Cosmetic gynecology (also referred to as female genital plastic and cosmetic surgery) has garnered substantial attention and notoriety in recent years. Much of the controversy in this field can be distilled into three points. There is a concern that cosmetic gynecology procedures encourage or even pressure patients into either achieving or fitting an anatomic ideal. Critics also point to an ambiguous nomenclature, a relative paucity of data, and express concern that the quality of literature is flawed or biased. Finally, as these are elective nonmedically indicated procedures, they are generally not covered by insurance and offered on a fee-for-service model. These are valid criticisms, and although the detailed discussion necessary to adequately address each point is beyond the scope of this chapter, we hope that the evidence presented here will begin to allay some of these concerns. Despite these caveats, patient requests for cosmetic gynecology procedures are increasing dramatically with practitioners from multiple specialties offering these interventions. Between 2014 and 2018, there was a 50% increase in the number of labiaplasty procedures performed in the United States.1 At its foundation, cosmetic gynecology is an extension of female pelvic medicine and reconstructive surgery in the same way as cosmetic surgery is subspecialty of plastic and reconstructive surgery.
In order to address the growing interest and lingering ambiguity in this subspecialty of urogynecology, the International Urogynecological Association (IUGA) and American Urogynecologic Society (AUGS) convened a joint working group to establish standardized terminology classification systems (Table 60.1) and adverse event metrics for cosmetic gynecology.2 In addition to reviewing the information in that document, this chapter expands on the surgical techniques for each procedure.
The boundaries of cosmetic gynecology must be clearly delineated to distinguish it from either medically necessary procedures or female genital mutilation (FGM). Preoperative counseling and assessment will then be considered followed by a focused discussion on procedures of the labia majora, labia minora, clitoris, and vagina. Additionally, energy-based therapies, a new and promising treatment modality in aesthetic gynecology, is briefly surveyed. Procedures on the mons pubis are not covered in this text.
TERMINOLOGY AND SCOPE
Concomitant with development of this chapter, the American Urogynecologic Society (AUGS) and International Urogynecological Association (IUGA) developed a Joint Report on Terminology for Cosmetic Gynecology.2 This document expands upon the terminology surveyed in this chapter along with including staging systems and an adverse event reporting scale.
Cosmetic gynecology encompasses interventions to the mons pubis, labia majora, labia minora, clitoris, and vagina. Cosmetic gynecologycan be defined as elective interventions to alter the aesthetic appearance of the external genitalia or modify the genital organs or elective functional vaginal procedures (in the absence of pathology) with the goal of improving a person’s quality of life. This definition is left intentionally broad as it is meant to include purely aesthetic procedures in addition to those that are intended to improve function. Specifically, this is in reference to vaginal tightening (either surgically or with an energy-based device [EBD]) and injections into the clitoris and anterior vaginal wall with the intent of improving sexual function. Traditionally, these interventions have been considered within the umbrella of cosmetic gynecology, and furthermore, they should be considered only in the absence of medical pathology. For example, a 66-year-old gravida 4 patient who presents with a stage III Pelvic Organ Prolapse Quantification (POP-Q) and a genital hiatus (GH) of 5 cm has a medical pathology and should be counseled on appropriate treatment options. Similarly, a woman with dyspareunia and biopsy documented endometriosis also should be offered medically indicated counseling and treatment. In both scenarios, a cosmetic gynecology procedure should not be offered as it would neither be beneficial nor indicated. To qualify this, there are some scenarios in which a woman with POP requests surgical correction for her medical condition in addition to concomitant surgical vaginal tightening; however, these should be considered as separate entities. Alternatively, if a patient presents without medically significant pelvic organ prolapse (POP) on POP-Q or a diagnosis of sexual dysfunction and is requesting a procedure to narrow the vaginal caliber, this would be considered a cosmetic gynecology procedure.
There have been parallels drawn between cosmetic gynecology and FGM, so a sharp distinction should be made. FGM is defined by the World Health Organization as “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.”3 This is further classified into four types:
Type I: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type II: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type III: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Type IV: All other harmful procedures to the female genitalia for non-medical purposes for example: pricking, piercing, incising, scraping, and cauterization.3
The difference between FGM and cosmetic gynecology centers around both intent and patient autonomy (Fig. 60.1). In FGM, procedures may be performed on children or young women without their consent in order to exert control over them or in an attempt to cause either physical or psychological harm. In cosmetic gynecology, procedures on the other hand, the patient makes the decision to proceed with intervention to improve her overall quality of life.
