Surgical Vaginal Rejuvenation

Vaginal Rejuvenation

As we get older our bodies get worn, torn, stretched and some of our youthful resilience is reduced. The same happens to the vaginal tissues and pelvic floor, especially after pregnancy and childbirth, menopause and aging, or simply from increased abdominal pressure from excess weight or weight bearing over time.  The vaginal vault and pelvic floor are stretched, dilated, pelvic muscles become too relaxed, loose strength and tone, and you loose some or all support and control.  The vaginal vault becomes stretched and weakened and it looses the constricting effect during sexual intercourse.   As a result you no longer have the ability to contract, squeeze and relax your vaginal muscles at will.  The loose feeling that many women feel can be noticed even more by their male partner during sexual intercourse.

Vaginoplasty is an elective surgical procedure that makes the vagina tighter and pelvic floor stronger by bringing together stretched surrounding soft tissues and then removing excess vaginal skin.  Vaginal Rejuvenation is the lay term that refers to the same posterior reconstruction of the vaginal vault and perineum.  The terms are interchangeable.  Another popular term, “Laser Vaginal Rejuvenation (LVR)™ is doing the same exact surgery by using a 980 Diode laser as a knife or cutting instrument.  “Laser Vaginal Rejuvenation” does not shrink the inner vaginal tissues by using a laser as many have been led to believe.  Vaginoplasty typically tightens the vaginal muscles and strengthens the pelvic floors, resulting in greater contraction strength and control, increased frictional forces, thereby enhancing the sexual experience for the man and the women.

The surgery is a modification of a standard gynecologic vaginal procedure where the vaginal vault and pelvic floor are made smaller, and the foundation muscles of the vagina are made stronger. The G-spot, which many believe lies in the anterior proximal vagina, is not affected by this procedure. Also at this time other problems that can result in painful sex can be corrected.  For example, some patients may have a cystocele, rectocele, or enterocele (which are hernias of the bladder, rectum, or bowel respectively) in the vagina which may protrude out the vaginal opening. During vaginoplasty these hernias can be repaired, the pain eliminated, and satisfaction during intercourse restored.  Vaginoplasty can give your vagina a youthful appearance, give you more control of your vaginal muscles, and greatly increase the sexual satisfaction for you and your partner during intercourse.

Labiaplasty refers to the trimming of labia minora or labia majora, more commonly known as the inner and outer lips of the vagina. Some women have very long, unequal labia minora which may be bothersome or may interfere with sexual activity. At times the unsightly appearance of the excess skin causes personal distress that results in the loss of sexual desire for both partners. Women who have this excessive skin are often embarrassed and hesitant to speak of the problem or seek help.

Vaginoplasty and labiaplasty can be performed in the office using gentle sedation and local anesthetics without IVs having to be placed.  Vaginoplasty takes about 1-2 hours to complete.  Labiaplasty takes a similar amount of time to finish.  Both can be done at the same time.

What is the difference between Labiaplasty and Vaginal Rejuvenation?

Many people ask this very common question. Even established doctors have a hard time differentiating between the two surgeries.  It is actually quite simple if you think of what you see and what you don’t see.

First, what you see in a woman’s genital area is called the “vulva.”  This includes the clitoris, inner smaller lips (labia minora), larger outer lips (labia majora), and the perineum (space between the vaginal opening and the anus).  Some even include the anal area, inner thighs, and the fat pad above the pubic bone as part of the vulva since it is visible.  This is the visible genital your own eyes without the aid of retractors, microscopes, or other devices.  This is the area where labiaplasty surgery is done.  Specifically, labiaplasty usually involves the surgical trimming, reduction, or re-sculpting of the smaller inner lips.  However, it can also refer to the surgical procedure to reduce the saggy skin of the larger outer lips.  Together, the inner and outer lips are called the labia, hence labiaplasty or labioplasty.  If there is a flap of excess skin on the sides or on top of the clitoris that is large and floppy, pulls, or is constantly irritated then a clitoral hood reduction (also called prepuce reduction) is often done as part of the labiaplasty surgery.  If the clitoris is buried resulting in reduced sensitivity, surgery to expose the clitoris more is often referred to as “hoodoplasty.”

