Every external part of the human body has been a subject of aesthetic contouring. It would appear that the more visible the part of the body, the more likely it is to be subjected to a cosmetic body contouring procedure although operations such as breast reduction are often done, especially on the NHS, for apparent medical reasons, either physical or psychological. However, as millions of women inject botox, reshape noses, augment breasts, lift buttocks and suck away unwanted fat, a growing number are now exploring a new frontier, genital aesthetic surgery.

There is an ever-growing trend to tighten vaginal muscles, plump up or shorten labia, liposuction the pubic area and even restore the integrity of the hymen for so called cultural reasons! Interestingly, every clinic offering vaginal surgery prefaces their patient information on Labiaplasty by saying that “not all women are created the same”, which of course can be said for any body part.

“We are all created equally in the eyes of God…if not identically…” 

The United Kingdom is dwarfed by the United States and Brazil in terms of cosmetic surgery but there remain more procedures carried out in the UK than any European country. Trends in this field tend to follow those from across the Atlantic with a year on year increase in procedures. According to the British Association of Aesthetic surgeons (BAAPS), figures were up 31.2% between 2005 and 2006. A recent survey suggests that two thirds of British women are unhappy with their body and would undergo “plastic surgery” to achieve “the perfect look”. The most hated parts being the hips, thighs, bottom, abdomen, waist, legs and arms and yet the popular procedures are to the face, from botox to face lifts, and breast augmentation. Liposuction saw the highest percentage increase, perhaps in keeping with the above perception, and there were nearly half as many breast reductions as there were augmentations! Only 8% of procedures were on men.

Anatomy… 

In engineering terms, the female form is a flawed design. The pelvic floor or urogenital diaphragm is important in providing support for pelvic organs, like the bladder, intestines and uterus. In addition it also has to absorb pressure transmitted from the chest (coughing, sneezing) and abdomen (straining, etc) and the effects of gravity, which would not be so drastic if humans remained quadripaedic. In the middle of the pelvic floor is a major ‘defect’ to facilitate passage and support for the rectum and birth canal. It is also important in maintenance of continence as part of the urinary and anal sphincters and in sexual function. This ‘defect’ also has to expand to accommodate expulsion of a baby the size of a melon during vaginal childbirth and recoil to its pre-pregnancy capacity.

Women also now live half their lives in a hormone deficient state, menopause, which is reflected in the deterioration of the state tissue in general. The function of the visible genital anatomy in a female is less obvious and more controversial. Most of the structures are analogous to the male external genitalia, the labia analogous to the scrotum and the clitoris the penis. The labia may have a sanitary function, which is not well appreciated.  One can of course ask why the peacock has colorful feathers and why the male does not shy away from the less visually attractive female…? What if the female was to be dyed a more striking colour? 

“Is the reflection in the mirror bad enough to risk surgery…?” 

The reasons for the increasing interest in genital aesthetic surgery are multiple. This area however still remains very private to most women and many do not dare, or care, to examine themselves closely let alone discuss it with friends or professionals. The ravage of time, trauma of childbirth and the effect of gravity conspire with other factors like chronic cough, smoking, chronic constipation and unfortunate genetics to eventually make some women seek medical help. In the past women would voice their dissatisfaction to doctors on the back of another problem such as urinary or faecal incontinence. Some women would typically request labial surgery on the NHS because of discomfort on wearing tight pants or riding bicycles or horses. Often the woman would have had problems following childbirth but had accepted this as a right of passage and that ‘things are never the same after childbirth.’ After all, a third of women have a degree of faecal or flatus incontinence three months after vaginal delivery! This remains more of a taboo subject in comparison to discussing facial wrinkles brought on by age and worry over the growing children. 

The brave new world… Are private parts no longer private? 

Television programs like Sex and the City are now cult viewing across the world and discuss cosmetic surgery widely in all its aspects. In one episode of Sex and the City Samantha says to Miranda “I happen to love the way I look” to which she replies, “You should. You paid enough for it.” This, as many other subjects discussed, gave cosmetic surgery a degree of credibility amongst disciples of the program. It even ventured to discuss areas not often spoken about, Miranda defining “Perineum” as “Latin for “not without an engagement ring”. When she used the ‘C’ word saying to Carrie, “Its my clitoris, not the sphinx”, Carrie retorted, “I think you have just found the title of your autobiography”, presumably also to provide an avenue for the conservative majority to explain to their sons and husbands what this enigma is.

Following one episode on self-examination, millions of women took mirrors to discover that the ‘sphinx’ and the surrounding pyramids did not live up to their imagination and in some cases required major restoration leading to increased doctor visits! Attitudes to sex and female sexuality have also evolved. Women have the contraceptive pill and are soon to have their very own libido-enhancing patch, it is alleged. A lot more women now describe themselves as bisexual or bicurious and are willing to explore sex beyond its reproductive function. This non-reproductive or recreational sexual activity when the female is not in estrus is unique to humans, bonobos and dolphins, with the human possibly having the highest intellectual input to the process. Human sexual behaviour, as indeed is the same to a lesser extent in other species, is an interaction between all senses; touch, smell, taste, sound and most importantly, in this context and the example of the peacock, vision. Vision of features extending from head to toe and includes areas whose appearance may have been rearranged by childbirth or may be created differently.

The brain is perhaps the most important sex organ and a woman with anxiety about her body or her partner’s perception of it may loose the desire. Most women fail to be reassured by men who say, “I love you just the way you are.” Women are increasingly being exposed to marketing of flimsy underwear, pubic hair sculpturing and nudity in magazines, films and the Internet. Not only are they less inhibited to self-scrutinise, but they have something to compare with in the same manner as they may do their nose or breasts. They also know an increasing number of friends who have had cosmetic surgery. 