FIGURE 60.1 Is this cosmetic gynecology?
PREOPERATIVE CONSIDERATIONS
On consultation, a thorough history should be obtained in order to understand the patient’s motivators for pursuing surgery. Why does she feel that she needs cosmetic surgery? It is of the utmost importance that she is making this decision voluntarily and without undue influence or coercion from either family members or the provider. Counseling on the wide spectrum of normal anatomic variants can help to allay concerns many patients may have about their bodies. All patients should be screened for body dysmorphic disorder (BDD) and referred for additional care as indicated. The Cosmetic Procedure Screening Scale (COPS) is a validated 9-item survey that can be used to help identify patients with BDD. Each question is scored from 0 to 8 with total ranges from 0 to 72 with scores greater than 40 suggesting possible BDD.4 A version of this, the COPS-L, has also been validated for patients seeking labia minora reduction.5 Additionally, the Genital Appearance Satisfaction (GAS) scale is a validated 11-item questionnaire that assesses a subject’s perception of her anatomy. On a scale of 0 to 33, higher scores suggest greater dissatisfaction (Table 60.2).6
During the physical examination, she should be evaluated for medical conditions such as POP, lichen sclerosus, or genitourinary syndrome of menopause (GSM), which could be contributing to some of her symptoms. In order to avoid any misunderstanding, offer the patient a hand mirror and allow her to point to any area of concern and describe how she would like this altered. If the patient is amenable, medical photographs both in lithotomy and in the standing-dependent position can help to both document and understand patient concerns. After the exam, her anatomy should be reviewed on a female pelvic anatomy illustration along with discussion of any potential interventions. Is the proposed intervention feasible and will it result in the desired outcome for the patient? A similar understanding of postoperative expectations between physician and provider is paramount.
OUTCOME METRICS
One of the most common criticisms of cosmetic gynecology is a lack of safety and efficacy data. A systematic review evaluating the peer-reviewed literature on cosmetic gynecology found that there are multiple metrics used to assess results; however, they are highly variable and not standardized.7 Aesthetic outcome measures can be grouped into either objective or subjective. Establishing the former is nearly impossible unless a precise anatomic metric is stipulated. For example, a sample metric could be that a labia minora reduction procedure is successful if the minora do not extend past the majora. Although these definitions can be constructed to illustrate that a procedure is successful, it does so at the expense of defining an anatomic ideal. Establishing these definitions may unduly suggest that anyone who does not meet these criteria is not normal. It should be clearly stated that in the absence of medical pathology or physical discomfort, there is no anatomic ideal for the female genitalia, and there is a wide physiologic range in the population.
A separate albeit less defined objective approach is to use photography with blinded evaluators asked to rate preoperative and postoperative photos. Although this can illustrate evidence of improved cosmesis (in the opinion of reviewers), it carries little weight if the patient is not satisfied. This leads us to patient-driven outcomes such as numeric satisfaction scales, such as the GAS described earlier which can be used both to screen patients for BDD or determine efficacy after treatment.5 This is a good option for evaluating women who are interested in labia minora reduction. Alternatively, the Patient Global Impression of Improvement (PGI-I) is a 7-point scale that asks patients how their condition has changed since the intervention and varies from very much worse (1), through no change (4), and to very much better (7).8 The PGI-I can be applied to any patient procedure and is well suited to cosmetic interventions to gauge patient satisfaction.
TABLE 60.2 Genital Appearance Satisfaction Scale
ITEM
NEVER
SOMETIMES
OFTEN
ALWAYS
1. I feel that my genitals are normal in appearance.
3
2
1
0
2. I feel that my genitals are unattractive in appearance.
0
1
2
3
3. I feel that my labia are too large.
0
1
2
3
4. I am satisfied with the appearance of my genitals.
3
2
1
0
5. I experience irritation to my labia when exercising/walking.
0
1
2
3
6. I feel, or have felt, conscious in sexual situations because of the appearance of my genitals.
0
1
2
3
7. Embarrassment about the appearance of my genitals spoils my enjoyment of sex.
0
1
2
3
8. I feel discomfort around my genitals when I wear tight clothes.
0
1
2
3
9. I feel that my genital area is visible under tight clothes.
0
1
2
3
10. I worry about the appearance of my vaginal area.
0
1
2
3
11. I feel that my genital area looks asymmetric or lopsided.
0
1
2
3
NOTE: Add all responses with total scores ranging from 0 to 33, with higher scores indicating greater dissatisfaction.
