Increasingly, there is more media “chatter” about women’s sexuality issues—how many women have sex, how they feel about it, what does and does not affect libido, what type of men most women prefer. The questions seem unending.
Fifteen or more years ago, this type of discussion was virtually unheard of in the media. In fact, it was rarely, if ever, discussed in private in mixed company. Arguably, this revolutionary change may have begun with the creation of Laser Vaginal Rejuvenation (LVR), a trademarked procedure invented and popularized by my colleague David Matlock, MD, MBA, FACOG, in the late 1990s.
As the popularity and acceptance of this procedure have grown, the entire industry of female plastic pelvic reconstruction has evolved into a much sought-after specialty.
In addition, the LVR procedure has become very popular among women along with other pelvic plastic procedures such as labiaplasty, vaginoplasty, and “designer vaginas,” to name a few.
One technical question to ask is, are these procedures a specialty or a subspecialty? Do they belong to gynecological surgery, pelvic and reconstructive surgery, urogynecology, plastic surgery, or cosmetic surgery?
Who should be performing the bulk of these procedures? Female plastic pelvic reconstruction has a nice ring to it. Vaginal rejuvenation has certainly become a specialty area and involves much more knowledge of pelvic anatomy and pathology than the term may suggest.
What Is Vaginal Rejuvenation?
Vaginal rejuvenation involves the dissection, identification, and plication of the fibromuscular and supportive layers of the vagina, with the trimming of excess skin, then reconstruction in an anatomically correct and cosmetic fashion.
These vaginal fascial and muscular layers, as with so many other areas of the body, suffer damage and can weaken from the onset of aging, the trauma of childbirth, genetic factors, parity, menopause, prior pelvic surgery, connective tissue disorders, body habitus, and personal habits.
With vaginal rejuvenation, the emphasis is on cosmetics with consideration of correction of the defects.
Historically, the procedure evolved from a more traditional gynecological surgery, the anterior/posterior colporrhaphy. This surgery was reserved for the patient who was experiencing low pelvic pressure, urinary stress incontinence, rectal splinting, and the feeling that something was falling out of their vaginas.
On examination, these patients were found to have a well-developed cystocele and/or rectocele—a weakening of the anterior and posterior walls of the vagina. These patients were generally older women with large parity. Strong emphasis was placed on these patients having advanced vaginal prolapse before they were considered candidates for surgery.
Vaginal rejuvenation, on the other hand, places more emphasis on patients with less severe anatomical defects, but with more subjective symptoms of vaginal laxity, cosmetically displeasing appearance of the vagina, loss of libido, and lack of sexual pleasure.
One question that arises is, when do you perform the more traditional procedure? What about a patient with hypo-
estrogenization? What about a patient with an enlarged uterus? Does this patient plan on having more children? What about other gynecological pathology? What about the condition of the vaginal tissue? Should this patient have a separate procedure performed for stress urinary incontinence?
In recent years, a huge industry has evolved surrounding pelvic support issues. Specialties and subspecialties have evolved. Graft materials have found their way into reconstructive procedures. The American College of Obstetricians and Gynecologists has tried to ignore the cosmetic aspect of a woman’s health, stating that it sees no value for the cosmetic aspects of this industry—and, therefore, no justification for vaginal rejuvenation.
From the point of view of a gynecologist and gynecological surgeon who has been performing vaginal rejuvenation almost since the coining of the term and the promotion of the concept—as well as someone who is well trained in the more traditional procedures, such as anterior and posterior colporrhaphy for pelvic organ prolapse—I believe that patients are best served by a gynecologist who has trained specifically in this procedure.
I believe there is a place for a special and separate area of combined gynecological/cosmetic surgery. Because of the many aspects to be considered in performing these procedures in a medically correct and beneficial fashion, physicians must study pelvic organ prolapse and gynecology in-depth.
For someone who understands, pelvic anatomy is clear. For the general medical physician or even the general gynecologist, it can be confusing.
