Cosmetic gynecologic surgeries aim to subjectively improve the structure and appearance of the female genitalia. External genitalia may be modified to a desired shape or size to increase sensation, decrease interference during intercourse, or relieve pain and discomfort with clothing and exercise. Female genital cosmetic surgeries (FGCSs) are typically not medically indicated and do not include procedures that repair significant labial asymmetry or hypertrophy due to congenital anomalies or excess androgen exposure.1 Likewise, pelvic reconstructive procedures performed for pelvic organ prolapse, urinary incontinence, or fecal incontinence are not included. Examples of FGCS are vaginoplasty, perineoplasty, labiaplasty, clitoral hood reduction, G-spot amplification, O-shot with platelet-rich plasma, radiofrequency wand and laser therapy, as well as others.
The number of women undergoing cosmetic gynecologic surgeries has increased. In the last 5 years, the number of labiaplasty surgeries performed in the United States rose by 53%.2 In 2018, 12,756 labiaplasties were performed, making it one of the top 12 cosmetic surgeries in the United States. The amount spent on labiaplasties and other FGCS in 2018 was >35 million US dollars.2
FGCS articles first appeared in the literature in 1976.3 The concept of cosmetic gynecology as a form of sexual enhancement emerged in the 1970s. During this time, pubic hair grooming became increasingly popular. The trend continued with the advent of Brazilian waxes. With less hair, the vulva became more visible, and opinions regarding enhanced vulvar appearances emerged. During this same time, the pornography industry came forward with images of “Barbie doll” looks akin to prepubertal early Tanner stage genitalia, which created a new standard for vulvovaginal appearance. By minimizing the labia minora, shortening the genital hiatus, and building up the perineal body, labiaplasty and vaginoplasty became a new vulvovaginal standard.4
Overview of Surgeries
Surgeries classified under FGCS include vaginoplasty, perineoplasty, labia minora labiaplasty, clitoral hood reduction, labia majora augmentation or reduction with monsplasty, G-spot amplification, and the O-shot with platelet-rich plasma injection among others (Table 1). Surgeries are performed with scalpels, as well as other energy sources such as lasers. Despite increasing numbers of publications, robust long-term data from studies with rigorous methodology on the efficacy and safety of these procedures are lacking, particularly regarding sexual enhancement.
Radiofrequency and Laser Devices
Lasers and radiofrequency devices are used in FGCS as noninvasive instruments and devices. There are several commercially available energy devices (Table 2). None have been cleared nor approved by the US Food and Drug Administration (FDA) for a specific gynecologic indication, but the table does include published descriptions for use.
Lasers produce a focused beam of light at a particular wavelength. The wavelength produced is chosen based on the wavelength absorption of the molecule it is designed to affect. Hemoglobin, water, and connective tissue absorb light at different wavelengths. When a molecule absorbs that wavelength of light, it undergoes permanent thermal damage while the surrounding tissue remains intact, a process termed “selective photothermolysis.”
Cutting lasers include contact (Nd9 YAG and 980 nm diode) and carbon dioxide (CO2) lasers. These lasers are used in cosmetic gynecology to decrease thermal damage to the epithelium and bleeding as compared with traditional cautery.11 Selective photothermolysis is thought to theoretically improve wound healing with less scarring and loss of sensation than traditional surgical techniques. However, no studies confirm the superiority of laser to the traditional scalpel, scissors or electrocautery.11
The term “laser” in various cosmetic gynecologic procedures is trademarked. Vaginal rejuvenation is performed to decrease the caliber of the vagina, which theoretically improves sexual function. In “laser vaginal rejuvenation (LVR),” a laser is used to perform the cutting in a vaginal rejuvenation procedure. Traditionally, a vaginal rejuvenation procedure combines an anterior colporrhaphy and/or posterior colporrhaphy and/or perineoplasty. In “designer laser vaginoplasty” a laser is used to perform a constellation of procedures to alter the shape and appearance of the vulva such as labiaplasty and clitoral hood reduction. These procedures differ from LVR because they address the appearance, rather than a function of the vulva. Designer laser vaginoplasty can be combined with LVR procedures.12
Lasers are also used for the nonsurgical treatment of several genital disorders such as genitourinary syndrome of menopause (GSM), stress urinary incontinence (SUI), and lichen sclerosus which do not fall under the category of FGCS. In addition, they are used to perform nonsurgical vaginal rejuvenation. These lasers include the Er:YAG and the CO2 based laser. Lasers can thicken the postmenopausal epithelium, increase neovascularization, increase neocollagenesis in the lamina propria, and improve vaginal wall tightening.13 Paraiso and colleagues conducted a randomized control trial comparing the 6-month efficacy and safety of fractional CO2 laser therapy to vaginal estrogen cream in treating vaginal dryness/GSM. Of the 58 women who completed the protocol, both groups reported a similar improvement in vaginal dryness. No serious adverse events were reported in either group.14
