Cosmetic vaginal procedures: Surgeons must address potential medical, psychological issues beforehand

In the preliminary steps of a vaginal tightening procedure, a triangular wedge of the perineal body is marked for excision (left), followed by dissection (right) to expose the levator muscles. (Photos credit: Marco Pelosi III, M.D.)

"While changing appearance is an outcome that is well understood by cosmetic surgeons, success in changing the sexual experience is more complicated, and will require more discussion and counseling to elicit the patient's concerns and determine if her goals can be achieved through surgery," says Dr. Pelosi, chairman of obstetrics and gynecology, United States Section of the International College of Surgeons, and associate director, Pelosi Medical Center, Bayonne, N.J. "In addition, performing cosmetic surgery involving the vagina and/or perineum mandates careful assessment for urologic and gynecologic pathology.

"Surgeons without gynecologic training should collaborate with an experienced colleague to make sure the patient receives proper evaluation and treatment for pelvic pathology. However, even after medical causes are ruled out or treated and 'cosmetic' surgery appears to be an appropriate option, meeting the goal of improving pleasure can be challenging, because the endpoint is more nebulous," Dr. Pelosi says.

The mons pubis region is familiar territory for many cosmetic surgeons, as it is a common site for hair removal and liposuction procedures. For surgeons who perform abdominoplasty, lifting of the mons pubis is a natural consequence of an abdominal tightening procedure. However, in contrast to areas where larger-volume procedures are performed, mons pubis liposuction is done using a smaller-gauge, 2.5 to 3.0 mm cannula in order to avoid over-aggressive fat removal that would result in depressions.

"Patients seeking this procedure are typically not obese and do not need a large correction, but rather desire some limited sculpting to fine-tune their appearance," Dr. Pelosi says.

Lifting of the mons pubis can be done as a stand-alone procedure in women whose primary complaint is excessive pubic laxity, and it may be combined with liposuction in heavier women. It can also be achieved as part of an abdominoplasty. Success after the latter procedure requires an understanding of the tension vectors to guide proper incision planning and suture alignment. An optimal lift requires avoiding both excess tension at the angles of the pubic triangle and curving the center of the scar cephalad.

"Lifting of the mons pubis is not an area to fear, but one to study and analyze when performing abdominoplasty. So, make sure that the mons pubis is not fully draped and pay attention to how pulling and tucking in different directions affects the mons pubis contours," Dr. Pelosi says.

LABIA MAJORA Labia majora procedures include reduction majora plasty and augmentation with autologous fat transfer. The reduction surgery addresses excessive loose skin and represents subcutaneous excisional and reapproximation techniques originally designed for treatment of cancer, precancer and genital warts.

Surgeons may gauge the amount of tissue to resect by pushing with a cotton-tip applicator, and they should confirm the plan with the patient in the lithotomy position to check for symmetry in size and skin appearance. For augmentation procedures, planning and marking are performed with the patient standing, but the procedure is done in the lithotomy position. The fat transfer is performed with a blunt-tip, 15 cm, 14-gauge Coleman Type 2 cannula, delivering about 20 to 30 mL of purified fat subcutaneously in a fanlike pattern into the fat layer under tumescent anesthesia and a pudendal nerve block. Deeper injection can lead to complications.

LABIA MINORA PROCEDURES Procedures involving the labia minora include reduction minora plasty and reconstruction. Reduction may be for cosmetic reasons to address elongated, asymmetric and/or hyperpigmented tissue. Alternatively, the indication may be to relieve pain associated with tissue traction or damage sustained during childbirth. The procedure may be done under local anesthesia with a pudendal nerve block given to infiltrate superficially, using only a low volume to avoid tissue distortion.

CLITORAL SURGERY Cosmetic clitoral surgical procedures include prepuce/hood resection of excess tissue, correction of asymmetry and reduction clitoroplasty of an excessively long clitoris (a condition seen primarily in women who have been exposed to excess androgen). Success requires an understanding of the tissue's normal anatomic shape, structure and innervation so that incisions are properly placed to avoid injury to the clitoral neurovascular bundle or its innervating pudendal nerve, Dr. Pelosi says.

POSTERIOR VAGINAL OPERATIONS Vaginal cosmetic surgery aims to reduce vaginal caliber. The procedure involves tightening of the levator sling and perineal body by excising a triangle of skin and subdermal tissue of predetermined size and plicating the levator muscles, the bulbocavernosus muscles and the superficial and deep transverse perineal muscles, resulting in elevation of the hymen and widening of the distance between the anus and vagina. Planning the amount of tightening to target is based in part on discussion with the patient combined with measurements taken intraoperatively.