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Red M. Alinsod, M.D., FACOG, FACS, ACGE 73

In the News

Int Urogynecol J
DOI 10.1007/s00192-013-2117-8 Int Urogynecol J
REVIEW ARTICLE
Western perception of ideal female external genitalia cutting and treatment for labial hypertrophy or asymmetry
differs from other countries. In Rwanda and Mozambique secondary to congenital conditions, chronic irritation, or ex-
elongated labia minora are considered attractive [10, 11]. cessive androgenic hormones [17].
Female genital cosmetic surgery: a review of techniques Elongated labia minora are seen as a sign of modesty in Surgeons focused on vulvar aesthetics also cite vaginal
and outcomes Mozambique, and the butterfly appearance of the labia relaxation, feeling loose or lacking friction during intercourse,
minora is considered desirable in Japan [11, 13].
and enhancement of a partner’s sexual experience as additional
reasons to pursue FGCS [18]. In one multicenter retrospective
Cheryl B. Iglesia & Ladin Yurteri-Kaplan & Red Alinsod study, 76 % of 258 women underwent surgery for functional
Cosmetic gynecological surgery versus female genital reasons; 53 % percent had surgery for cosmetic reasons and
mutilation 33 % to enhance self-esteem. Fifty-four percent of women who
underwent vaginoplasty and perineoplasty and 24 % of those
Critics of FGCS note parallels with female genital mutila- who had a combined vaginoplasty, perineoplasty, labiaplasty,
tion surgery (FGMS) [13]. According to the World Health and clitoral hood reduction did so to enhance their male
Received: 15 April 2013 /Accepted: 18 April 2013 Organization, female genital mutilation comprises all pro- partner’s sexual experience. Only 5 % of participants
# The International Urogynecological Association 2013 cedures that involve partial or total removal of external underwent surgery because they were urged by their partner
female genitalia, or other injury to female genital organs [18]. In another retrospective study on labiaplasty, 94 %
Abstract The aesthetic and functional procedures that com- Keyword Female genital cosmetic surgery . Cosmetic for non-medical reasons [14]. There is legislation and call (503 women) felt that their labia minora protruded beyond
prise female genital cosmetic surgery (FGCS) include tradi- gynecology . Vaginal rejuvenation . Labiaplasty . for reform in some European and Western countries based the edge of the labia majora, 46 % felt that their labia
tional vaginal prolapse procedures as well as cosmetic Vaginoplasty on this definition [15]. Clearly, opponents of FGCS are minora were enlarged, and 71 % felt that the edges were
vulvar and labial procedures. The line between cosmetic motivated by a desire to protect women from the potential dark [19]. Fifty-two percent wanted the labia minora edge
and medically indicated surgical procedures is blurred, and dangers of elective genital surgery and the societal pressures below the labia majora [19].
today many operations are performed for both purposes. The Introduction some girls and women may feel about the appearance of
contributions of gynecologists and reconstructive pelvic their own genitalia. While FGMS should be prosecuted,
surgeons are crucial in this debate. Aesthetic vaginal sur- Consumer marketing and media hype have spawned the con- FGCS is a matter of debate. The decision to operate should Types of cosmetic surgery
geons may unintentionally blur legitimate female pelvic siderable controversy over female genital cosmetic surgery account for the physical and mental health of each patient,
floor disorders with other aesthetic conditions. In the ab- (FGCS). FGCS articles first appeared in North American including assessment for body dysmorphic disorder. The types of cosmetic surgery are detailed in Tables 1–3.