Radiofrequency devices emit electromagnetic energy. When this energy is absorbed by molecules it induces motion and produces heat. The generated heat produces a local temperature increase in the tissue. The amount of heat produced is affected by both the current of the radiofrequency device and the amount of contact time between the device and the target tissues.15
Radiofrequency devices are mainly used in the nonsurgical treatment of genital disorders and have been used for FCGS. The radiofrequency treatment has been shown to induce neocollagenesis and elastogenesis, reduce skin laxity, and improve the mechanical strength of the skin.15 A few studies with small sample size and short-term follow-up have examined radiofrequency therapy on women with SUI and found a significant imrovement in patient-reported outcomes and cough stress test as compared with controls.16,17 Fifty-five percent of patients in a study by Lalji et al17 reported being completely leak-free after treatment. Improvements in patient-reported vaginal laxity scores have also been documented.18
Although some studies have shown positive results for lasers and radiofrequency devices, few data support the use of these technologies in treating genital conditions, pelvic floor disorders or for cosmetic purposes. Most of the available literature consists of retrospective case series with short-term follow-up and the use of nonvalidated outcome measures.19 Data are needed to determine the long-term effect of energy-based devices, the most effective types of energy-based devices for each specific indication, the frequency of session intervals, the effect of add-on therapies such as corticosteroids and estrogen, the cost-effectiveness, and long-term side effects and complications. Several randomized, multisite, and international studies are currently underway to help answer some of these questions.13
FGCS is highly debated with vocal proponents and opponents. Debated aspects include the exact definition of normal anatomy and its variants, the relationship of cosmetic surgery to female genital mutation, the presence of coexisting psychiatric disorders including body dysmorphia within the population seeking surgery, and the ability of cosmetic surgeries to enhance sexual function and meet the goals of women who request them. Below we address each of these controversies.
NORMAL EXTERNAL GENITALIA
Although studies on female genital measurements are limited, wide variation exists in what constitutes normal vulvovaginal anatomy. In their cross-sectional study, Lloyd and colleagues measured the external genitalia of 50 premenopausal and postmenopausal women undergoing routine gynecologic surgery. They reported wide ranges in all of the measurements including clitoral length (5 to 35 mm), labial majora length (7 to 12 cm), labia minora length (20 to 100 mm), labia minora width (7 to 50 mm), and vaginal length (6.5 to 12.5 cm).20 Furthermore, they did not find a statistically significant association between genitalia measurements and age, parity, ethnicity, hormonal use, or history of sexual activity. Basaran and colleagues conducted a similar study on 50 premenopausal and 50 postmenopausal women and found significant differences in mean vaginal length (premenopausal: 90.3±14.8 mm vs. postmenopausal: 82.3±11.2 mm) and labia minora width (premenopausal: 17.9±4.1 mm vs. postmenopausal: 15.4±4.7 mm) between the 2 groups.21
McFadden et al22 measured the external genitalia in 168 premenopausal women with pelvic floor dysfunction including at least stage 2 pelvic organ prolapse, urinary incontinence and/or fecal incontinence. They also evaluated the relationship between measurements and genital self-image. These data have only been published in abstract form. They found that the labia majora length ranged from 4.0 to 11.5 cm, labia minora length ranged from 3.8 to 1.5 cm, and labia minora width ranged from 0.3 to 7.0 cm (Fig. 1). Significant asymmetry between the right and left labia minora width and length was noted. They also found no significant correlation between external genital measurements and Modified Body Image or Female Genital Self Image Scale (FGSIS) scores.22
The classification of abnormally appearing or enlarged genitalia is lacking. Some argue that the lack of consensus is because cosmetic gynecologic surgeries are performed on women with labia within the normal variation of human anatomy. A study by Crouch et al23 measured the labia minora length and width of women requesting labial reduction surgery and found the mean labia width (measured from left to right side of the labia minora) to be 26.9±12.8 and 24.8±13.1 mm for the right and left labia minora, respectively, measurements which are within the limits among women seeking routine care. These findings were reproduced by Veale and colleagues who compared genital measurements between 55 women seeking labiaplasty and 70 women who did not desire surgery. Between the 2 groups, they found no significant difference in protrusion of the labia minora.24
Since women undergoing FGCS have vulvovaginal measurements that are equivalent to those of women not seeking surgery, something other than differences in anatomy may be influencing women to desire these procedures. Some argue this influence stems from the representation of genitalia in the media. In fact, several studies have documented the impact of images on genital self-perception.