The pelvic girdle is composed of a number of interlocking and overlapping supportive fascial layers and muscles that contribute to the overall support and normal functioning of the vagina and its surrounding structures. When these support mechanisms fail, one is faced with some of the complaints that we hear from patients seeking pelvic reconstruction.
For older patients, traditional symptoms include pelvic pressure, vaginal pressure, stress urinary incontinence, heaviness, difficulty voiding, difficulty defecating, back pain, and discomfort. For these symptoms, one may want to perform an anterior/posterior colporrhaphy or even one of the newer mesh procedures.
Younger or more sexually aware patients have different complaints, such as a lack of sexual gratification and difficulty feeling their partner; feelings of loss of sexuality, lack of self-worth and self-consciousness, and a sense of being unattractive and less feminine; and a lack of sensitivity during intercourse.
These feelings may result in the avoidance of other people and the avoidance of their own sex partners. Some patients have said they are afraid of getting undressed in front of their husbands or partners.
Many newly divorced women seek reconstruction procedures because they believe that they are unable to bond with a new partner without fixing things “down there.” These patients, upon physical examination, may be less obvious candidates in need of a vaginal repair than those with typical complaints consistent with prolapse. However, they may need a cosmetic—or a plastic—repair.
This does not eliminate the patient who has symptoms of vaginal relaxation, such as urinary incontinence or rectal splinting, from being a candidate for plastic pelvic reconstruction. It just means that all these symptoms must be taken into consideration when evaluating a patient for vaginal rejuvenation.
The idea that a woman might need to have vaginal surgery to give her feelings of self-worth has never really been considered or held in any high regard. Nonetheless, we are faced with a new generation of women who request—and will eventually find—a physician who will listen to their complaints and act on them.
The Cosmetic Mind-set
The procedure differs from a traditional anterior/posterior colporrhaphy in a number of ways. One has to have the mind-set of performing a cosmetic procedure, because patients who seek this procedure are looking for functionality and beauty.
One has to consider the development of clear tissue planes in order to reconstruct the tissue properly. The avoidance of long-term complications, such as stricture, recurrence, and dyspareunia, depends on the careful dissection and plication of all muscle layers in a very systematic fashion.
The Preoperative Evaluation
The office evaluation consists of taking a complete medical history, including urinary and bowel function, and a surgical history—has she had a hysterectomy or previous pelvic surgery, and how did she respond to previous surgery?
In addition, has she had previous bladder repair surgery, or any history of pelvic pathology such as an abnormal PAP and uterine problems? What are her reproductive plans and hormonal status?
Evaluate her sexual activity and the normality of sexual activity.
Is bowel function normal? What is her quality of life? You should perform some sort of psychological evaluation.
The vaginal examination should focus on thickness of the vaginal wall, pelvic abnormalities, hormonal effects, severity of prolapse (if any), abnormal sensation, urethral status, degree of cystocele and rectocele, perineal body thickness, vaginal closure pressure, and apical prolapse defects. Urinalysis, evaluation of bladder status and incontinence, vaginal cultures, and menstrual history should also be evaluated.
Possess a clear understanding of the normal anatomy, interactions of the connective tissue, and muscular support; as well as an understanding of the relationship between anatomy, support, and sexual function.
What else is necessary to provide the best correctional surgery (with an emphasis on plastic reconstruction)?
More in-depth analysis and study are needed in the areas of pelvic organ prolapse, vaginal support, anatomical considerations, and their specific relationship to different compartmental symptoms attributable to sexual dysfunction.
One of my concerns is that certain specialists who perform these procedures have not been trained in basic gynecological surgery and basic gynecology. They may not consider some of the conditions that will influence success rates as well as the statistics on these procedures.
For example, will they recognize when a patient will need pretreatment with estrogens? What about patients who have concomitant paravaginal defects, other pelvic pathology, vaginal apical defects, or stress urinary incontinence? Even though anterior colporrhaphy can correct stress urinary incontinence, newer and more successful procedures are now available. Has the physician learned how to do these as well?
