Female Genital Plastic and Cosmetic Surgery

Michael P. Goodman

• Publisher: Wiley-Blackwell
• Year: 2016
• Print ISBN: 9781118848517
• eBook ISBN: 9781118848487
• Edition: 1
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

Female genital plastic surgery has become an increasingly sought-after option for women seeking ?improvement? in genital appearance, relief from discomfort, and increased sexual pleasure. These surgeries are a combination of gynecologic, plastic, and cosmetic procedures. Every year sees a higher demand for physicians properly trained and able to perform them.

This unique text from the acknowledged experts in the field covers;

• the anatomy of the area
• the specific surgical procedures and all their variations
• patients? rationales for surgery
• training guidelines and ethical issues
• outcome statistics
• sexual issues
• patient selection
• potential risks and complications.

Examining the issues from individual patient?s perspectives, it is written in an academic but easy-to-read style with understandable and unambiguous drawings and photographs. It contains a step-by-step surgical approach, how to best select the right surgical candidates, how to treat this select group of patients, the sexual issues involved, how to individualize techniques for each specific patient, how to deal with criticism from colleagues or journalists, psychosexual issues, and patient protection.

CHAPTER 1
Introduction

Michael P. Goodman

Caring for Women Wellness Center, Davis, CA, USA

The time is the time. After the time is sometimes the time. Before the time is never the time.

Francois Sagan

Female genital plastic/cosmetic surgery (FGPS), aka female cosmetic genital surgery (FCGS), vulvovaginal aesthetic surgery (VVAS), aesthetic (vulvo)vaginal surgery (AVS), or cosmeto-plastic gynecology (CPG), has mounted the stage of twentieth-century cosmesis. Adding in the promise of improvement in sexual function makes for an intriguing debut.

As this elective plastic/cosmetic surgical discipline, like many novel surgical and medical disciplines, traces its genesis to a community rather than academic setting, the succession of different but related names have mirrored the semantic directions of individuals and subspecialty organizations. Although any of the terms noted above will do, for the purposes of this textbook the quite descriptive term FGPS will be utilized.

As women become more comfortable with the idea of elective procedures on their faces, breasts, skin, and so forth designed to enhance their appearance and self-confidence, it is not surprising that they may wish to alter, change, “rejuvenate,” or reconstruct even more intimate areas of their bodies [1].

Although surgeons for years have unofficially performed surgical procedures resulting in alterations in genital size, appearance, and function (labial size alteration, perineorrhaphy, anterior/posterior colporrhaphy, intersex and transsexual surgical procedures, and alterations on children and adolescents for benign enlargements of the labia minora), Honore and O’Hara in 1978 [2], Hodgekinson and Hait in 1984 [3], and Chavis, LaFeria, and Niccolini in 1989 [4] were the first to discuss genital surgical alterations performed on adults for purely aesthetic reasons. While there are at present no accurate and ongoing published statistics from either the American Society of Plastic Surgeons, American Academy of Cosmetic Surgeons, or American College of Obstetricians and Gynecologists, it has become apparent in the lay press that aesthetic surgery of the vulva and vagina is gaining significantly in popularity. As far back as 2004, Dr. V. Leroy Young, chair of the emerging trends task force of the Arlington Heights, Illinois, American Society of Plastic Surgeons, commented in a personal communication that he felt that “labiaplasty and vaginal cosmetic surgery are the fastest growing emerging growth trend in cosmetic plastic surgery.”

Aesthetic surgery of the vulva and vagina has heretofore not been officially described as such, nor “sanctioned” by specialty organizations, as they are community rather than university or academically driven. The operations themselves, however, are really not new; the only new thing is the concept that women may individually wish to alter their external genitalia for appearance or functional reasons, or tighten the vaginal barrel to enhance their sexual pleasure. However, since any surgery has potential for causing morbidity including pain and distress (both physical and psychological) if not performed properly, and especially since FGPS involves concepts and procedures that are not yet fully researched nor understood, guidelines for training, surgical technique, and patient selection should be discussed.

This textbook will give an overview of the most commonly performed procedures: labiaplasty of the minora and majora (LP-m; LP-M), size reduction of redundant clitoral hood epithelium (RCH), clitoral hood exposure for symptomatic phimosis (RCH-p), perineoplasty (PP), vaginoplasty (VP), colpoperineoplasty (CP; a combination of VP and PP), and hymenoplasty (HP), and will discuss rationale for surgery, ethical issues, patient expectations, patient selection and patient protection, complications, training issues, psychosexual issues, the procedures themselves, and all presently available outcome data. “Vaginal rejuvenation” (VRJ), a slippery and colloquial—although frequently used—term used to mean elective VP, PP, and/or CP (and for some, even LP) will be discussed.

First performed by community gynecologists or plastic surgeons in response to occasional patient requests in the mid-/late 1990s and early 2000s, by the mid-2000s the alternative of surgical alteration or reconstruction for “enlarged” labia/clitoral hood, and vaginal operations geared primarily to a goal of tightening for reasons of enhancement of sexual satisfaction, became more widely available and a subject of comment, blog, search, and consultation.