Moran and Lee25 studied whether the appearance of vulvas can be influenced by prior exposure to images of natural or surgically modified vulvas. In their study, they randomized 97 women to view images of either surgically modified vulvas, nonmodified vulvas, or no images. All of the participants then viewed a set of images that included nonmodified vulvas followed by modified vulvas and were asked to rate each for image normality and the extent to which it represented society’s ideal. Women exposed to images of modified vulvas were more likely to rate them as more normal than nonmodified vulvas as compared with women who had viewed a blank screen. All 3 groups rated modified vulvas as more like society’s ideal than the nonmodified vulvas, with the effect strongest for the women who had viewed the modified images. Laan et al26 performed a similar study. They assessed the influence of pictures of unmodified vulvas on genital self-image as measures by the FGSIS. In this study, 29 women were shown pictures of unmodified vulvas and 14 women were shown pictures of neutral objects. The neutral objects consisted of household objects, art, nature, animals, and architecture. Women exposed to unmodified vulvas had a more positive genital self-image irrespective of levels of sexual function, sexual distress, self-esteem and trait anxiety both immediately after the exposure and 2 weeks later as compared with women who viewed images of neutral objects.
Others argue the pressure to attain the perfect vulva is caused by male partners. Mazloomdoost et al27 conducted a web-based survey evaluating preferences for vulvar anatomy among 2403 men ages 18 to 80 years. They found that 51% of male participants believed the appearance of a woman’s labia influenced their desire to engage in sexual activity, but 60% denied that appearance affected sexual pleasure. Moreover, 75% of all respondents stated that they would not encourage a female partner to change her genital appearance. In light of the above-mentioned studies, many argue the greatest influence women have to proceed with cosmetic gynecologic procedures is the media and their promotion of a vulvovaginal standard only possible through surgery.
FEMALE GENITAL MUTILATION (FGM)
FGM, also known as female genital cutting or circumcision, refers to any procedure that permanently and intentionally alters or causes injury to otherwise healthy female genital organs for nonmedical reasons.28 These procedures are almost entirely carried out on minors. FGM “violates a person’s rights to health, security, and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death.”28 As such, this practice has been criminalized in the following 12 countries: Australia, Belgium, Canada, Cyprus, Denmark, Italy, New Zealand, Norway, Spain, Sweden, the United Kingdom, and the United States. Nonetheless, it is estimated that >200 million girls and women alive today have undergone FGM with the prevalence highest in Africa, the Middle East, and Asia.28
Cosmetic gynecologic procedures have been argued by some to be a form of FGM because they involve modifying otherwise healthy external genitalia. The World Health Organization states “Some practices, such as genital cosmetic surgery and hymen repair, which are legally accepted in many countries and not generally considered to constitute FGM, actually fall under the definition. It has been considered important, however, to maintain a broad definition of FGM to avoid loopholes that might allow the practice to continue.”29 Whether cosmetic gynecologic surgeries should be classified as a form of FGM is a point of contention. Both FGM and FGCS procedures are performed on vulnerable women, with those seeking cosmetic procedures considered vulnerable due to the anxiety and feeling of inadequacy related to their genital appearance. However, cosmetic procedures are performed on consenting adult women, while the majority of FGM is performed on young girls without permission or regard to their desires. Others argue that, compared with cosmetic surgery, FGM is associated with greater long-term complications and pain. Although the magnitude of suffering has not been measured, both procedures can result in pain, infection, scarring, adhesions, altered sensation, and sexual problems.30 Furthermore, more recent data have shown fewer complications related to female genital cutting than previously reported by activists.31 As health data on complications from FGM continues to develop, the argument against performing these procedures has shifted from one based on health complications to one based on ethics.31 Literature is lacking on the long-term follow-up for both types of surgeries. Proponents