Statistically, we are now looking at the success rates of anterior colporrhaphy against mesh procedures. These mesh procedures use propylene mesh to replace the defective fascial support of the pelvis. They are showing statistics that indicate better long-term results in patients undergoing mesh placement.
However, what are they looking at? Recurrent prolapse? How closely are they looking at the experience and technique of the surgeon who performed the colporrhaphy? Does using a laser make a difference? Is the surgeon performing a complete vaginal rejuvenation procedure or an anterior colporrhaphy?
They may look at dyspareunia, but I have yet to see articles that address sexual gratification. Can the mesh contract around the penis the way a retightened levator ani muscle will, once reconstructed? After the mesh is in place, does the patient feel as sexually knowing as she once did?
All vaginal rejuvenation procedures do not involve reconstruction of the anterior wall of the vagina. Some patients need only rejuvenation of the posterior vaginal support.
One thing we need to look at is when a cosmetic gynecologist examines a woman coming in for a plastic pelvic reconstructive procedure: Does he or she look at not only the gynecologic pathology and how it will influence the outcome, but also the cosmetic aspect of the repair? Does the number of children this patient has had influence the way he or she will approach the surgery? What about the patient’s age as well as psychosocial factors? What support has the physician made available for problems that may arise after the surgery, such as stricture, dyspareunia, and vaginal shortening?
PATIENT PSYCHOLOGY IS KEY
Psychosocial issues must be addressed. I know of a colleague’s patient who returned to the office multiple times after her vaginal rejuvenation because her husband thought she was still “too loose,” she was “still not feeling anything,” she could not achieve orgasm, and so forth.
The patient’s vagina barely admitted two fingers, which is the standard size for the tightening, and she exhibited strong vaginal closure pressure. No amount of counseling, reassurance, or therapy seemed to remedy the situation.
Let us not all grow so anxious to perform these procedures that we neglect to investigate why the patient seeks out surgery in the pelvic area. A woman who wishes to have a breast augmentation, a tummy tuck, or a nose job usually has a more obvious dilemma. It is not always so obvious when it comes to the vaginal rejuvenation patient.
All patients need to be counseled on the available alternative procedures before they book the vaginal rejuvenation procedure. It has to be clear to them that they are choosing this procedure mainly for the cosmetic benefits, and that it may not address some of their other problems. They also should know that the jury is still out regarding some of the claims of newer procedures. Evidence supporting some of these procedures is still under investigation, and complications and outcomes may outweigh any benefit.
One point is clearly evident. Vaginal rejuvenation is a trend that will probably grow. Many women want to feel sexually secure. Just as women seek breast reconstructions and tummy tucks to feel attractive, they also wish to feel sexually attractive in the genital area. It is no more ridiculous that vaginal tightness can make a woman feel secure than that a woman wants larger breasts or a smaller waist.
Whether considered significant or not by the medical establishment, the trend is very real. There is a place for female pelvic cosmetic reconstructive surgery, just as there is a cosmetic procedure for just about every other area of the body. This is not the same as performing routine surgery for bladder prolapse, vaginal apical prolapse, or other clinically significant gynecological procedures. It is cosmetic surgery.
Physicians have to take many clinical aspects into consideration when branching out into this arena in order to give it validity and to serve our patients appropriately. Many in-depth studies need to be conducted in this area in order to completely evaluate the impact that vaginal rejuvenation has on women’s sexual and psychological health.
We need to look at the effects on pelvic organ prolapse. In performing some of the procedures as early as we tend to do in younger women, we need to look into the procedure’s impact on long-term anatomical function—it may even be preventive for certain pelvic problems.
As techniques become more refined as our experience grows, I look forward to seeing where this revolution takes us.
Dolores Kent, MD, FACOG, is certified by the American College of Obstetrics and Gynecology, and is a member of the American Academy of Cosmetic Surgery. She can be reached at or (310) 860-9490.