Next, what is not visible is inside of the vagina.  This is the canal where tampons are placed, where babies pass through, where vibrators are placed internally.  This is the inside of the vagina that is stretched over ten times its normal size when a baby passes though the birth canal.  Even with a C-Section this inside space of the vagina can be severely stretched.  When this happens, the walls of the vagina become loose and saggy on the invisible inside.  This is the area where vaginoplasty surgery is done.  Specifically, vaginoplasty usually involves the surgical tightening of the unseen vaginal tissues to narrow its size by both suturing together inner deeper tissues and trimming more inner superficial vaginal skin.  When surgery is done on the space in between the vagina and the anus it is called a perineoplasty or perineorrhaphy.  This is if there is a bulging structure in this space or if a prior delivery tore up the appearance of this region.  Prior tears or episiotomies are the most common cause of looseness in this entry point into the vagina.

Plastic surgeons do their vaginoplasty surgeries more in a perineoplasty manner.  During a plastic surgeon’s residency program, and even in their fellowship programs, most will only get a couple of months of surgical time with the gynecology department.  During these two-months the plastic surgery resident typically assists the gynecology resident or fellow doing the vaginal surgery.  The only other time most plastic surgeons get any vaginal surgery experience is during their two to three month rotations as medical students in the obstetrics wards.  During this time, they may get a few deliveries in which they repair superficial lacerations and tears in the perineum.  It is rare that the plastic surgeon will be given the responsibility of repairing deep damage since the anatomy is difficult and rips into rectum, bowel, or bladder may occur during the repairs.  In their gynecology training a medical student is never the primary surgeon doing deep pelvic repairs.  As a plastic surgery resident or fellow it is rare that they do the primary deep pelvic repairs since they have to battle with the gynecology resident or fellow for these precious learning experiences.  This usually means that a plastic surgeon advertising that they do vaginoplasty is really doing a perineoplasty and only tightening the opening into the vagina and doing little to no tightening of the deeper inner canal.  Most plastic surgeons who have learned how to do full length vaginoplasty surgery have learned this after their formal training years in residency or fellowship.  No plastic surgery training program have advanced to provide deep vaginal surgery training to their doctors as of 2017.  To be fair, most gynecologists have absolutely no training in cosmetic surgeries such as labiaplasty, breast implants, tummy tucks, and Brazilian Butt Lifts.  In fact only a very few gynecologists actually do these cosmetic procedures.  In almost all cases these skills were learned after graduating from their formal residencies and fellowships and were learned in seminars or as an “apprentice” to a plastic surgeon.  Few gynecologists are formally trained to do labiaplasty surgeries and even fewer plastic surgeons have the training to do them safely though that has changed somewhat in the past few years as acceptance has increased in cosmetic surgery and plastic surgery training programs.

What is Laser Vaginal Rejuvenation™

Laser Vaginal Rejuvenation™ (LVR™) is the aesthetic surgical enhancement of the vagina using laser and plastic surgery techniques. LVR™ improves the overall appearance of the vagina and enhances muscle tone, strength and control, which can give a woman a more satisfying sex life.  LVR™ is owned and created by David Matlock, M.D.

The medical names for the structures which can be adjusted are the labia minora, labia majora, mons pubis, perineum, introitus, hymen and clitoral hood. As with any other part of the body, some women may not be happy with the appearance of these structures, while other women may have noticed changes or damages due to childbirth and agind. Women may desire alteration to a different “look” or they may wish to have these structures returned to the way they were prior to childbirt. They may also find that since having children the vagina and introitus (the opening to the vagina) have become stretched and their enjoyment of sex is reduced due to reduced frictional forces. In vaginal relaxation syndrome or in vaginal laxity, the muscles and supporting tissues are have poor tone, strength and control. The internal and external width are increased and the muscles of the perineum (the area between the vagina and anus) are weak and poorly supported. Under these circumstances sexual gratification is reduced.  Surgery is often needed if non-surgical options fail.