of FGCS argue that the intent of these procedures is what sets them apart; cosmetic surgeries are performed to enhance sexual function while FGM is thought to curb sexual function. However, not all women who have undergone FGM report destroyed sexual function or lack of enjoyment with sexual encounters.32 Sexual gratification relies on both social, cultural, and psychological factors and this partially explains why women who have undergone FGM may continue to experience positive sexual encounters. Residual presence of clitoral tissue, as well as other nerve endings in women who have had the glans removed, may account for some of the physiological sexual responses of women who have undergone FGM.31 Furthermore, advocates of FGCS debate that women should have access to these surgeries like they do other esthetic surgeries. For example, women with breast sizes within the normal range frequently and freely undergo augmentation. Yet, these procedures gain less media attention than FGCS. The counter-argument by opponents of FGCS is that altering one’s genitalia, which is a private part of the body, is not the same as altering other, less intimate body parts.
Women undergoing FGCS have a higher incidence of psychiatric disorders than women who do not elect to undergo these procedures. Veale et al24 performed a case-control study comparing various psychometric measures as well as labia measurements between 55 women who desired labiaplasty and 70 women who did not desire the procedure. Women who did not desire labiaplasty were either undergoing a noncosmetic gynecologic procedure or identified by an email to them through a research volunteer database. Compared with controls, women seeking labiaplasty did not score higher on measures of depression or anxiety but did have an increased dissatisfaction towards the appearance of their genitalia as evidenced by the Genital Appearance Satisfaction (GAS) and the Cosmetic Procedure Screening for Labiaplasty, lower sexual function as measured by the Prolapse-Urinary Incontinence Sexual Function Questionnaire, a poorer quality of life in terms of body image as measured by the Body Image Quality of Life Inventory, greater frequency of avoidance behaviors, and a greater frequency of safety-seeking behaviors. Ten of the women desiring labiaplasty met diagnostic criteria for body dysmorphic disorder (BDD). Interestingly, no significant correlation was found between measurements of the protrusion of the labia minora and GAS scores for patients desiring and not desiring labiaplasty.
BDD is a psychiatric pathology characterized by an obsessive preoccupation that some aspect of one’s own body part or appearance is severely flawed although the perceived defect is either not observable or appears slight to others.33 Individuals with BDD find their perceived defect to be significantly distressing to the point that it may cause social or occupational impairment. BDD is present in about 6% to 15% of patients seeking cosmetic surgery.33 Patients with BDD who undergo cosmetic surgery are frequently dissatisfied with the outcomes of their surgery and continue to obsess about their perceived flaws. Occasionally, this dissatisfaction results in litigation or violence towards the surgeon. A diagnosis of BDD is a contraindication to the performance of genital cosmetic surgery. Surgeons should have women who have had multiple cosmetic surgeries, including repeat surgeries evaluated for this disorder.
Psychiatric disorders may be impacting women’s decisions to proceed with elective FGCS that may have long-term impacts on both their physical and mental health. Furthermore, women who have undergone surgical enhancement of other organ systems have a higher incidence of depression and suicide. For example, compared with the general population, women with breast implants have a 3-fold higher rate of suicide and deaths from alcohol or drug dependence as well as deaths from accidents and injuries related to substance abuse or dependence.34
ENHANCEMENT OF SEXUAL FUNCTION
The enhancement of sexual function is often cited as a reason for women to pursue FGCS. Goodman et al6 evaluated sexual function through a cross-sectional study of 258 women undergoing various cosmetic gynecologic procedures. They found that 20% to 75% of women had chosen to undergo these procedures for sexual improvement. Specifically, women desired to decrease discomfort during intercourse, increase friction, and enhance their partner’s sexual pleasure. Fifty-eight percent of vaginoplasties and/or perineoplasties were performed for the sole reason of “increasing partner’s sexual pleasure” rather than the woman’s own sexual pleasure.
