Introduction

The history of cosmetic gynecology dates back to the early 20th century, with early procedures focused on genital reconstruction following trauma or congenital abnormalities. However, the field has evolved to encompass a broader range of procedures aimed at enhancing the aesthetics and function of the female genitalia. In the late 20th century, the rise of labiaplasty as a cosmetic procedure marked a significant turning point in aesthetic gynecology. Since then, advancements in surgical techniques, technology, and patient demand have driven the field forward. However most of the gynecological surgeries being done for medically indicated cases are the traditional gynecological procedures or modifications of previously done surgeries. With the increasing advertisement more and more women are opting for these procedures for both functional and cosmetic reasons. Cosmetic Gynecology (CG) is also known as Aesthetic Gynecology (AG) or more appropriately as Aesthetic Functional & Regenerative (AFR) Gynecology. The field faced a lot of controversies in the beginning, but slowly different gynecological societies have started accepting the need for further development in this field keeping medical ethics and patient safety in mind. Efforts are continuously being made to develop standardized protocols for the better patient selection, patient counselling and management for better outcome and greater patient benefit. Since issues related to sexuality and reproductive organs still remain a taboo in most of the societies, progress, in the field of cosmetic gynecology gives an opportunity to talk about related issues with a trained medical professional openly. It also gives the opportunity to educate women about the normal anatomy of their body and its normal variations and clear their perception of abnormality or self-doubt. Studies have shown that many women who suffer from Body Dysmorphic Disorders (BDD) tends to consult and ask for gynecological cosmetic surgeries [1]. Hence, it is clear that if the screening is done properly giving enough time, trained cosmetic gynecologists can be the first point of contact for screening of women for any psychological issues and help them seek treatment and counselling.

What is normal?

Wide variation is seen in the size and shape of the female external genitalia and hence the definition of a normal genitalia is difficult. Most of the standards for normal genitalia come from the internet images hence, it is very important to educate woman about what is normal when she is in doubt [2]. Women may consider their external genitalia as abnormal in appearance when it is perfectly normal. For the purpose of standardization and documentation of preoperative and postoperative outcome International Uro-gynecological Association (IUGA) and American Gynecological Association (AUGA) developed classification for labial anatomy (Annexure 1) [3].

Patient selection

Female cosmetic gynecological surgeries are being done for three main cause (1) Functional (2) Cosmetic (3) Both functional and cosmetic [4].

It is very important to take a thorough history to know what made her think of treatment. Issues related to female genitalia and sexuality are sensitive and not easy to discuss and one should be careful while discussing these issues. Sometimes more than one visit is required to build trust in difficult issues. A woman will not just walk in to get a cosmetic gynecological procedure done. So, it’s very important to understand what brings her to care provider. Sometimes its simple perception of abnormality when everything is normal and mere counselling and education regarding normal anatomy and its variation will reassure them. However, sometimes a deep-seated trauma, childhood abuse, interpersonal relationship issue and body image disorders can be associated and needs further evaluation and treatment. In such cases referral to an appropriate facility for psychological support is must before deciding on any procedure. Another important issue in such cases is to rule out any chance of coercion and exploitation.

Finally knowing what are her wishes and expectations is important. Women might have unrealistic expectations and may be disappointed if these expectations are not met. Hence, educating about what is normal, what to expect, possible outcome and complications are important aspects of optimal care [5,6]. Wherever possible a written information should be provided and women should be given time to think over the procedure when they are for cosmetic reasons only. A well-informed patient always makes a wise decision under care providers guidance.

Types of procedures

Different procedures which are used in cosmetic gynecology can be divided into surgical and non-surgical depending on the modality used. Depending on the effect the procedure is going to provide they can be further be divided into augmentation or reduction procedures.

Surgical procedures: Labiaplasty/labioplasty/labia minora reduction: It is the most common cosmetic surgical procedure done for labia minora elongation. Most of the labiaplasty procedures are done for functional reasons where women can have dyspareunia or discomfort caused due to elongated labia minora. Women can also present with discomfort during sports, walking, running, or other physical activities, wearing tight fitting clothes and maintaining proper hygiene due to chaffing and multiple skin folds. Sometimes women can request such procedure only for cosmetic reason. Most common techniques involved in labia minora reduction are linear excision (edge resection), wedge excision (modifications include W-plasty or Zplasty) and de-epithelialization [7,8].

Labia majora reduction: Done in cases of bulky labia majora interfering with sexual functions or significantly affecting women’s self-esteem. Liposuction with or without mons pubis reduction or surgical labia majoraplasty can be performed to reduce the redundant skin or the fat pad deposited at labia majora. Mostly the procedure is done for aesthetic reasons and in women who are overweight [9].