Dr. Matlock’s experience and techniques as well as modifications introduced by Drs. Alinsod, Bader, Goodman and others, provide the ability for almost any vulvar or vaginal enhancement. The most common LVR™ procedures are:

  • Laser Vaginoplasty rejuvenates the vagina and vulva by enhancing vaginal muscle tone, strength and control. It effectively decreases the internal and external vaginal diameters as well as building up and strengthening the perineal body. This procedure is often combined with Laser Reduction Labioplasty. The 980 diode laser is used as a cutting instrument and not actually as an ablative laser to shrink skin and tissues. CO2 lasers and radiofrequency are often used when shrinkage is desired.
  • Laser Reduction Labioplasty can sculpture elongated or unequal labia minora (small inner lips of the vulva) according to a woman’s desires by again using the 980 dioed laser as a precise cutting instrument. Most women requesting this procedure tell us they do not want the small inner lips to project beyond the large outer lips. Our labioplasty techniques can also reconstruct conditions that are due to the aging process, childbirth or injury. Radiosurgical cutting devices like the Ellman Surgitron or Ellman Pelleve are also used for extreme precision labiaplasty surgery.
  • Laser Perineoplasty can rejuvenate the relaxed or aging perineum. The procedure can provide a youthful and aesthetically appealing vulva by using the 908 diode laser to cut and sculpt the vaginal opening the underlying tissues below it. Standard cautery and radiofrequency units can achieve similar results.
  • Hymenoplasty (reconstruction of the hymen) can repair or augment the hymen to restore it to its “virginal” state. Find a surgeon sensitive to the needs of women from all cultures who can embrace issues of cultural, social or religious reasons. Precision radiofrequency devices are the most precise tools to work in these small and delicate areas without fear of large lateral thermal burns.
  • Clitoral Hood Reduction is often requested by women who find that there is excess skin covering the clitoris, which interferes with stimulation of the clitoris during sexual intimacy. Removing some of this excess vulvar skin exposes the clitoris to stimulation during arousal and heightens pleasurable sensations. This is usually done at the same time as labiaplasty surgery to achieve balance to the vulvar appearance.

Laser Vaginal Rejuvenation (LVR™) combines several conventional gynecologic surgical procedures (anterior colporrhaphy, posterior colporrhaphy, perineorrhaphy) with elective labial surgery to achieve aesthetic and functional goals.   LVR™ refines these procedures by adding the elegance of the surgical laser combined with cosmetic surgical principles and techniques. Addition of radiofrequency devices for refinements and revision cases brings the entire arsenal of devices able to bring women results they are looking for.

Laser Vaginal Rejuvenation™ and radiosurgery are one to two hour outpatient surgical procedure that can be done in the office under local topical creams and anesthetics. There is rapid healing and resumption of daily activities in a short period of time.  In most cases walking and driving are permitted the next day after surgery. Normal exercise and activities are allowed at 6-8 weeks including sex.

What is a Perineoplasty?

What is the procedure:  Perineoplasty is surgery to correct defects in the space between the vaginal opening and the anal opening.  This area of tissue is called the perineum.  It is where most tearing and stretching occurs during childbirth and where episiotomies are cut.  The muscles involved/stretched/cut are the superficial transverse perinei, bulbocavernosus, and the anal sphincter.  These muscles and fascial tissues can be brought back together in a tighter fashion to provide tighter and more petite vaginal opening.  Many plastic and cosmetic surgeons who do vaginal tightening procedures actually are performing a perineoplasty when dealing only with external appearance of the vaginal opening (reduction in the gaping) and not performing a deeper full vaginal tightening, called a “vaginoplasty.”  Experienced vaginal surgeons who perform vaginal tightening surgery often do a combination of a perineoplasty and vaginoplasty together as a combination surgery.