Evidence on whether FGCS successfully increases sexual function is limited. In the same study referenced above, Goodman and colleagues documented a 60% to 90% improvement in sexual satisfaction after surgery using nonvalidated measures at 6 to 42 months follow-up. Pardo and colleagues evaluated the results of colporrhaphy and perineoplasty on 53 women complaining of a wide vagina and decreased sexual satisfaction. At 6 months after surgery, 94% of patients experienced a tighter vagina and were able to achieve orgasm, and 74% of patients reported the surgery fulfilled their expectations.35 Turini et al36 assessed the impact of labiaplasty on sexual function. They enrolled 24 sexually active women who desired to undergo labiaplasty and divided them into 2 groups: 12 women underwent labiaplasty immediately and 12 were asked to delay their surgery by 6 months, which marked the end of the study. They administered the Female Sexual Function Questionnaire (FSFQ) at baseline, 3 and 6 months. At 3 months, women who underwent labiaplasty had a significant improvement in the FSFQ total score, and in the pain and enjoyment domains. Interestingly, there was no significant improvement in scores observed from baseline to 6 months and 3 to 6 months, although scores did not return to baseline.
All of these studies are limited by a methodology that may have included the use of nonvalidated questionnaires, lack of sexual function assessment before surgery, and lack of long-term follow-up. Women undergoing cosmetic gynecologic surgeries for the enhancement of sexual function have little data to inform them on the success of these procedures.
The increased popularity of FGCS has sparked the development of position statements by several societies. Collectively, our leading societies recommend against the performance of these procedures. In 2007 the American College of Obstetrics and Gynecology stated, “Absence of data supporting the safety and efficacy of these procedures makes their recommendation untenable.” In this statement, they also stress the importance of counseling patients on the wide array of potential complications including “infection, altered sensation, dyspareunia, adhesions, and scarring.”1 Similar statements were produced by the Society of Obstetricians and Gynecologists of Canada in 201337 and The Royal Australian and New Zealand College of Obstetricians and Gynaecologists in 2008.38
In 2013, The Royal College of Obstetricians and Gynaecologists in the United Kingdom developed a robust statement regarding the ethical considerations of cosmetic gynecology with a review of the surgical epidemiology, risks, and lack of proved efficacy.39 Specific recommendations regarding the advertisement of these surgeries and the need for psychological assessment of patients desiring these procedures were also included. Their statement also states that such surgeries should not be performed under the National Health Service (England’s public health service that provides free health care at the point of use and is paid for from general taxation) for esthetic reasons alone.
In 2018 the US FDA released a communication statement regarding the use of energy-based devices used for the purpose of cosmesis where they stated “To date, we have not cleared or approved for marketing any energy-based devices to treat these symptoms or conditions, or any symptoms related to menopause, urinary incontinence, or sexual function. The treatment of these symptoms or conditions by applying energy-based therapies to the vagina may lead to serious adverse events, including vaginal burns, scarring, pain during sexual intercourse, and recurring/chronic pain.”40
In 2019 the International Society for the Study of Vulvovaginal Disease and the International Continence Society released a joint practice consensus document supporting the FDA communication. They advised against the use of lasers and radiofrequency devices in the treatment of genitourinary disorders including lichen sclerosus, vulvodynia, urinary incontinence, vulvovaginal atrophy, or for rejuvenation due to the lack of well-designed studies supporting their use.41 That same year, The International Urogynecologic Association released a committee opinion where they similarly stated the need for more robust data from methodologically rigorous studies to fully evaluate the safety and efficacy of these laser-based vaginal devices on vulvovaginal tissues specifically in the treatment of SUI, GSM, and vaginal laxity.42
The field of cosmetic gynecology has recently seen an upward expansion in popularity. Several strong arguments in support and against the field of cosmetic gynecology exist. Robust data on the efficacy, complications, and long-term consequences of cosmetic gynecologic procedures are lacking. Consequently, governing organizations specializing in the care of women have failed to support the performance of these procedures. As data continue to develop, particularly in the use of lasers for the treatment of genital disorders, we may see these opinions change.
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