.  Hodgkinson DJ, Hait G. Aesthetic vaginal labioplasty.Plast Reconstr Surg. 1984;74(3):414-6.

2. American College of Obstetricians and Gynecologists. Committee on Gynecologic Practice. Committee Opinion #378: Vaginal "rejuvenation" and cosmetic vaginal procedures. September 2007; reaffirmed 2014. Http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Vaginal-Rejuvenation-and-Cosmetic-Vaginal-Procedures. Accessed January 13, 2017.