Who needs to consider this procedure:  Those who have a great deal of loose and redundant tissue and skin in this area that may result in painful or irritating intercourse, those who have had tearing and stretching and damage during childbirth, and those who do not like the cosmetic appearance of the area can be helped with a perineoplasty.  It is also appropriate for those who have a bulge there that acts like a reservoir for stool and makes evacuation difficult and prolonged.  Patients who have to do push in this area or inside the vagina to aid stool to come out can benefit from a perineoplasty.  This pushing is called “splinting.”  Those who must reach into their anal canal to remove stool (digitation) may also benefit.

Benefits:  Cosmetic improvement and functional improvement.  This means bowel movements may be easier and normalized and physical bulges can be eliminated.  Excess skin removed may make the perineum both better looking and less irritating.  Both splinting and digitation can be resolved and not necessary.  A tighter vaginal opening can result in more friction and a more satisfying sexual experience.

Risks: Bleeding, infection, broken sutures, too tight a vagina, need for revision surgery, need for use of a dilator to get the vaginal opening to the right size.

Downside:  The tightening effect of a perineoplasty is only at the opening of the vagina and the entire length of the vagina is not achieved.  Those wanting a full length tightening of the vagina will need a vaginoplasty that goes 2-3x deeper into the vagina.

Recovery: 6-8 weeks for full recovery and normal sexual function

Costs:  $4,000 to $5,000

Summary:  Perineoplasty is often referred to by plastic and cosmetic surgeons as “vaginal rejuvenation” or vaginoplasty surgery.  However, in reality, is only the repair of the tissues between the vaginal opening and the anal opening, the space where vaginal tears and episiotomies are made.  It is tightening of the opening to the vagina and not the actual deep vagina itself.  In many instances this is acceptable when the only worry the patient has is the external appearance and the internal tightness is not affected.  However, for those who want a full length vaginal tightening, a more appropriate surgery is vaginoplasty, a full length vaginal repair.  Perineoplasty takes about an hour to perform under local anesthesia and healing takes about 6 weeks.  In most instances, perineoplasty is combined with vaginoplasty for a full vaginal reconstruction that aims to improve both appearance and function.

Clitoral Hood Reduction

What is the procedure:  Removal of excess and redundant skin that covers the clitoris.  Most are done by surgically reducing the amount of skin on the lateral (side) portions of the clitoral hood.  Some surgeons also perform vertical clitoral hood reductions by removing segments of the clitoral hood and suture them in the middle

Who needs to consider this procedure:  Those who have labiaplasty may want to have this done to obtain balance and symmetry and prevent a “Top Heavy” appearance after  a labia minoraplasty.  This procedure can also be performed for those with lack of clitoral sensitivity if their clitoris is buried deep inside the clitoral hood.  Those born with a wide clitoral hood or with redundant and loose skin may want a cosmetic improvement by reduction of the clitoral hood.

Benefits:  Improved appearance, increased comfort, increased clitoral stimulation.

Risks:  Bleeding, infection, removing too much skin, exposure of the clitoral bulb that results in short term or long-term hypersensitivity.  Some will need revision surgery.

Downside:  Only the superficial skin is reduced and the clitoral nerves and vessels are not touched.  Inadvertent damage to blood vessels and nerves can occur but it is exceptionally rare when surgery is done by an experienced and high volume vaginal surgeon.

Recovery: 6-8 weeks for full recovery and normal sexual function

Costs: $2,500 to $3,000

Summary:  Loose or redundant skin on the sides and above the clitoris often causes the clitoris to look enlarged or uneven. Exposure to estrogen and testosterone can affect the way the clitoral area appears. Simple genetics is the main factor or how the clitoral hood area appears.  Labial surgery may result in the appearance of a relatively larger clitoral area because labial removal draws the eyes to the clitoral region that then looks larger now that the lower labial tissues are smaller. Dr. Alinsod improves this imbalance in the  genital area by excising the extra folds of skin lateral to the clitoris. The clitoris itself and its nerves are left alone. This is NOT clitoral mutilation or clitoral un-hooding. For those with a buried clitoris and lack of clitoral sensitivity there is a different “hoodoplasty” procedure that can reduce the coverage of the clitoral bulb.  Clitoral Hood Reduction is done in the office comfortably awake. It takes 30 minutes to perform.

