This is the complete presentation delivered at Baystate Medical Center, Springfield, Massachusetts, on March 20, 2013. View the references here. View the slides-only YouTube version here. It is the pro stance in a pro-con debate on cosmetic gynecology delivered to an audience of non-cosmetic medical professionals, mostly gynecologists.

Beauty is sometimes described as a cultural currency. Nature distributes beauty randomly & this doesn’t sit well with our sense of wanting to treat individuals equally. But this is simply an observation.

The Egyptians were great admirers of beauty and left us with a large historical record of their efforts to enhance appearance. The ancient Greeks and the Romans personified their visions of beauty in the statues of their gods.

The Greek root of the word “aesthetics” means that which relates to sensory perception.

Aesthetics is the application of values and judgments to that which we sense, it’s totally subjective. Beautiful, good, bad, ugly, are applied to anything we perceive. We do this universally. But why do we do this?

It is theorized  that our thinking processes adapted along with our bodies to ensure survival  in the primitive world of the Stone Age. Our brains evolved  to do this.

The study of this topic is termed evolutionary psychology.  It’s a relatively new field, but it is gaining incredible traction among scholars in many disciplines. We're only going cover a few of the relevant aspects of evolutionary psychology as they relate to cosmetic surgery.

Evolution favors processes that maximize the reproductive potential of the population as a whole. 

Individuals who display reproduction-positive thinking processes will be more likely to reproduce & pass on those thinking processes to future populations. 

Over many generations and hundreds of thousands of years, the majority of individuals in future populations will display these traits.

Aesthetic standards of human beauty are an example of an evolved thinking process.

These unwavering qualities of human appearance have been deemed beautiful, attractive and desirable in every culture from the beginning of recorded history.

These standards have always existed and they are NOT arbitrary. 

They are a good complexion, symmetrical features, and youth.

But why are these the standards...?

Because they’re blatant displays of reproductive mate value.

They’re not perfect markers by any means, 

but if you’re back in the primordial savannah of the Stone Age, attraction to young, symmetrical, & smooth-skinned mates gives you the best reproductive odds.

Complexion, symmetry, & youth are the universal standards of beauty.

Psychologists, anthropologists, sociobiologists and others have studied people from vastly different cultures.

All of them have come the same conclusion. Study after study demonstrates consistency in judging beauty.

Photographs are shown to people from different cultures yet they all consistently agree on which people are most beautiful.

We don’t learn what beauty is, we know what beauty is…and it’s not in the eye of the beholder...

This startling revelation has been documented consistently in psychological studies using photographs of faces judged attractive by adults.

One study demonstrated this in 3-to-6 month-olds.

Another study, by one of the giants in this field, Judith Langlois, showed it in 2-to-6 month-olds.

A study in the late 1990s showed this tendency in newborns less than one week old.

One week old babies have standards of beauty.

And it’s the nature of both sexes.

Male or female, it’s seems unnatural to be attracted to anything else.

Let’s discuss the relationship between standards of beauty, which are natural, and the media, which is man-made.

Is the media really creating unhealthy stereotypes that otherwise wouldn’t exist?

Does the media really decide what beauty is?

If we suppose that advertising defines beauty, then we have to presuppose that complexion, symmetry and youth have no intrinsic attraction to begin with. 

Does anybody really believe that? Newborn infants don’t believe that. Stone Age man didn’t believe that. The ancient Egyptians didn’t believe that.

And marketing firms don’t believe that either.

So what’s their angle?

They hope that your attraction to complexion, symmetry & youth will spill over onto their product if it’s attached to it... Thank Dr. Pavlov and his dogs for the concept.

Advertising is all about getting attention. Catering to our natural attractions has always been the solid bet.

The problem with the media is perceptual contrast.

What that means is that to outcompete each other for attention, competitors need to use increasingly attractive people to succeed.

If you overexpose yourself to the media you might develop a distorted sense of what constitutes an average level of attractiveness, but you’re still attracted to complexion, symmetry and youth.

