This article was originally published on LinkedIn on August 30, 2018.
I just got off the phone from two calls. The first was a surgeon seeking vaginal rejuvenation training and the second was a patient seeking a vaginal rejuvenation procedure. They sought my expertise on two completely different things. The never-been-lucid definition of vaginal rejuvenation is growing in many directions unimagined in years past. On a regular basis, it takes twists and turns as educated proponents, ignorant proponents, and detractors add narrative- and agenda-loaded meanings to this volatile term.
Why is this happening? I see a few major reasons: Foremost is large-scale marketing. Second, is the catalytic effect of social media on a level unknown when the first iteration of vaginal rejuvenation made its debut in the late 1990s. A public whose sole education on the term arises from repetitive marketing to their smartphones and whose knowledge of their bodies appears quite limited has no filter with which to distill whatever the Oprahs and Dr. Ozs of the world feed them via colorful Hollywood-quality vignettes. Their “research” is overwhelmingly a collection of marketing materials dressed up with pseudoscience. It’s time to separate fact from fiction.
Vaginal childbirth has been has been destroying vaginas since the beginning of time and modern pelvic floor research has been confirming what mothers have known for generations. Focus has been on the vaginal supports, bladder and bowel dysfunctions, and prolapse. Curiously, vaginal laxity is excluded from this conversation in medical circles, in the gynecologic literature and at meetings of large academic gynecologic societies. I invite you to search the term “vaginal laxity” on the websites of ACOG and FIGO, the two largest gynecologic academic societies in the world and that of AUGS, the largest urogynecologic society in the world to witness this void personally.
I have yet to find a female patient who states that sex improved after vaginal childbirth. These women have gynecologists who deliver babies every day. Many gynecologists are mothers themselves. They see the vaginal trauma of childbirth day in and day out and experience the aftermath personally. Sadly, I would have trouble swinging a cat in a room full of academic gynecologists without hitting an opponent to the concept that tightening the vagina might improve sex after vaginal childbirth.
You can live without treating it. It’s a lifestyle issue they say. True. That was the world pre-1996. But what else can we live without treating – fertility, infertility, unwanted pregnancy, foreskins. All of the latter are essentially lifestyle issues on which the specialty is deeply rooted.
The Day Sex Got Better
A patient underwent gynecologic anterior and posterior vaginal repairs for medical indications in Beverly Hills, California, in 1996. A few months later she told her surgeon, David Matlock, that her sex life had also improved; she said that it was because her vagina felt tighter. She referred a friend to him for the same operation. She had no medical indications, but she had a lax vagina that she wanted tighter to improve her sex life too. Dr. Matlock acceded to the request. Her sex life improved. Vaginal rejuvenation was born. (ref: conversation with Matlock, 1999)
David Matlock, MD, became David Matlock, MD, MBA. In the process, he learned about marketing, intellectual capital, and trademarks. In 1998, he labelled his operation Laser Vaginal RejuvenationTM and added Designer Laser VaginoplastyTM (a labiaplasty procedure despite the name), and the G-shotTM (a dermal filler injection for the G-spot) to his repertoire.
Why Laser? Two reasons: Matlock preferred the laser scalpel to the steel scalpel for his anterior and posterior repairs having learned to use the technology in his residency training. Lasers were introduced to the field of gynecology in the early 1970s and were a topic of intense academic and private practice interest and study well into the 1980s and 1990s. Second reason: To this day, “laser” has unparalleled marketing power to patients.
A Bodacious Adolescence
When you launch Laser Vaginal Rejuvenation in the epicenter of aesthetic culture and entertainment media, it gets noticed. Matlock became a global celebrity. Women added Laser Vaginal Rejuvenation to their Mommy Makeover bucket lists and other surgeons, naturally, wanted in on the action.
Matlock saw the potential market and created the Laser Vaginal Rejuvenation Institute of America to train surgeons in his techniques and license his trademarks. He utilized a franchise model and Laser Vaginal Rejuvenation began its widespread growth. Competitors emerged and, unable to use the trademarked terminologies, created their own nicknames for their versions of these procedures. The most common of these was simply vaginal rejuvenation.
The End of the Beginning
Gynecologic academia had consistently stayed out of the aesthetic/cosmetic arena and periodically reaffirmed this stance in public statements. However, the emergence of social media (Facebook 2004, YouTube 2005, Twitter 2006, iPhone 2007) created a wave of global attention on vaginal rejuvenation on which the academics were forced to offer commentary. In September 2007, the prominent American College of Obstetricians and Gynecologists (ACOG) released ACOG Committee Opinion No. 378: Vaginal "Rejuvenation" and Cosmetic Vaginal Procedures – a document which was parroted by academic societies around the world.