Procedures of Aesthetic Vulvovaginal Surgery

 

Pelvic Organ Prolapse: What is it?  What is is associated with?

The incidence of pelvic organ prolapse (falling down of various anatomic structures in the pelvis and out towards the vagina) has been rising with the baby boomer population approaching middle and menopausal ages.  Typical symptoms of pelvic organ prolapse include pelvic pressure and heaviness, a feeling of constant fullness in the vagina, rectum, and pelvis.  Patients complain of more urinary urgency and frequency and leaking with activities.  Running, coughing, laughing, and exercise are more uncomfortable due to the heavy feeling and leaky bladder.  There is more “toilet mapping” and awareness of where all the toilets are.  Preventive urination and defecation is done before leaving the house or taking a car ride.  Patients will also complain that there is less friction during sex, that vaginal tissues feel spongy, that there is less muscle strength and control with squeezing and Kegels exercises.  Unfortunately, many primary care physicians fail to make a diagnosis and fail to even examine women with these symptoms.  A referral is typically made to a gynecologists who examines the patient and diagnosis the presence of pelvic organ prolapse and loss of structural support of the bladder, rectum, small bowel, uterus and urethra.  Studies may be requested such as a pelvic ultrasound or urodynamic studies (“bladder studies”) and even defecography (“bowel student studies”) to evaluate the extent and degree of impairment.  Once a diagnosis is made the decision can then be made for treatment or no treatment, lifestyle changes, non-surgical to surgical management.  Below is a listing of common procedures that may be recommended once pelvic organ prolapse is diagnosed.

 

Cystocele Repair

A cystocele, often referred to as a “fallen bladder,” is when the bladder falls down and often becomes palpable and visible like a golf ball starting to protrude from the vagina. Urinary leakage often accompanies a cystocele. Cystoceles may cause pelvic pressure and heaviness or just be unsightly. Cystocele repair (also called Anterior Repair or Anterior Colporrhaphy) is the surgical reduction of the bulge to place the bladder back into its normal anatomic position. This is typically an outpatient surgery covered by insurance.  The traditional repair of plicating or overlapping or bunching up tissues with suture has a high failure rate ranging from 25 to 60 percent. It is certainly one of the most challenging surgeries gynecologists, urologists, and urogynecologists perform. More modern surgery treats cystoceles as a hernia of the bladder into the vagina, hence, the use of mesh or donor tissues as a patch or graft has gained steady acceptance for bladder repairs though more recent legal issues have reduced augmented repairs in general. With augmented repairs the failure rates can be as low as 5-10% but the complication rates do go up with more exposure of mesh or biologic material and more pelvic pain and painful sex that can occur.  In general, most surgeons will do a standard anterior repair or modify it as a primary procedure and only use graft material for severe cases or failed prior surgeries.  It is widely accepted and shown in review of clinical studies that for cystoceles the augmented repair is more durable and with a higher chance of long term cure.  A highly skilled, high volume, and proficient surgeon should be doing the augmented repairs to reduce the complication rates.  Cystocele repairs takes about 30-60 minutes to perform and is usually in an outpatient setting.  If surgery is not wanted by the patient radiofrequency shrinkage of tissues can be offered to shrink the mild to moderate cystoceles enough to reduce symptoms.

Urethrocele Repair

The urethra is the tube that empties the bladder and where urine passes as it leaks out. The urethra is where you see urine coming out. The urethra may fall down just like the bladder does. This can result in leakage of urine when one coughs, laughs, jumps, or bends down. Repair of this organ requires a skilled vaginal surgeon to plicate tissues below it or place a mesh underneath for support to stop the leakage of urine. Many women have asymptomatic urethroceles. No surgery is needed in these asymptomatic patients.  It is often difficult to tell a urethrocele from a full cystocele falling out.  Both are repaired at the time of surgery.  Both can be shrunk with radio waves if no surgery is wanted.