Portable technology attached to media distribution networks overexposes us to the media if we overuse it.

The Greek origin of the word “cosmetic” means to adorn or to make beautiful.

Cosmetic relates to the process of enhancing something to make it more aesthetic.

The term aesthetic surgery is a misnomer – what it really implies is that the surgery itself, like a ballet  is beautiful to watch regardless of what’s being done. It has no reference to intent.

Plastic means simply to reshape. It too, is without reference to the intent of the reshaping effort. 

If we use language precisely, then cosmetic surgery is the only term that appropriately defines surgery done with the intent to enhance aesthetics.

Like advertising, cosmetic medicine, surgery and products promote complexion, symmetry and youth.

But they promote it as something that you can participate in.

As a global culture, we don’t just accept cosmetic surgery & medicine.

We celebrate it and we participate in it…because it aligns with our attraction to complexion, symmetry and youth.

Just like the mirror in your purse, like the braces on your teeth, like the paint on your hair.

There has never been a shortage of opinion on cosmetic surgery, but in every culture that has ever existed people have willingly availed themselves of the methods and technologies available at that time 

to pursue enhanced complexion, symmetry and youth.

Some people don’t like cosmetic surgery,

and they don’t like that other people like cosmetic surgery. And they don’t like that people do cosmetic surgery,

but since our culture tolerates cosmetic surgery they try to attach cosmetic surgery to things that people don’t like

to try to convince people to think like they do.

They claim that cosmetic surgery is equivalent to false advertising.

Nobody likes false advertising.

Sure, there are plenty of examples of false advertising in cosmetic surgery, in non-cosmetic surgery, and in every industry that advertises, but that’s a judgment on advertising, not on the merits of surgery itself.

Some say that cosmetic surgery is porn-driven. It’s not.

Porn is media. They want to display complexion, symmetry and youth to sell their product just like any other type of media.

It’s another example of advertising promoting universal innate standards.

If porn were the global arbiter of style, then we could also make the case that leanness, bleached hair, overdone lips, breast implants and fake orgasms are porn driven too.

Don’t try to argue that pornography has ever set standards of beauty.

Porn is simply another messenger of the innate message of complexion, symmetry and youth.

Some people allege that since their elders didn’t discuss cosmetic surgery, that it’s a new fad.

Today’s Baby Boomers went through puberty in the 1950s. The parents of that generation were raised to consider many desires as things to remain unspoken 

& technology didn’t permit any outlet for information or access to products and services that exist today so that argument doesn’t hold up well at all to scrutiny.

Mom’s generation and Stone Age man would have behaved identically  to today’s generation if they had access to our knowledge and technology.

Let's explore the aesthetics of cosmetic gynecology in the light of what we know about human nature.

Despite the obvious fact that the genital area requires effort to make it viewable,

and that not everyone chooses it to make it viewable,

those who do view it from an aesthetic angle apply the same standards of beauty we are all born with.

When they view the genital area through the lens of complexion, symmetry and youth, they will develop an opinion.

Whatever that opinion is, they may choose to express that opinion by leaving nature alone, by decorating it, or by altering it with or without the aid of a surgeon.

If your opinion becomes your obsession you’ll need the services of a psychiatrist.

If not, you might visit someone like me.

This thought process applies to any part of the body.

Anyone who provides cosmetic services will tell you that the key to a successful outcome is in setting a realistic expectation.

Cosmetic expectations are unique to the individual & they can’t be measured like treatment outcomes because they are opinions.

You can perform identical cosmetic surgeries on identical twins with perfect healing, but the one who expected something else will not be happy.

That being said, public displays of some body parts are more ubiquitous than others so that there is a greater general awareness of the variety that exists in any dimension of a given part that is more widely displayed.

Thankfully, displays such as "The Great Wall of Vagina," by artist Jamie McCartney,  are permitting previously difficult- to-view areas become more publicly viewable.

Clearly, this allows for more robust opinions and therefore better decision making.