Although certainly the vulva and vagina are areas under the purview of gynecology and gynecologic training, virtually no training is offered in OB/GYN residencies in plastic technique, cosmetic labiaplasty, or pelvic floor surgery designed specifically for enhancement of female sexual pleasure (see Chapter 21). With the subject adequately addressed by only a portion of plastic surgery residencies (and in these, usually LP/RCH only), an individual patient finds herself on her own when endeavoring to navigate a path to successful reconstruction. With little guidance from specialty or regulatory agencies, “caveat emptor” became the rule, and un- or undertrained surgeons began performing these plastic procedures, frequently with less-than-optimal, and occasionally disastrous, results.

A textbook cannot substitute for a teaching program, observation of proper technique, and actual performance of procedures with expert proctoring. However, this text will point the way and provide guidance toward those ends. It is designed to be a complete teaching guide to be used concomitantly with a hands-on teaching program, designed to develop competency leading to proficiency for female patients putting their trust in the hands of their gynecologic, plastic, or cosmetic surgeon. It is intended to educate the uninitiated and point the way toward the goal of comfort working with—psychologically, sexually, physiologically, and surgically—women who desire a guide to help them achieve their cosmetic, functional, sexual, and psychological goals.

After an introduction to the relatively brief “history” of the surgical specialty and discussion of pertinent anatomy, and after a thorough discussion of patient rationale for surgery, elements of patient protection, and the relevant ethical issues involved, the specifics of the most commonly utilized surgical techniques for both vulvar and vaginal procedures will be dissected and discussed in detail. Following this, patient selection technique and the biomechanics and physiology of tightening operations as they relate to the female orgasmic cascade will be discussed in depth. After a review of surgical risks, individual chapters will be devoted to important topics such as choice of anesthesia, surgical venue, complication avoidance, transgender surgery, and the important topic of revisions and re-operations. The book continues with in-depth discussions of psychosexual issues, up-to-date outcome data, and a chapter devoted entirely to brief “pearls” involving physician and patient protection. The editor’s suggestions for implementing training programs and minimal “standards of care” will conclude the book.

References

1. 1. Goodman MP. Female cosmetic genital surgery. Obstet Gynecol 2009;113:154–96.
2. 2. Honore LH, O’Hara KE. Benign enlargement of the labia minora: Report of two cases. Eur J Obstet Gynecol Reprod Biol 1978;8:61–4.
3. 3. Hodgekinson DJ, Hait G. Aesthetic vaginal labiaplasty. Plast Reconstr Surg, 1984;74:414–6.
4. 4. Chavis WM, LaFeria JJ, Niccolini R. Plastic repair of elongated hypertrophic labia minora: A case report. J Reprod Med 1989;34:3737–45.

CHAPTER 2
Genital plastics: the history of development

Michael P. Goodman

Caring for Women Wellness Center, Davis, CA, USA

With a contribution from David Matlock

The only reason some people get lost in thought is because it’s unfamiliar territory.

Paul Fix

Documented since the time of the pharaohs in ancient Egypt, women throughout history have modified their genitalia via adornments, devices, colorations, bleaches, and reductive and expansive techniques.

Although gynecologic surgeons have for years performed surgical procedures resulting in alterations in genital size, appearance, and function (repairs after obstetrical delivery, perineorrhaphy, anterior/posterior colporrhaphy, intersex and transsexual surgical procedures), in addition to reductions for pediatric labial hypertrophy, Honore and O’Hara in 1978, Hodgekinson and Hait in 1984, and Chavis, LaFeria, and Niccolini in 1989 were the first to discuss genital surgical alterations performed for aesthetic and/or sexual reasons (see references 2–4 in Chapter 1).

Traditionally taught in OB/GYN residencies as surgical procedures designed for symptomatic pelvic floor herniations of bladder, urethra, rectum, or peritoneal cavity, but never proposed as a sexual-enhancing surgical procedure, traditional anterior and posterior “repairs” (colporrhaphies) are being adapted to improve sexual function by strengthening the pelvic floor and tightening the vaginal barrel to produce greater friction and vaginal wall pressure. This “shifting” of indications and modification of traditional gynecologic surgery primarily for reasons of enhancement of sexual function has not been without controversy, as gynecologic academic organizations such as the American Congress of Obstetricians and Gynecologists (ACOG) have official...

Table of contents

• Cover
• Title Page
• Table of Contents
• List of contributors
• Preface
• Acknowledgments
• CHAPTER 1: Introduction
• CHAPTER 2: Genital plastics: the history of development
• CHAPTER 3: Anatomic considerations
• CHAPTER 4: Definitions
• CHAPTER 5: Philosophy, rationale, and patient selection
• CHAPTER 6: Ethical considerations of female genital plastic/cosmetic surgery
• CHAPTER 7: Patient protection and pre-operative assessment
• CHAPTER 8: Surgical procedures I
• CHAPTER 9: Surgical procedures II
• CHAPTER 10: The biomechanics and physiology of clitoral and vaginally activated orgasm
• CHAPTER 11: The G-spot
• CHAPTER 12: Post-operative care
• CHAPTER 13: Aesthetic male-to-female transsexual surgery
• CHAPTER 14: Anesthetic choices and office-based surgery
• CHAPTER 15: Non-surgical cosmetic vulvovaginal procedures
• CHAPTER 16: Surgical risks and untoward outcomes
• CHAPTER 17: Revisions and re-operations
• CHAPTER 18: Psychosexual issues
• CHAPTER 19: Outcomes
• CHAPTER 20: Pearls for practice
• CHAPTER 21: Standards of care
• Index
• End User License Agreement