Fiona M. Lewis There is a wide variation in the normal appearance of the vulva, but this is not promoted online or in popular media. The ‘perfect’ vulva, which is then often perceived as the ‘normal’ appearance to be attained, is often portrayed without hair with a prepubertal appearance [1,2]. Women are very interested in the appearance of the genital area, and over 95% had heard of labial reduction in one study, with 14% feeling that their vulva was abnormal [3]. Hence, there has been a significant increase in requests for cosmetic procedures involving the vulva in recent years. This is led by a perception of abnormality, with little recognition of the massive variation in normality (see Chapter 2). These issues can cause great distress, and reasons for requests for cosmetic surgery include loss of self‐esteem, effect on relationships and sexual pleasure, and media and peer pressure. Some patients with symptoms will believe that removing tissue will help, and this is rarely the case, especially in vulvodynia. Most of these ‘treatments’ are unregulated and therefore may be performed by non‐medical and untrained personnel. They are aggressively marketed, with frequent conflicts of interest as procedures are often commercially driven. There is also an ethical debate about the fine line that exists between female cosmetic surgery and what can be considered as female genital mutilation [4]. By definition, cosmetic treatments are not medically necessary, and the evidence base for efficacy is extremely poor. Some are offered to treat anatomical structures such as the G spot, where there is no scientific evidence for their existence [5]. There can also be blurring of lines between aesthetic issues and function, with several being recommended for functional problems. Different types of laser treatment are promoted for ‘rejuvenation’, treatment of urinary incontinence, poor sexual sensation, and inflammatory dermatoses, with little evidence base for their use [6]. Few studies have good outcome measures and rarely include complication rates. Several professional societies have clear guidelines about cosmetic surgery and the lack of evidence that indicates they should not be recommended [7]. Recommendations about fully informed consent, procedures done by experienced and appropriately trained surgeons, and the importance of preoperative counselling have been made. In one study, only 29% went ahead with hymenal surgery after a good explanation of the issues involved [8]. Any procedure or non‐surgical treatment has a potential to cause harm and known side effects must be fully explained, together with the unknown long‐term effects on tissue and function. Many countries have issued guidelines that cosmetic procedures should not be undertaken in any patient under 18 years of age. Some information about cosmetic procedures is included here, not because they are recommended, but because it is important to have some knowledge of these in order to recognise complications and to be able to advise patients in an informed manner about the lack of evidence for them. A labiaplasty is the most common cosmetic procedure undertaken with patients seeking treatment for functional, cosmetic, or sexual concerns [9]. However, of 55 women, 10 fulfilled the criteria for a diagnosis of body dysmorphic disorder, and full assessment preoperatively is vital. It is known that women who have pre‐existing sexual dysfunction have a higher rate of complications after surgery [10]. There are several techniques for labiaplasty, but a review of eight different procedures showed no difference in outcome [11]. The complication rate was about 6% with wound dehiscence, haematoma, bleeding, and urinary retention the most common. Repeat surgery was done in 1.7% as there was dissatisfaction with the amount removed in the initial surgery.
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Cosmetic Procedures and Complications
Procedures on vulval structures
Labia minora
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