Most of the anti- cosmetic vaginal surgery noise comes from Great Britain. A small group of critics gets quoted widely.

Their real gripe is that their socialized medicine National Health Service is getting stuck with the bill for cosmetic vaginal procedures under the guise of bogus medical indications.

Australia and New Zealand have similar socialized healthcare & they mimic the British critics. It’s about limited money better spent elsewhere.

I would agree wholeheartedly that the cost of cosmetic surgery should come out of the patient’s pocket, but everything else they claim is poorly argued & unsubstantiated.

Cosmetic gynecology is a group of procedures.

The efficacy of any procedure is completely dependent on what is expected to happen via the procedure.

These procedures share the features of many existing procedures in therapeutic gynecology & the risk profile should be similar provided the surgeon has experience in the relevant therapeutic operations.

There is no single component of any cosmetic gynecology procedure that doesn't already exist in therapeutic gynecologic surgery.

These are general categories of cosmetic vaginal surgery in my current practice.

Cosmetic vaginal surgery is not intended to produce or enhance orgasms.

Some say that a gaping vagina isn’t a problem if it lacks pain, bowel dysfunction, or urinary dysfunction.

They dismiss the importance of vaginal sensation as something that benefits only the male partner & that women could care less.

This might apply to some women, but it doesn’t apply to many, many others. But if you don’t ask them, they won’t tell you.

The concept of tightening the vagina to enhance sex is over 1,000 years old.

The book, Treatments for Women, part of a popular medieval ensemble of books known as the Trotula was written by a woman in Salerno, Italy in 1050 AD.

It lists 5 recipes for tightening the vagina with constrictive agents.

Arnold Kegel wrote extensively of vaginal laxity and sex. He didn’t think that vaginal laxity was a bogus, male-oriented concern.

Increasing vaginal sensation, or coital grasp, is not the same thing as producing or augmenting an orgasm, but that doesn’t mean that some women don’t enjoy improving their sensation,

Especially if it has decreased greatly over time.

I had a vaginal delivery, kegels don’t work, I don’t have any of the problems on your pelvic floor checklist & I’m healthy.

Is there anything you can do? A woman may have a tight vagina, a gaping vagina, or anything in between, but this is the most common story I hear.

I saw a patient in consultation yesterday who was belittled and dismissed by a “pelvic floor surgeon” for raising these concerns & it’s not the first time.

Thanks to a general misunderstanding of somebody’s Committee Opinion, many gyns are uncomfortable treating this woman further and even hesitate to inquire about the sex life of their established patients – don’t ask, don’t tell, or go to hell.

They’ll either send her my way or tell her nothing can be done. Sad, but true. I hear these stories all the time.

In my practice, this patient gets a full pelvic floor evaluation which every gynecologist should know how to do and her kegel technique gets checked for adequacy. That's the starting point.

The method of a vaginoplasty is to tighten the caliber of the lower or distal vagina via posterior colporrhaphy and perineorrhaphy. 

This can only be done effectively if the pelvic floor suspension is relatively intact and the endpoint is defined. This can only be done effectively if the amount of tightening is measured with precision.


If not you’ll need to repair the pelvic floor a preliminary step.

If you skip the pelvic floor repairs, the existing floor damage might get worse or your tightening procedure might fail. 

The bottom line: don’t do vaginoplasties if you’re unfamiliar with these types of repairs unless you get someone experienced in these procedures to help you.

The procedures don't fail in achieving the goals they are designed to accomplish. Failure is in choosing the wrong procedure for the wrong reasons.

Labiaplasty is performed for various reasons, it’s not always bilateral, it’s not always excisional, and the anatomy varies widely.

If we’re going to discuss labiaplasty we need to keep these things in mind. Especially since the procedure may involve just a little bit of surgery or something more involved.

Also, labiaplasty is not a new operation, and neither is "cosmetic" a new indication. The first labiaplasties were done in seventh century AD for aesthetic reasons as well as for symptomatic ones, but not necessarily for both together.

This knowledge has been widely available for over three hundred years.

