Female genital cosmetic surgery

What is female genital cosmetic surgery?

Female genital cosmetic surgery incorporates a range of procedures performed on the female genitalia to alter its aesthetic appearance and/or function. The procedures are usually classified by the anatomical structure undergoing change. Terminology is non-standardised.

Vulvoplasty refers to augmentation or more frequently, reduction of the external female genitalia, and may include:

• Labiaplasty — the augmentation or reduction of the labia minora, or less commonly the labia majora; this may involve direct excision of the labial edge, wedge resection, or de-epithelisation techniques to reduce size while preserving the edge of the labia
• Hymenoplasty or ‘revirgination’ — the restoration of the intact hymen
• Perineoplasty — the restoration of perineal length
• Clitoral hoodoplasty — the reduction of the clitoral hood to expose the underlying clitoris
• Vulvar lipoplasty — the removal of fat from the mons pubis.

Vaginoplasty refers to alteration of the internal female genitalia, and may include:

• Surgical vaginal tightening
• 'Laser Vaginal Rejuvenation'® — a trademarked procedure for vaginal tightening using laser therapy
• G-spot augmentation or amplification ('G-shot'®) — consisting of autologous fat, collagen, or various filler injections into a pre-determined 'G-spot'
• Orgasm Shot ('O-Shot'®) — a trademarked procedure in which a patient’s own blood products are injected into the clitoris and upper vaginal wall with the intention of inducing inflammation and tissue repair.

It should be noted that many of these techniques vary considerably between practitioners due to lack of evidence-based standardised procedures.

Who has female genital cosmetic surgery?

The incidence of vulvoplasty has increased dramatically over the last two decades, notably in high-income Western countries. The Australian Government’s 2014 Vulvoplasty report reported a 105% increase in Medicare claims for vulvoplasty and labiaplasty from 2008 to 2013. Similar statistics have been reported in the United Kingdom and the United States.

A large population-based study from 2001 to 2013 in New South Wales, Australia, revealed the following facts about women undergoing vulvoplasty.

• The highest incidence is in women aged 25–34 years (32.6%), followed by ages 35–44 (25.8%), and ages 15–24 (25.3%).
• The likelihood of vulvoplasty is inversely proportional to the number of their children: 68.7% had never given birth, 15.1% had had one baby, 10.8% had had two babies, and 5.4% had given birth to three children.
• Women undergoing vulvoplasty are more likely to have undergone previous cosmetic procedures (10.1%) than the general population (1.7%).
• Women with prior vulvoplasty are significantly more likely to have an elective caesarean section (20%) than the general population (11%).

Who performs female genital cosmetic surgery?

Female genital cosmetic surgery may be performed by anyone with a medical degree as no formal training is required. However, it is most commonly performed by:

• Gynaecologists
• Obstetricians
• Plastic surgeons
• Cosmetic surgeons — GPs or non-specialist surgeons (including dermatologists), with additional training in cosmetic procedures
• Urologists.

In Australia, approximately half of all vulvoplasty surgical procedures are performed by gynaecologists and one third by plastic surgeons.

What are the indications for female genital cosmetic surgery?

Medically indicated female genital cosmetic procedures (and those covered by Medicare in Australia) include:

• Reversal or repair of female genital mutilation, cutting, and trauma
• Repair of major urogynaecological and urinary tract congenital anomalies, such as the fusion of the labia, hermaphroditism, or vaginal agenesis (absence of a vagina).
• Treatment for localised gigantism (hypertrophic labia minora) that causes significant functional impairment, where non-surgical treatments have failed.

Non-medically indicated female genital cosmetic surgery may be pursued for a diverse range of reasons, which can broadly be divided into three categories:

1. Aesthetic reasons — to reduce dissatisfaction associated with actual or perceived abnormality of genital anatomy
2. Psychological reasons — to address embarrassment, poor self-esteem, anxiety, inhibition in relationships, or to be more 'normal'
3. Functional reasons — to reduce pain or interference with sexual intercourse, discomfort when exercising or wearing tight clothing or chronic infections associated with personal hygiene; note that certain functional reasons may also be medically indicated.

Until quality peer-reviewed evidence of efficacy and risk profiles are available, numerous professional bodies including the Royal Australian and New Zealand College of Obstetricians and Gynaecologists have advised against non-medically indicated female genital cosmetic surgery, including Laser Vaginal Rejuvenation®, hymenoplasty, and G-spot amplification, to avoid unnecessary harm. In particular, they recommend that these procedures should not be performed in children.

What are the complications of female genital cosmetic surgery?

Few studies have assessed the long-term satisfaction, safety, and complication rates for non-medically indicated female genital cosmetic surgery procedures.

Potential risks and complications include:

• Surgical risks and complications — swelling, bruising, bleeding, pain
• Dehiscence (wound infection and/or breakdown)
• Allodynia (increased sensitivity of tissues to painful stimuli) due to removal of too much tissue
• Nerve damage, resulting in reduced genital sensation
• Permanent colour change (postinflammatory pigmentation or hypopigmentation)
• Reduced lubrication
• Dyspareunia (painful sexual intercourse)
• Adhesions and scarring
• Lack of recognition of inflammatory skin disease affecting the vulva
• Scarring and ‘scalloping’ of the labial edge
• Urinary tract symptoms, including urinary incontinence
• Pelvic floor dysfunction
• Birth complications, such as tearing of scar tissue during vaginal delivery
• The cosmetic result not meeting the patient’s or their partner’s expectations
• Psychological distress.