Rectocele Repair

When the bulge into the vagina comes from the rectum it is called a rectocele or fallen rectum.  This is a hernia of rectal tissue protruding into the vagina from the floor of the vagina. As with other forms of pelvic organ prolapse (cystoceles, enteroceles, vaginal prolapse) childbirth, chronic cough, chronic constipation, and obesity are predisposing factors. Furthermore, the need of reaching into the vagina to push stool out is not uncommon. Symptoms are similar to cystoceles such as pelvic pressure, an unsightly bulge in the vagina, and constipation. It is difficult to make a diagnosis of cystocele versus rectocele versus enterocele based on history alone and a pelvic exam is recommended.  Surgical repair consists of using sutures to bunch up and plicate the bulging tissues together.  Plication of the levator muscles (levatorplasty) can also be done giving a tighter vagina during the process.  Levatorplasty is an accepted procedure with excellent results but with more pelvic discomfort post op.  The pain and pressure from a levatorplasty lasts approximately one month then goes away.  More modern repair consists of the use of mesh or donor tissues but this practice has also diminished and not augmented repairs of rectoceles is uncommon and not generally warranted.  Mesh and biologic repairs for failed prior rectocele surgeries is controversial. Its failure rate is about 1-5%.  Standard rectocele repairs have a failure rate of about 20%.  Levatorplasty has a failure rate of less than 5% in trained hands.  Rectocele repairs are outpatient surgery that take about 30-60 minutes to complete.  If surgery is not wanted by the patient radiofrequency shrinkage of tissues can be offered to shrink the mild to moderate rectoceles for symptoms reduction.

 

Enterocele Repair

A bulge caused by small bowel pushing the vaginal tissues from the top (apex) of the vagina. This is called an enterocele. It is difficult to diagnose and often is seen at the time of surgery when small bowel appears and pushes outwards.  Enteroceles can occur at the same time as a cystocele and a rectocele. In fact, we often cannot tell what is causing the bulge in the vagina whether it is bladder, rectum, or bowel, or all! Traditional repair has been to open and enter this sac, excise it, and then close the sac, then plicate tissues over this defect.  This procedure has a high failure rate down the line as enteroceles are sneaky and find a way to fall back down as they look for the weakest tissues and push on them again.  Modern repair uses mesh or donor tissue with excellent success found but with potentially more complication due to the mesh or biologic used. This repair is technically quite challenging and few are trained in the modern repair of this problem.  Radiofrequency shrinkage of enteroceles does not work well.

Vaginal Vault Suspension

A vagina that lost its support may come down and out into the open air. The degree of vaginal prolapse may vary from just having the top fall down a few centimeters to ones that completely go inside out, like a sock. If a woman still has her uterus then this is called a uterovaginal prolapse. If only the uterus falls out and the top of the vagina is still well suspended then it is called a uterine prolapse.

Vaginal vault suspension can be done in many ways. Some physicians prefer an abdominal approach to attach the top of the fallen vagina to the sacrum typically using a mesh. Some highly skilled surgeons do this laparoscopically. The procedure is called a sacralcolpopexy. More often a vaginal approach is performed. The top of the vagina can be sutured to the uterosacral ligaments or to the sacrospinous ligaments.  These ligaments are strong and can be quite supportive attachment sites. Either approach works well with different complications to consider.  Robotic laparoscopic surgery has had a huge influence on this particular diagnosis with more and more doctors getting trained for robotic repairs.  Robotic repairs of post hysterectomy vaginal vault prolapse with sacralcolpopexy is now a standard repair that competes with the vaginal sacrospinous ligament suspension and uterosacral suspensions.  If the uterus is still present the patient can choose to have a hysterectomy or have a uterine suspension performed.  Uterine suspension is an advanced surgery that can be done laparoscopically or vaginally and typically uses mesh that acts as a new pseudoligament to hold up the uterus.  The mesh is attached to the sides of the uterus, typically near the cervix or on the cervix itself, then secured into one of the strong ligaments on the sides of the pelvis.  Others will attach the uterus to a midline ligament on top of the sacrum.  The success rates of all methods are approximately the same at 80 – 90%.  These are typically outpatient surgeries.  Robotic surgeries take longer in general.  Duration of surgery can be 30 to 120 minutes depending on approach and ease of dissection.