The British opponents of cosmetic vaginal surgery have attempted to extrapolate the complications of extensive surgery performed on newborns in the 1970s

by techniques abandoned in the 1980s

as potential complications of cosmetic labiaplasty on normally developed adult women.

All of these troublesome effects of intersex surgery are related to nerve damage associated with partial amputation of the clitoris, folding of the clitoral shaft, or with the creation of false labia from surrounding tissue.

None of this bears any similarity to cosmetic labiaplasty nor to cosmetic alterations of the loose skin around the clitoral hood which do not impinge upon the clitoral nerve supply.

I don’t like the way they protrude. They don’t cause any discomfort whatsoever...

This is a pure cosmetic request. Her request is not about sexual function. She needs to understand that, you need to understand that.

The intent of cosmetic labiaplasty is to achieve the anatomic endpoint requested by the patient. If the request or expectations are unrealistic, the intent will not be realized.

They bother me...

This is either a pure cosmetic request in disguise or a valid complaint. Evaluation for causes of vulvar pain is the first step. 

Sadly, if labiaplasty is required many physicians and all insurance companies will deny the request.

There is a misconception among gynecologists and other surgeons that labiaplasty is a quick and easy procedure.

They believe that the procedure consists of a crude amputation with oversewing of the labial edge. It is true that butchery of that sort can be accomplished quickly.

But that is not cosmetic labiaplasty, that is labial amputation & it will never yield satisfactory aesthetic results.

Sadly, I've seen the technique used on documentaries painting labialplasty in a negative light.

A real cosmetic labiaplasty takes thoughtful aesthetic planning, anatomic caution, and meticulous technique. This takes time, patience and skill.

It's not a coincidence that those who perform a large volume of cosmetic labiaplasties take their time.

Another poorly constructed argument by the British opponents of cosmetic labiaplasty postulates that since labia vary greatly in dimensions and patients requesting cosmetic labiaplasty fall generally within the normal range of measurements, they shouldn't be permitted to alter these dimensions.

Not only is this argument absurd & inconsistent when one considers that the majority of all cosmetic requests on any part of the body involve structures which fall within the normal range of dimensions, but it completely misses the point that those who request cosmetic alterations wish to be in a specific ideal range within the normal range.

It's hypocritical & patriarchal when these small groups with extreme ideas intolerantly criticize those who have a differing opinion on cosmetic surgery and they remain silent on parallel procedures performed performed upon males or upon other body parts.

Those who are unfamiliar with cosmetic surgery fees claim that prices seem high. Their basis for comparison might be the low frequently undervalued reimbursement rates that they accept for their work from third-party payers for therapeutic medical services.

But cosmetics is not therapeutics. It's a luxury service. 

In fact, taking similarities in operating time and requisite resources into consideration, cosmetic vaginal surgery fees are in the same range as most breast augmentation and liposuction procedures, and less than those typical of abdominoplasty, face lifts, and cosmetic dentistry.

No talk about cosmetic gynecology would be complete without talking about David Matlock.

David started out practicing Ob Gyn in Beverly Hills in the 1980s. He started offering vaginoplasties to enhance sex in a newspaper ad after a few patients who underwent colporrhaphies for gyn conditions mentioned that it had a positive effect on sex.

He went to business school several years later and made this the focal point of a business school project.

He trademarked his style of vaginoplasty and labiaplasty, then added the G-shot for the G-spot to round out his portfolio of cosmetic gyn services.

Then he developed a franchise model for others to learn the procedures and perform the procedures using trademarked terminology.

But what really departed from anything that had been done by anyone in medicine before was that he instituted a gag clause.

He started this business in 2002 with heavy advertising in journals and then at meetings.
Around the same time, cosmetic surgery exploded in popularity worldwide thanks to the introduction of botox, reality tv, a lax credit market and the birth of social media.

Cosmetic gyn was all over the media even though in reality, the number of cosmetic gyn surgeries, even in David’s clinic didn’t approach the number of procedures performed for breast augmentation or liposuction in busy cosmetic practices including his own.

