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    The feminine mystique

    Female rejuvenation goes mainstream

    Dr. ShambanEvolving attitudes about aesthetic treatment of the vulvar area are driving increased interest in female rejuvenative procedures, said experts who spoke at Cosmetic Boot Camp, held here.

    The United States' first breast implant occurred in 1963, said Daniel L. Kapp, M.D., a plastic surgeon based in West Palm Beach, Florida. In 1966, the first American transgender operation – performed by his mentor's mentor, plastic surgeon Milton Edgerton Jr., M.D. – followed.

    "So if you think you operating on genitalia is new in plastic surgery, it's actually one of the oldest things in plastic surgery," says Dr. Kapp.

    Form and function

    The reasons why plastic surgeons perform any aesthetic procedure is more basic than improving someone's appearance and self-esteem, he said.

    "We're bringing self-esteem to our patients and improving their sexuality, so they'll be more successful in reproducing. It's a basic biologic function."

    The first aesthetic labiaplasty publication appeared in 1984.1 In 2007, the American College of Obstetricians and Gynecologists advocated against labiaplasty unless medically necessary. "They reiterated this position in 2008, 2012 and 2014,"2 said Dr. Kapp. So when patients go to their OB/GYN with aesthetic concerns, he said, "They are told, 'we just operate on the vagina for medical problems.' They have nowhere else to turn," except for core aesthetic specialists.

    In dermatology, said Beverly Hills-based dermatologist Ava Shamban, M.D., "There's been a big debate. Is this within the scope of our practice? Should this be the gynecologists' area? But it is tied up with self-esteem and skin health. It used to be dicey to talk about menopause. We've moved way beyond that in our culture – no area is out of bounds" for aesthetic or functional enhancement.

    When the ThermiVa radiofrequency (RF) device (ThermiAesthetics) debuted, she said, "I wasn't going to go there." But talking – and especially listening – to her patients convinced her that such procedures are appropriate for dermatologists, said Dr. Shamban, whose patients must get clearance from their gynecologist before they can undergo treatment.

    Her patients' concerns include loosening of the vaginal mucosa, loss of sensation, vaginal atrophy and dryness. Patients who have been treated for cancer cannot take estrogens, she said, and atrophy and dryness can make sex very uncomfortable for them. Patients also may suffer from stress incontinence or pelvic floor prolapse, she added.

    Over the last three years, said Dr. Kapp, the number of labiaplasty procedures performed in the United States has increased fivefold. Driving factors range from advancements in facial aesthetics and body contouring to the near-ubiquity of pornography, he said.

    "And the truth is, in plastic surgery, we've been doing vaginal surgery for a long time. Almost every time we do a tummy tuck, we do a monsplasty, elevating the mons to a normal anatomic location. Doing surgery such as labiaplasty is a natural progression."

    Female genital surgery can involve repositioning or performing suction lipectomy on the mons.

    "These are things we've always done,” says Dr. Kapp. “We move down below the Mons and look at the labia and clitoris. We can improve the exposure of the clitoris by reducing the clitoral hood, and tailoring the labia minora to get the 'Barbie' look."

    Regarding the labia majora, he said, "As we get older, women lose fat in the labia majora. So we do fat grafting, or infrequently, resection of the labia majora. Vaginal tightening, perineoplasty, urinary incontinence – I leave that to my GYN colleagues."

    A black patient in her mid-40s treated by Dr. Kapp told him in consultation that she and her husband disliked the appearance of her labia minora. From a surgeon's perspective, said Dr. Kapp, "The labia minora is like any other lip with any other dog ear – for a good outcome, resect and respect the vermilion border so it's a natural appearing vagina." For the patient in question, "We resected her excess labia minora and gave her a look she was very happy with. She felt good about herself. And by feeling good about herself, she felt good about her relationship with her husband. And that is why I do this operation – it's all about fulfilling our destiny." The procedure's over 90% satisfaction rate doesn't hurt either, he said.

    Next: Nonsurgical treatments

    John Jesitus
    John Jesitus is a medical writer based in Westminster, CO.

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