Incontinence Sling

The surgical standard of care for stress incontinence (leakage of urine with an increase in the intraabdominal pressure such as laughing or coughing) involves the use of polypropylene, an inert nylon-type material, that is placed right under the mid urethra to act as a backboard when one sneezes or coughs to then occlude or block the urethral opening and either decrease of stop the leakage of urine.

These procedures are all called “Tension-Free” because the slings are not sutured into muscle, fascia, or bone and are just left alone for fibroblastto grow into and hold the mesh in place.  You may hear the term TVT or TOT or Mini Sling or Single Incision Sling. They refer to the route the slings are placed. TVT, or tension-free vaginal tape can be placed through an incision right above your pubic bone. TOT, or transobturator tape, is placed through incisions on the crease of your inner thighs. These incisions are just about invisible. Single Incision Slings or Mini Slings are usually placed through one midline anterior vaginal incision right below the urethra and dissected laterally towards the obturator region.  In simple terms, it is placed through an incision just below where the urine comes out of and are undetectable to the eye.  These procedures are outpatient surgeries of about 15 to 30 minutes in duration. The success rates vary from 80 to 95 percent.  They can be performed at the same time as bladder and rectal surgery.  For those not wanting surgery for leaky bladders there are options including pelvic floor physical therapy, home Kegel exercises, various vaginal devices (cones, balls, weights, electrostimulators, diode lasers) that can attempt to strengthen vaginal and urethral muscles for improved continence.  More recently, the use of radiofrequency, lasers, and platelet rich plasma have been used to improve the patient’s quality life while avoiding surgery.  Radiofrequency treatment shrinks the tissues supporting the urethra and also helps the muscle function better.  Non-surgical treatments are best for mild to moderate stress incontinence and overactive bladder symptoms and not as effective for the more severe problem called “Intrinsic Sphincter Deficiency” where the urethra may be rigid and “Stove Pipe” like with weak urethral sphincter muscles.

 

Vaginal Rejuvenation/Vaginoplasty/Perineoplasty

This elective aesthetic vaginal surgery aims to remove excess vaginal skin to narrow the diameter of the vagina resulting in a smaller and tighter introitus (opening) and vaginal vault. Vaginoplasty is meant to be a full-length repair of the vagina.  It is a modification of the rectocele repair more akin to a levatorplasty where loosened muscles of the sidewalls of the pelvis are approximated towards the middle to narrow the vaginal canal and push down any rectocele that may be present.  Lasers or standard cautery or radiofrequency devices can all successfully be used for this surgery.  Many advertise this procedure for the “Enhancement of Sexual Gratification” as well as a cosmetic procedure.  If only the opening space of the vagina is rebuilt, or if only the space between the vaginal opening and the rectal opening is repaired, the surgery is more precisely called a “Perineoplasty.”  Perineoplasty is helpful for improving the look of the genitals and reducing the gaping appearance but does not tighten the entire vaginal canal.  Full length vaginal tightening, or vaginoplasty, aims to reduce the diameter of the vagina all the way up the canal about 7-9 cm deep.  This is usually done in the operating room under general or spinal anesthesia or under local anesthetic with some sedation.  Surgical time is about 60 minutes.

Perineoplasty/ Perineorrhaphy

The visible area between the vagina and the rectum is called the perineum.  It is the space where episiotomies are cut and where tears during childbirth occur. Perineoplasty (or Perineorrhaphy) aims to make this region appear normal by excising excess skin, loose skin tags, and suturing the underlying muscles of the perineal body closer together to give a snug sensation of the vaginal opening. This procedure has also been advertised by many to “Enhance Sexual Gratification.” The procedure almost always accompanies vaginoplasty surgery but can be done independently or by itself.  Many plastic surgeons refer to their vaginal tightening surgeries as vaginal rejuvenation when it more accurately should be identified as a perineoplasty. This procedure takes 30-60 minutes to perform.