What’s on offer out there…? 

This “quality of life” surgery forms only part of the solution and is not for everyone. Counselling should be detailed and non-directive to inform the patient’s decision. The surgeon should also be satisfied that he/she is comfortable with executing the patient’s wish.  Many phrases are used to describe what surgeons do and the catch all phrase lay people have become accustomed to is “vaginal rejuvenation” or “designer vagina” and has even gained universal attention in print and television.

In reality, vaginal rejuvenation is a marketing term referring to vaginoplasty when the vaginal canal and introitus are tightened. Surgery usually entails a modification of a standard gynecological procedure called “posterior repair” along with rebuilding of the perineum (the space between the vagina and rectum), perineorrhaphy. This procedure was traditionally performed for a fallen or prolapsed rectum, or rectocele. A rectocele is a bulge of rectum going into the vagina. A similar vaginal bulge in appearance is an enterocele, a true vaginal hernia, and is a bulge of small bowel going into the vagina. A bulge of the bladder seen in the front part of the vagina is called a cystocele.

Excellent surgical correction can be achieved, although it is better to avoid factors, which may cause them, exacerbate them or cause recurrence after surgical correction, such as chronic constipation or vaginal childbirth. Vaginoplasty is technically straightforward and lasts approximately an hour. It can be done under local, regional (similar to an epidural) or general anaesthestic in a standard operating theater. The length of hospital stay depends on the extent of surgery required and ranges from a day to four days. Some women are able to return to work in a week but a six-week recuperation period is more realistic, which normally coincides with the postoperative check-up. There is an overlap therefore between procedures done for apparent medical indications and purely aesthetic reasons. When considering whether surgery is indicated one should explore alternatives as well as the reasons for the patient seeking surgery and their expectation from it. The patient and their surgeon need to understand the functional anatomy of the vagina and appreciate that injudicious surgery may lead to unsatisfactory outcomes such as an over-tight vaginal entrance leading to painful intercourse or difficulty or misdirected voiding.

Patients presenting to an NHS gynaecology clinic requesting labial refashioning will normally complain of discomfort when wearing tight clothes, riding bicycles or horses or marked asymmetry between the two sides leading to physical or psychological symptoms. There is a small group who would have an associated organic condition such as a tight clitoral hood, which may only become symptomatic when sexually aroused or can lead to decreased clitoral sensation and inability to achieve an orgasm. A few brave souls would complain of embarrassment at being anatomically aberrant in appearance or may state their partner as the reason for wanting surgery. They would have had to convince the gatekeeper of the NHS, the GP, that their plight is worth their 8 minutes consultation time let alone referral to an expensive gynecology clinic. The gynaecologist, who just like the GP may never have had this request, may also be unsympathetic to their needs, let alone carried out the procedure before.

Labiaplasty can be performed as a day procedure under either local or general anaesthetic. The operating time is between 30-60 minutes and a week off work is often advised. Several techniques have been described but it would appear reasonable to select one that is likely to cause the least scarring and best aesthetics. The timing of resumption of intercourse depends on the amount of discomfort but it is perhaps common to wait until the postoperative check up, usually at six weeks. Complications are few and include hypersensitivity of the scar and sometimes the clitoris, if the prepuce is included in the reduction. Other less popular vaginal procedures include liposuction of the fat overlying the pubic bone (mons pubis), augmentation of the labia, reconstruction of the hymen and hoodectomy, an operation analogous to the male circumcision and not to be confused with ritual circumcision. Permanent pubic hair removal or sculpturing using laser is gaining in popularity and is offered by most cosmetic surgery clinics including those not offering surgery. Complications from these procedures are thankfully few and transient. They include those common to any form of surgery like anaesthetic problems, bleeding and infection. Tight scar tissue formation may be a late complication. There may be dissatisfaction with the results of surgery depending on the motivation and expectation of the patient.

The Evidence…

Medicine is notoriously conservative and anecdotal. It was only several years ago when cosmetic vaginal surgery was attacked vigorously by some medical experts as barbaric, unnecessary, and frivolous. Debate also extends to whether surgery should be carried out by plastic surgeons, with their reputation for aesthetics or gynaecologists by an accident of anatomical geography and a wrong assumption that their knowledge of matters sexual extends beyond a 55-minute “Masters and Johnson’s” lecture from third year of medical school. Perhaps a new breed of surgeon, a gynaecological aesthetic surgeon, with greater appreciation of aesthetics and function should be trained. Both young women wanting a sleeker appearance of their genitals and older women wanting to repair the ravages of childbirth and time are in the forefront of demand to look different and feel young again. There is great controversy whether or not vaginal rejuvenation can, beyond altered appearance, improve the pleasure of intercourse or increase sexual desire. There are no, and can never be, randomized controlled studies showing that narrowing the vaginal canal improves orgasms or dramatically alters a woman’s or her partner’s sex life. Reports of improved sexual sensation from increased friction or increased clitoral sensitivity are by anecdotal experience and less scientific surveys. However, many couples do report more satisfying lovemaking, more tightness, and a belief that surgery has helped their sex lives.  One would hope, however, that these have a positive psychological and physical impact.  The economic argument can be made very strong for these and other cosmetic (or restorative surgery) procedures on the basis of Quality Adjusted Life Years, QALYs, although assessing quality of life on these matters will continue to challenge scientists! Cosmetic surgery, which can enhance the quality of many lives, should not be a luxury saved only for those with the wealth or disposable income to benefit from it. 

Xavier Mmono MRCOG LL.M

Consultant Gynaecologist