A brief five paragraphs and one reference long, this document has been misquoted, misinterpreted and misused widely by people at all levels of intelligence ever since it came out. The opinion attempts to define vaginal rejuvenation, yet opens with the admission that the authors are unclear of the exact nature of the procedures upon which they are opining. It lists Dr. Matlock’s trademarked portfolio procedure-by-procedure sans the word “laser,” yet they neither interviewed Matlock nor observed his work (ref: conversation with Matlock 2007; conversation with ACOG committee members 2008).
The second paragraph reiterates the trademarked terminology, questions its safety and effectiveness, and adds that it lacks data. Perhaps, if they had learned that Laser Vaginal Rejuvenation was an alias for gynecologic vaginal repairs with over a century’s worth of robust data, they might have concluded differently.
The third paragraph disparages the businesses of franchising, marketing, and paying for education. This is a direct objection to Matlock’s business model, but it didn’t apply to anyone else in the vaginal rejuvenation arena. Hypocritically, most if not all college and postgraduate educational programs require payment to the educators and most if not all academic societies, ACOG included, demand annual fees for the right to use their letters of distinction.
The fourth paragraph is best characterized as The Insanity Plea: a woman requesting these procedures needs a long talk to convince her that she’s normal. The lone reference in entire opinion is attached to this paragraph - a study that found that labia minora came in different shapes and sizes in 50 British women.
The concluding paragraph complains that women are being misled, that the procedures are not routine, reiterates the lack of data misconception, and out of thin air adds a list of potential complications that may arise from procedures on which the authors already stated they are unclear.
The Rise of the Machines
For the first decade and a half of it’s existence, vaginal rejuvenation was a surgical procedure for vaginal tightening with a steep barrier to entry - expertise in internal vaginal surgery – skills limited to gynecologists, urogynecologists, and some urologists. Then, the game changed.
Beginning in 2009, pioneering gynecologists in Argentina and Italy began developing techniques for nonsurgical laser treatments of the vagina aimed initially at vaginal atrophy. Working in conjunction with the industry’s standard laser platforms, they devised equipment and protocols for fractional carbon dioxide laser ablation based on existing dermatology protocols. Over the next few years, other groups began clinical investigations into the treatment of urinary incontinence and vaginal laxity working with a variety of lasers. This era culminated with the entry of Deka (MonaLisa) and the Alma (FemiLift) CO2 lasers for noninvasive vaginal ablation into the US market in late 2014. From then until now, the market has literally exploded and almost every major laser manufacturer makes a vaginal probe for their platform and radiofrequency technologies have followed suit.
The Marketing Paradox
How do you market a vaginal laser in the US? This was the challenge for the industry in 2014. Most lasers owners were plastic surgeons, dermatologists and other aesthetic professionals who hadn’t done a pelvic exam since medical school. All of the applications for vaginal lasers to date were purely gynecologic in nature – atrophy, incontinence, and laxity, but most gynecologists weren’t early adopters and wouldn’t buy a laser unless they were sure of a steady market for the service and saw homegrown proof of its efficacy from experts in the field irrespective of the overseas experience.
Marketing took a two-pronged approach: For existing aesthetics based laser owners, the theme became nonsurgical vaginal rejuvenation to get a piece of the vaginal laxity market and leave the rest to the gynecologists. For gynecologists, it was marketed first to academically inclined urogynecologists to establish credibility of efficacy. Since many in the gynecologic academic community had been mentally “poisoned” to the term vaginal rejuvenation in 2007 and eschewed any mention of vaginal laxity treatments, vaginal atrophy and urinary incontinence were the exclusive focus. For patients, the terms vaginal health and feminine health were created for direct marketing.
Mass Confusion Wins
By mid-2015, gynecologists and non-gynecologists alike were marketing laser vaginal rejuvenation, vaginal rejuvenation and nonsurgical vaginal rejuvenation online as synonyms for a variety of surgical and nonsurgical procedures well beyond the original meaning and intent of Matlock’s vaginal repairs. To confound matters further, patients doing online research on incontinence and vaginal atrophy were finding themselves in the offices of non-gynecologists without the benefit of a gynecologic assessment. The confusion persists to this day and continues to worsen as the number of devices and treatments continue to grow. At the present time, vaginal rejuvenation has so many possible meanings that it has no specific meaning.
When a woman tells me that she wants vaginal rejuvenation today, I have absolutely no idea what the term means to her and what issues she is seeking to address. It might be a gynecologic issue. It might be an aesthetic issue. It might be surgical. It might be nonsurgical. I also have no idea what her expectations might be as her judgement may have been seriously clouded by whatever “research” she has chosen to believe.
Vaginal rejuvenation in 2018 is a conversation starter, an icebreaker. The challenge in the conduct of this conversation is to understand that the average patient is clueless about her body, jaded with the expectations of mass media marketing hype, and completely at the mercy of the physician’s ethical compass.
Marco A. Pelosi, III, MD, is a cosmetic gynecologist, surgeon, lecturer & cofounder of the ISCG. You may contact him directly at firstname.lastname@example.org