Labiaplasty/Clitoral Hood Reduction

This elective surgery is for the removal of excess, floppy, or uneven labia minora (smaller interior vaginal lips) that can cause chronic irritation, rubbing, or discomfort during sex. The term “Labiaplasty” can also relate to the cosmetic surgery of the labia majora (larger outer lips) to make it less prominent and floppy and to reduce the “Camel Toe” look that is often mentioned in the media.  Labia minoraplasty can be done at the same time as labia majoraplasty and clitoral hood reduction to achieve a balanced and natural look.  Clitoral hood reduction is the removal of excess or redundant tissues over the clitoral bulb (typically on the sides of the clitoris) to achieve a more petite and balanced appearance.  At times the clitoris is buried and difficult to access and a “Hoodoplasty” surgery can be done to gain more exposure for the clitoris.  Few surgeons are trained in these complex combined procedures.  Surgical volume and experience is important to research.  Labiaplasty is most often done in the operating room but in most cases surgery can be done in the office under local anesthetic at dramatically decreased costs.  Labiaplasty can be done with knives or scissors, lasers or radiofrequency devices.  The Ellman Surgitron is the tool of choice by many surgeons due to its extreme precision for this delicate surgery. This procedure takes 60-180 minutes to perform depending on complexity.  Combinations surgeries are the most challenging surgeries to perform for even the most highly trained surgeon.

Hymenoplasty

This surgery is the elective reconstruction of the hymen. Cultural, religious, or social reasons predominate when this controversial surgery is contemplated. Hymenoplasty is performed to make the patient appear virginal and function like a virgin.  Its intent is to have bleeding at the time of intercourse. It works for women who have not had vaginal deliveries, and preferably, in those who have never been pregnant. For those who have already had a baby vaginally a perineoplasty or vaginoplasty may be needed to approximate the look and feel of a virginal woman.  The radiofrequency surgery with the Ellman Surgitron is the tool of choice to make extremely precise incisions into the vagina and remnants of the hymeneal ring to bring them into close approximation to allow delicate sutures to hold the tissues in place. Once healed, the act of sexual intercourse can result in bleeding when the hymen is torn or stretched. This procedure takes 30-60 minutes to perform.

Laser Resurfacing

CO2 lasers have been used for over 20 years to ablate lesions in the vaginal area. Examples include venereal warts and skin tags. They have also been used to treat precancerous vulvar, vaginal, and cervical lesions. We often marveled at the beautiful new tighter skin that grew after a laser treatment. We have used the CO2 lasers since 1986 with excellent success. Now, the CO2 laser is getting more acceptance by other gynecologists as a tool for cosmetic vaginal rejuvenation and resurfacing. Other lasers that have been used in the vaginal region include Erbium Yag and diode lasers of varying wavelengths. Laser resurfacing takes 5 to 15 minutes to perform.

Radiofrequency Resurfacing

Surgical radiofrequency devices, such as the Ellman Surgitron, have been used for over 20 years to resurface, ablate, smoothen, and excise tissues.  Examples include removal or ablation of vulvar polyps, venereal warts, and skin tags.  Similar to lasers, they have  been used to treat precancerous vulvar, vaginal, and cervical lesions. LEEP procedures are often done with standard cautery or radiofrequency energy.  This was once the domain of CO2 lasers.  The need for bulky lasers, production of char, smoke, prolonged healing and stenosis of tissues has made laser use decline.  As with the use of lasers, radiofrequency resurfacing also brings about beautiful new skin with new collagen and elastin.  CO2 and Erbium lasers have not been known to increase elastin to the same degree as radiofrequency energy. There has been extensive clinical research of radiofrequency use for gynecologic conditions and surgery.  It is now the main tool of many aesthetic gynecologists performing labial surgeries and refinements as well as revisions to smoothen out “Dog Ears” and irregular edges after labial or vaginal surgeries.  It has also been used for shrinkage and removal of external anal skin tags and external hemorrhoids.