Clitoral hood reduction: Frenulectomy, clitoral hood reduction, clitoral subdermal hoodoplasty and hydro-dissection with reverse V-plasty are some of the techniques used in clitoral reduction procedures. Clitoral hood reduction traditionally was used to manage cases of clitoral phimosis [10]. Here the removal of redundant central hood or lateral preputial folds is done to expose the clitoral glans, hence this procedure is widely being used to improve the sexual functions and cosmetic appearance. Clitoroplasty (nerve sparing) is also used to treat clitoromegaly. However women should be informed about the possibility of nerve injury and loss/altered sexual function in rare instances [11]. Hydrodissection with reverse V-plasty is another technique used in cases of lichen sclerosis with buried clitoris or clitoral prepuce phimosis/adhesions. Clitoral subdermal hoodplasty is used to correct asymmetrical thickness of clitoral prepuce. Clitoral frenuloreduction used in cases of hypertrophy of frenulum or asymmetry in the frenulum shape.

Vaginoplasty/Colpoperineorrhaphy: Done mostly for functional reasons than aesthetic. Women often complains of lax vagina with loss of libido, sexual dissatisfaction, dyspareunia and difficulty in holding the tampon [12-14]. Hence these procedures are done to reduce the diameter of vaginal canal. Different techniques used are posterior vaginal wall repair with perineal repair, isolated perineal repair, and lateral colporrhaphy.

Mons pubis reduction/Monsplasty: Obese women with excessive fat deposition on mons pubis, interfering with sexual functions, personal hygiene or low self esteem may benefit from reduction of fat in this area. Liposuction or open excision with pubic skin graft are accepted techniques [9].

Hymenoplasty: Reconstruction of hymen using hymenal remnants or a small flap of posterior vaginal wall [12].

Emerging trends- non-surgical procedures

Energy based sources like lasers (CO2 , Erbium: Yag), radiofrequency, High Intensity Focused Ultrasound (HIFU) for vulvovaginal rejuvenation and High Intensity Focused Electromagnetic Therapy (HIFEM) for pelvic floor muscle strengthening [15,16].

Platelet Rich Plasma therapy (PRP) for vulvovaginal rejuvenation and sexual enhancement procedures.

Botulinum toxin (Type A) for treatment of severe cases of vaginismus.

Autologous fat transfer: for labia majora augmentation in cases of sexual dysfunction (pain and discomfort during intercourse). Some women opt for this procedure for aesthetic than functional problem [15].

Vuvlovaginal fillers: Mostly used to treat symptoms related to vaginal atrophy.

Vulvovaginal threads: Elastic silicon threads are widely used for labial lift up surgeries, to restore enlarged /distorted vaginal introitus and for vaginal rejuvenation surgeries [15].

Transdermal CO2 gel: Used to treat genitourinary symptoms and female sexual dysfunction in postmenopausal women. This gel helps in regeneration of the vulvovaginal tissues [15].

Genital depigmentation: For genital hyperpigmentation. This can be achieved by using energy source known as genital brightening or by using chemical peels, glycolic acid peels, lactic acid or mandelic acid [17].

Contraindication

Female cosmetic surgeries should be avoided in patients with body dysmorphic disorder, active infections, medical disorders, vulvodynia, chronic pelvic pain and dyspareunia [18].

Complications

Like any surgical procedure FCGS are also not free from complications and patient should be aware of these complications in all cases whether done for functional reasons or aesthetic reasons. Bleeding, pain, infection, hematoma, swelling, wound dehiscence, altered sensation, asymmetry, dyspareunia, change in bowel and bladder control, need for repeat surgery, dissatisfaction and need for blood transfusion needs to be explained to the patient before undergoing the surgical procedure [18].

Ethical issue

In the era of social media and internet it is not unusual for the adolescent girls to fall prey for projected perfect body image. Adolescent girls can also present to the care provider with abnormal appearance of their genitalia [19]. No surgical procedure should be offered to girls under the age of 18 years just for cosmetic reason. They should be given education and information regarding normal anatomy and physiological changes during puberty. Efforts should be made to address psychological issues if any. Care should be taken to avoid negative remark and to reaffirm their negative perception. Another issue with these procedures is fear of coercion and exploitation, hence every attempt should be made to rule out and report such incidence. For initial few years there has been a debate regarding FCGS and Female Genital Mutilation (FGM). It is important to understand that female genital mutilation is illegal procedure done against the will of women because of certain cultural beliefs. FGM can be dangerous as these procedures involve complete mutilation of the female external genitalia. This can lead to both physical as well as psychological trauma to the women [11]. However, FCGS are voluntary procedure done to correct any functional or aesthetic aspects of women’s external genitalia. Even if these procedures are done merely for cosmetic reasons they will help by correcting the negative body image and hence improve their self esteem, provided psycho-sexual issues are ruled out prior to the procedure. Lastly though it is advertised that FCGS can provide women what they want (aesthetically) they should have a complete information of the procedures, their benefits versus risks, complications, alternative, what to expect in terms of success rate of the surgical procedures and long-term complications to avoid any litigation.

Conclusion

FCGS offers an opportunity to deal with number of functional and aesthetic concern related to female sexuality. A meticulous workup is required before offering them any surgical procedure. A holistic approach that considers patient education, ethical principles, and individualized care is crucial for optimal outcomes. As the field progresses, continued research, advancements in technology, and a patient-centred approach will shape the future of aesthetic gynecology.

References

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