For patients requesting a vaginal tightening procedure, many sexual function questionnaires have been used such as the Female Sexual Function Index (FSFI) or the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire Short Form (PISQ-12). It should be noted that although improvement in many domains of these questionnaires has been shown postoperatively, they are not specifically designed to measure improvements in vaginal tightness. Vaginal laxity has been defined by an IUGA/International Continence Society joint terminology document as the “feeling of excessive vaginal looseness,”9 and although nebulous, it truly encapsulates the condition. Given that the vagina is highly distensible and will stretch to accommodate large volumes, it is very challenging to develop objective measurements. A Brink score has been used as a proxy, but this is a much better indicator of pelvic muscular strength than resting vaginal tone. A more specific option may be the Vaginal Laxity Questionnaire (VLQ), which is a 7-point scale ranging from very loose to very tight. Along with this, the Sexual Satisfaction Questionnaire (SSQ) is a 6-point scale to assess sexual satisfaction from vaginal intercourse ranging from none to excellent (Tables 60.3 and 60.4).10
Ultimately for any aesthetic procedure, efficacy will ultimately be determined subjectively by the patient and results will vary substantially based on the skill and experience of the offering provider. That being said, a combination of objective and subjective outcome metrics may be employed to monitor results.
Equally important as outcome metrics, standardized reporting of complications in cosmetic gyn is paramount (Table 60.5). This table is adopted to suit cosmetic gynecology procedures from the Clavien Dindo Scale, which was developed for more acute general surgical complications. Importantly, the Revision rate is defined as repeat surgical intervention for an aesthetic indication (such as inadequate or over resection). In contrast, the reoperation rate is any additional procedure needed to address a medical complication (such as bleeding or necrosis).2
TABLE 60.3 Vaginal Laxity Questionnaire
“How are you now (vaginal laxity/tightness) compared to before treatment?”
1
2
3
4
5
6
7
Very loose
Moderately loose
Slightly loose
Not tight or loose
Slightly tight
Moderately tight
Very tight
Reprinted from From Millheiser LS, Pauls RN, Herbst SJ, et al. Radiofrequency treatment of vaginal laxity after vaginal delivery: Nonsurgical vaginal tightening. J Sex Med 2010;7(9):3088-3095. doi:10.1111/j.1743-6109.2010.01910.x, with permission from Elsevier.
TABLE 60.4 Sexual Satisfaction Questionnaire
“How are you now (sexual satisfaction) compared to before treatment?”
0
1
2
3
4
5
None
Poor
Fair
Good
Very good
Excellent
Reprinted from Millheiser LS, Pauls RN, Herbst SJ, et al. Radiofrequency treatment of vaginal laxity after vaginal delivery: Nonsurgical vaginal tightening. J Sex Med 2010;7(9):3088-3095, with permission from Elsevier.
TABLE 60.5 Classification of Cosmetic Gynecology Revisions and Complications
GRADE
DEFINITION
Grade 0 (revision rate)
Surgical revision for aesthetic indication
Suffix “a”
Asymmetry, contour irregularities
Suffix “o”
Overcorrection
Suffix “u”
Undercorrection
Suffix “s”
Scarring
Grade I
Transient or minor complications not requiring significant medical intervention
Examples: sepsis, myocardial infraction, organ failure
Grade NL
Complication profile not listed or clearly reported
ANATOMY (FIG. 60.2) The mons pubis is a hair-bearing region that covers the pubic symphysis with a mound of adipose tissue. The vulva is composed of the labia majora, labia minora, clitoris, and clitoral prepuce (clitoral hood). The labia majora form the most lateral aspect of the vulva and converge anteriorly above the clitoral prepuce where they become contiguous with the mons pubis and travel posteriorly where they converge at the fourchette just anterior to the perineum. The distal tip of the clitoral glans is exposed with the rest covered by the clitoral prepuce or hood. The inferior border of the clitoral hood extends to the frenulum where the labia minora begins. Superior to the clitoris are the paired deep dorsal arteries and veins with the superficial dorsal vein superior to that. The dorsal nerves of the clitoris can be found coursing at the 11 and 1 o’clock positions just superior to the clitoral body. As they travel distally, multiple small nerve fibers branch out to innervate the glans.11,12 Extending from the inferior aspect of the clitoris on either side is the frenulum of the clitoris, epithelial fronds, which enlarge to become the labia minora. The labia minora are bilateral folds of keratinized squamous epithelium lying just medial to the labia majora and lateral to the vulvar vestibule. The hymen is a membranous vestige with remnants encircling the introitus.
Only gold members can continue reading. Log In or Register to continue
