Like cosmetic procedures of the face, the breasts and the body, vaginal procedures focus on the elective alteration of normal structures. They are not treatments for medical conditions and offer no health benefits. Unlike these other established cosmetic procedures, the first public wave of cosmetic vaginal surgery emerged from the work of corporate-style entities which branded their procedures and treated their technical knowledge as private intellectual property. Over the past decade, cosmetic vaginal surgery has reached public awareness on par with other cosmetic procedures and a growing number of gynecologists, cosmetic surgeons and plastic surgeons are offering these services to their patients.
The Cosmetic Gynecologic Assessment
Following the initial conversation regarding the cosmetic request and the requisite psycho-social analysis, the physical examination is conducted. For cosmetic requests involving the vulvar structures or mons pubis, the physical examination is best conducted with the patient standing before a full-length mirror because this is typically the position in which they wish the appearance to be altered. The standard gynecologic dorsal lithotomy position is then assumed to better examine the full extent of the vulvar structures and to conduct a full gynecologic examination include an assessment of any infection which may interfere with the surgical procedure. For vaginal tightening operations there is no need for the standing examination unless there is suspicion of pelvic organ prolapse. However, there is a need to assess the existing width of the levator hiatus and the quality of the puborectalis muscle tone since this will be the focus of these procedures. A common practice is to measure the hiatus in fingerbreadths with the muscles at rest and with the muscles contracted then convert this data to centimeters.
The Mons Pubis
Liposuction of the mons pubis is a common procedure for the treatment of excess adiposity and is usually performed in conjuction with abdominal liposuction. The treatment tapers off into the anterior margin of the labia majora. Tumescent local anesthesia – a solution of saline, lidocaine, epinephrine and sodium bicarbonate – is the most common type of anesthetic used for this procedure. Mild postoperative swelling and slight temporary bruising extending to the labia majora are common in the first week after surgery. Mons pubis liposuction is also performed as an adjunct to abdominoplasty when the inferior edge of the incision line is significantly thicker than superior flap.
The mons pubis lift is a derivative of abdominoplasty techniques and targets significant laxity in the mons pubis region and sagging of the labia majora as viewed in the standing position. The procedure entails careful controlling of the central tension vectors when planning the resection pattern at the time of abdominoplasty. Whether the procedure is isolated or part of a larger abdominoplasty, excess tension at the lateral angles of the pubic triangle and curving the center of the scar cephalad are two aspects of the surgery which need to be avoided to generate an optimal cosmetic result. These goals are best accomplished with a high lateral tension-style excision pattern. The pubic lift integrates well with mons pubis liposuction.
The Clitoral Region
The Labia Minora
The Labia Majora
Varicose veins of the vulvar region respond to sclerotherapy in much the same manner as those of the lower extremity. Not infrequently, these varicosities are a source of pelvic pain and a gynecologic workup for pain should rule out other etiologies prior to treatment. Common sclerosing agents such as sodium tetradecyl sulfate are used and administered via small-guage needles attached to tuberculin syringes. The veins are targeted in the standing position and injected in the supine position. The technique is identical to sclerotherapy of the leg varicosities working from proximal to distal veins. A pelvic compression garment is worn for the first week post-injection.
Vaginal Tightening (Vaginal Rejuvenation)
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