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Until recently, the female genital area had not drawn the attention of plastic surgeons and it has been the exclusive preserve of gynecologists. But improved knowledge and advances in plastic surgery coupled with the demands from women has ushered in an entirely new field called cosmetic gynecology. International meetings are now being conducted exclusively on this subject. More improvements can be expected in this area in the future.

Why is this type of surgery needed? The female genital area goes through a lot of trauma and changes during life; be it as a result of child birth, ageing, hormone fluctuations, weight fluctuation, disease or surgery. The result? Physical discomfort, that many find too embarrassing to mention, partial loss of control over urine, diminished sexual enjoyment for both partners and a general feeling of looseness in the area. These changes may also lead to physical pain and recurrent urinary infections. The decline and changes may sometimes be so gradual that many accept these changes as inevitable and are not even aware that a better quality of life is possible. Almost every woman who has undergone genital cosmetic surgery commented that only after the surgery she realized what she had been missing in her life and what she had thought was inevitable. For many, it is a second chance at enjoying intimate relations and to be proud of what they can give to their partners. Many women seeking this type of surgery are in a second relationship and need to start afresh. The satisfaction rate of this type of surgery has been really gratifying.

While this may sound as hype, it really is not. There are many women who have badly healed tissues after childbirth/episiotomies leading to the vagina and anus coming closer. Many experience a constant discomfort or mild pain in the lowest parts [called perineum] and discomfort or displeasure during sex. The latter can initiate a slow attrition in marital relations. Loss of the important structure called perineal body leads to wrong dynamics during sex and leads to pain rather than pleasure. Further, almost 25% of women after childbearing report that their urine control is not perfect and that they have embarrassing leaks. So, restoring normalcy in these women is more corrective than cosmetic; so perhaps a better title for this blog would be restorative-rejuvenation of female genitalia but we will stick to cosmetic gynecology for brevity.

Who is a candidate?

Anyone who feels that her genital area is not the same as it was before can come for a consultation. This may have to do with feeling of looseness, unattractive appearance, aged appearance of the parts, sagging, or any structural changes for which her regular gynecologist has found no cause or remedy. Not every case needs surgery however. There are many that can be improved by regular practice of pelvic floor exercises. Called Kegel’s exercises, it involves consciously tightening the muscles around the anus and vagina [not inner thighs!] rhythmically, preferably by using a bio-feedback device to let her know that she is doing the exercise correctly.

What is done in this surgery?

A wide variety of plastic surgery procedures are combined as needed. The plastic surgeon brings his entire cumulative knowledge and experience to bear on the problems found in each case. Typically, it may include a few of the following steps:

Tightening and volumizing the outer labial lips, trimming and re-shaping the inner lips, removing loose vaginal mucosa [the inner pink skin], tightening the deeper lax muscles or repairing them properly*, narrowing the wide vaginal entrance and very importantly, restoring the perineum to its proper size and structure. This area of separation between the vagina and anus is called perineal body. It is a very important structure since all muscles of the area are attached to it and it separates the two systems. If the two are not well separated, there is increased chance of urinary infections due to cross contamination from the anus.

Certain additinal procedures may be performed for an enhanced sexual experience,however at the moment there is no proof for this. This refers to augmentation of the clitoral areas and the so called G-spot augmentation just inside the vaginal verge. This area is richly supplied with nerves and is capable of engorgement during sexual excitement. Enhancing this area with a filler such as fat grafts or filler gels might bring the area into better contact in cases where it is anatomically hidden.

The Mons lift: Another related procedure particularly in women who have a larger pendulous abdomen is to perform a mons lift. This should be incorporated ideally into a tummy tuck plan but can also be done by itself. In this procedure, the sagged pubic mound is lifted up to make the area look more normal.

LaservsRadiofrequency: In the much publicised laser vaginoplasty, laser is used to perform the cuts. The advantages are less bleeding and greater precision. But laser is not essential nor is it central to this surgery, it is only a tool. The same ends can also be achieved using a radiofrequency device or a very well adjusted diathermy. I use Radiofrequency device.

Fat grafting to the area: Fat grafts are used in different body area and the female genitalia have also benefitted form this technique. Fat grafts can be used to plump up the outer labia, improve G spot prominence and also to bring in new repair cells [stem cells] to this area so that scarring can be minimized. Recent studies in Italy have shown that fat graftng improved perineal pain syndrome – a condition of chronic pain for which there was no treatment.

Improving urine control. Tension-free vaginal tape, TVT, is a technique that aims to improve urinary continence. Most mild cases improve once the muscles of the area are restored and fat grafting is done but more advanced cases of incontinence need the TVT. Tension free Vaginal Tape insertion is performed by a gynecologist with special experience in this surgery; it can be combined with cosmetic vulvo-vaginaoplasty.

The recovery: Women generally take about 5-7 days to recover, hospitalization is not routinely required, most can go back to work after 1 week. Sexual activity is not to be resumed for 6 weeks. The post operative period is not painful, only mild discomfort is reported by most of my patients. Complications such as infection, blood collections, delayed healing, opening up of stitches, painful spots, excessive tightness etc can happen but have been quite rare.

*[in many cases where the muscles have remained in their torn state they are being repaired for the first time],