Nonetheless, in 2007, ACOG, for the first time addressed cosmetic vaginal procedures by means of a Committee Opinion from the Committee on Gynecologic Practice targeted directly at David’s business.

The committee which produced the opinion defines itself as a developer of state-of-the-art commentaries.

The ACOG Committee on Gynecologic Practice produced 3 Opinions in 2007.

As you would expect, they normally support their state-of-art opinions with references. As you can see, the first two had a total of 22 references combined, but this opinion only had one reference.

They carefully crafted their document to identify all of Matlock's trademarked terminology without infringing upon the trademarks and incurring legal exposure.

They stated that his terminology was unclear, they speculated as to what they thought the procedures might be, they speculated as to what they thought the complications might be based on their unreferenced assumptions, they filled it with innuendo.

But most importantly, what they didn’t do was interview David.

The ACOG motive for issuing an alarmist document lacking even the most basic review of relevant literature is unclear, but it does not appear that the motive was to produce a state-of-the-art commentary.

It only has one reference.

And what was this incredible reference...

A paper that states that vulvar and vaginal dimensions vary. That’s it!

Strangely enough, just one year later a non-physician from New Zealand submits a review article on cosmetic gyn and finds over 150 references many of which predated the ACOG opinion.

The merit of this document needs to be understood for the piece of political propaganda that it represents. It has stood unchallenged long enough and it has never been a state-of-the-commentary on cosmetic vaginal surgery.

I’m done talking about David & stirring up the pot.

We need to stop ignoring people who request cosmetic gynecology services.

We need to stop dismissing their concerns as trivial.

We need to accept that there is nothing wrong with cosmetic surgery.

We need to give realistic expectations of what cosmetic surgery can and cannot accomplish.

END OF LECTURE

Vaginal rejuvenation, or tightening, is over one thousand years old, and it was conceived by women. As mentioned in Part I, the work of the female physician Trotula de Ruggiero of Salerno was published in 1050 AD under the title Treatments for Women. In this volume are five nonsurgical recipes for "restoring" virginity. The section opens as follows:

Renowned Medieval historian Monica Green who spent decades researching all extant versions of the Trotula ensemble and Salernan culture prior to her definitive translation opines:

The Renaissance brought major advances in anatomic knowledge through cadaveric dissections best represented by Vesalius (1514-1564) at the University of Padua in De Humana Corporis Fabrica. Owing to the invention of the printing press, this knowledge became widely disseminated. However,  little if any change in took place in gynecologic surgical technique or instrumentation from that of the Greco-Roman era .

Nonetheless, celebrated French surgeon Ambroise Paré (1510-1590) in Gynaeciorium Physicus et Chirurgicus, then his pupil Jacques Guillemeau (1550-1612) in his 1609 text De la Grossesse et Accouchement des Femmes, were first to describe repairs of  rectovaginal lacerations at childbirth.

Spaniard Roderico a Castro (1546-1627) described clitoridectomy by a horse hair ligature tightened daily in Philosophiae Ac Medicinae Doctoris per Europum notissimi first published in 1604.

The first illustration of excision for clitoral hypertrophy was provided by the German surgeon Johann Schultes (aka Scultetus 1595-1645) in Armamentarium Chirurgicum published posthumously in 1655. 

Pierre Dionis, a Parisian surgeon,  described excision of the nymphae (labiaplasty) in his Cours d’opérations de chirurgie (1707) based on his work in the late 1600s in the court of Louis XIV.

German military surgeon Lorenz Heister (1683-1758) described labia minoraplasty in full detail in his text, Institutiones Chirurgicae (1739),  one of the most popular illustrated surgical texts of the eighteenth century:

1. Vaginal rejuvenation, or tightening, is over one thousand years old, and it was conceived by women.
2. Clitoroplasty, in the Western world, was performed for appearance only through the eighteenth century.
3. Labiaplasty was an established treatment for both symptomatic and aesthetic concerns by the late seventeenth century.