sence of quality outcome data, the value of FGCS in im- journals in 1978, and the first technical article appeared in Informed consent of the potential benefits, risks, and limited
proving sexual function remains uncertain. Women seeking 1984 [1, 2]. This review describes the techniques and outcome outcome data should be reviewed and consideration for Vaginoplasty/vaginal rejuvenation/vaginal tightening
FGCS need to be educated about the range and variation of data of labiaplasty, vaginoplasty, and other cosmetic gyneco- additional evaluation by a clinical psychologist or psychia-
labia widths and genital appearance, and should be evaluat- logical procedures. trist may prove useful. Vaginoplasty refers to plastic surgery of the vaginal opening,
ed for true pelvic support disorders such as pelvic organ vaginal canal, and vaginal epithelium. Perineoplasty is the
prolapse and stress urinary incontinence. Women seeking surgical reconstruction of the vaginal introitus and is often
FGCS should also be screened for psychological conditions Female genital perceptions Surgeons performing FGCS part of a complete vaginoplasty repair. Vaginoplasty is not
and should act autonomously without coercion from part- intended to correct pelvic floor defects; however, these repairs
ners or surgeons with proprietary conflicts of interest. Women seek FGCS for both aesthetic and functional reasons Traditionally, gynecologists are most comfortable with vag- are modifications of traditional colporrhaphy and are frequent-
including pain with intercourse or sports, vulvar irritation, chaf- inal and vulvar surgery. However, more plastic surgeons ly performed in conjunction with reconstructive procedures
ing, and discomfort with underwear or clothing [3]. Younger have been performing FGCS, and have added modifications for prolapse [20].
C. B. Iglesia generation X women (ages 18–44) prefer pubic hair removal, such as fat grafting. A survey of the American Society of “Laser vaginal rejuvenation” is a trade-marked term and
Section of Female Pelvic Medicine and Reconstructive Surgery,
MedStar Washington Hospital Center, Washington, DC, USA which allows for easier vulvar visualization compared with Plastic Surgeons revealed that more than half (51 % of the most commonly refers to traditional posterior and anterior
older women [4]. Konig et al. found that 78 % of 482 women 750 respondents) offer labiaplasty [16]. Only 31.5 % had colporrhaphies carried out to treat a “wide” vagina [8, 18,
C. B. Iglesia (*) learned about labia minora reduction via the media and 14 % formal training for this procedure. Case volume over 21, 22]. These procedures involve vaginal reconstructive tech-
Departments of ObGyn and Urology, Georgetown University thought their own labia minora looked abnormal [5]. Indeed,
School of Medicine, 106 Irving Street, NW Suite 405 South, 24 months ranged from 0 to 300 procedures with a mean niques to anatomically modify the vaginal caliber by decreas-
Washington, DC 20010, USA many women undergoing labia minora reduction perceive their of 7.37 procedures. Gynecologists, urogynecologists, and ing the diameter of the lower third of the vagina while
e-mail: cheryl.iglesia@medstar.net own genitalia as abnormal [6]. Feelings of embarrassment with urologists also perform FGCS. While no formal training reconstructing the perineal body [21, 23–26]. A “full-length
sexual function including a strong desire to improve strained programs exist, several marketing and franchised training vaginoplasty” consists of decreasing the vaginal caliber of the
L. Yurteri-Kaplan relationships are also commonly cited as reasons for FGCS [7].
Section of Female Pelvic Medicine and Reconstructive Surgery, programs have been developed in the USA and abroad. lower two thirds of the vagina as far up as the ischial spines
MedStar Washington Hospital Center, Georgetown University Issues of vulvar dissatisfaction can start in early adolescence [26]. The desired surgical outcomes of these procedures in-
School of Medicine, 106 Irving Street, NW Suite 405 South, and have been reported in girls less than 10 [8, 9]. Michala et al. clude improvement in both aesthetic external appearance and
Washington, DC 20010, USA evaluated 16 girls with a mean age of 14.5 years who presented Indications for cosmetic gynecological surgery an increase in frictional forces during intercourse; however,
for labia minora reduction [8]. Six girls were bothered by labia loss of sexual pleasure due to vaginal laxity has not been
R. Alinsod
South Coast Urogynecology, Inc, 31852 Coast Highway Suite 200, minora asymmetry while 10 complained of labia minora pro- In general, cosmetic surgery does not require a medical indi- established [24], and no currently published FGCS studies
Laguna Beach, CA 92651, USA trusion, despite having normal labial width. cation. According to a 2007 ACOG committee opinion, in- adequately address the complex psychological components
dications for FGCS include reversal or repair of female genital involved with sexual function and response. No comparative
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