Laser of the Vagina and Vulva
Kenneth D. Hatch
GENERAL PRINCIPLES
The laser used in gynecology is the carbon dioxide (CO2) laser. It is most often attached to a colposcope in order to provide magnification and take advantage of the laser’s capability to vaporize thin layers of the skin. The CO2 beam is not visible so the laser is coupled with a helium-neon (He-Ne) visible laser, similar to that used as a pointer in lectures. The CO2 laser is absorbed by water so wet towels are used around the vulva to prevent accidental burns. The focal length of the laser can be varied from 200 to 300 mm. The average colposcope has a focal length of 250 mm. The laser should be set at 250 mm if the colposcope is at that focal length. Focal length of the scope can be changed and since it may be used by other services, such as ENT, the lens should be checked before the laser is attached.
Anatomic Considerations
Vulva intraepithelial neoplasia (VIN) and vaginal intraepithelial neoplasia (VAIN) are neoplastic changes in the epidermis.
The laser is able to vaporize the epidermal layer of the skin leaving the dermis over which the new epidermal cells can migrate without leaving a scar.
The dermis is divided into the papillary dermis (referred to as the first surgical plane) and reticular dermis (referred to as the second surgical plane).
When the epidermis is lasered to the papillary dermis, the reticular dermis remains and is the foundation over which the epidermis will regenerate (Fig. 7.1).
After removing the epidermis, a second pass of the laser over the papillary dermis will reveal the reticular dermis. If the laser goes beyond this depth to the subcutaneous fat, then skin has to form new connective tissue before the epidermis can migrate over it. This may result in some scaring.
The labia minora, posterior fourchette,clitoral prepuce, and clitoral glans are the ideal structures to take advantage of the laser. The epidermis can be vaporized away to the level of the papillary dermis (Fig. 7.2A-C). Healing will be rapid without scar.
The mons pubis, labia majora, perineum, and buttocks have hair follicles and associated sebaceous glands that extend into the dermis and subcutaneous fat.
The VIN extends down into the hair follicles and sebaceous glands in approximately 50% of the VIN lesions on the hair-bearing areas. The average depth of extension is 1.2 mm (Fig. 7.3).
The laser can be used in these hair-bearing areas with good cosmetic results if the laser is limited to the papillary dermis (Fig. 7.4A,B).
Lasering to this plane will not destroy the entire hair follicle and healing of the area will take place from the squamous epithelium remaining in the base of the follicles.
If there is VIN remaining in the hair follicle, it may grow back as well (Fig. 7.5).
The labia minora, the clitoral prepuce, and the mucosal surface of the introitus and the vaginal vestibule contain just some superficial sebaceous glands and treatment to the papillary dermis is satisfactory.
The laser is the best treatment for these structures as the dermis can be lasered without disturbing the structure of the labia minora or the clitoral prepuce.
PREOPERATIVE PLANNING
Expert colposcopy is key to successful laser treatment. On the hair-bearing keratinized area of the vulva, it is useful to magnify the skin and identify margins. The thick keratinized skin will not react to the 5% acetic acid as it is too dry and resists the liquid.
Colposcopy is more important on the moist mucosal areas of the labia minora, the vaginal vestibule and on the clitoris. It is important to note that a faint acetowhite reaction will occur on nearly every person near Hart line. This is an active area of metaplasia and tissue regeneration. Therefore, it stains slightly acetowhite.
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