Cosmetic Gynaecology, the fastest growing specialty globally, is an area of special interest that covers a variety of procedures that includes both cosmetic procedures to enhance the aesthetic appearance of the vulvo/vaginal region, as well as functional vaginal repairs to enhance or help restore sexual function following the changes that may occur following childbirth and/or ageing. This includes labiaplasty or labia minora reduction with or without excess prepuce reduction, labia majora reduction or augmentation, vaginoplasty, vaginal introital repairs as well as reduction of lipodystrophy in the mons pubis region, and, G-spot amplification; and others. New non-surgical techniques are now available to enhance the labial and vaginal region (Vaginal Rejuvenation).
Cosmetic gynaecology is now on the high tide and the average age of females requesting a procedure is steadily decreasing. The demand for these is now on the rise secondary to the globalisation effect and more women taking to social media. People learn beauty standards within the sociocultural context and the sociocultural standards are inarguably established online. Social media provides users the opportunity to present the best versions of themselves. A study published last year found that increased engagement in social media correlated with increased consideration for cosmetic surgery, and more so with the use of certain applications that uses visual nature as Instagram and Snapchat. Overall, it is a significant driver of cosmetic interventions. There are potential societal benefits, such as dissemination of knowledge, potential for exchange of ideas, and community building. These aspects are used to the advantage of both doctors and patients in the realm of cosmetic surgery. Many physicians use their own websites/social media applications to publish educational materials regarding procedures. The availability of this information online ultimately leads to a shared vision and more alignment of patient and physician goals and expectations.
Labiaplasty procedures have been reported to be the largest growing trend (up 45 per cent year-on-year, a survey by International Society of Aesthetic Plastic Surgery [ISAPS] found) of cosmetic surgery procedures for women throughout the world, other than vaginoplasty. The increase in labiaplasty is not isolated to the U.S. In Australia, labiaplasty procedures performed four-fold over a 13-year period. The is even more pronounced in United Kingdom, with a five-fold increase in over a 10-year period. Middle Eastern countries also follow suit in these statistics. Most surgeons agree that there is no predominant reason why vaginal cosmetic surgery is on the rise. Instead, change in grooming practices, air-brushed images on social media, distorted view of “normal” genitalia, and growing focus on athleticism are factors identified. This procedure empowers women and helps them achieve a better quality of life through increased comfort and sexual confidence. Medical professionals typically only recommend surgery if the enlarged labia begin to interfere with everyday life or cause problems during sexual intercourse. A 2008 study reported that 32 per cent of women underwent the procedure to correct a functional impairment; 31 per cent to correct functional impairment and for aesthetic reasons; and 37 per cent for aesthetic reasons alone.
Though what essentially started as enhancing cosmesis of the female genitalia in the 90s that gave birth to this specialty, the past decade has seen a surge in technological advancements with the invention of tools and modalities for tissue functional restoration, to reverse age-related tissue remodelling (as an anti-ageing modality) that has opened up a completely new dimension and has also bridged the gap between cosmetic indications of this new field and those of conventional gynaecology. As women age, physiologic changes in the genital region occur due to variation in the hormones. In an ageing vagina, there is laxity and loss of tone in pelvic floor. Other factors that influence the tissue remodelling include genetic predisposition, radiation, diet, exercise, smoking, and surgery. The extra cellular matrix (ECM) of vaginal tissue largely determines its tissue tensile strength, and its mechanical stability is remodelled and maintained by fibroblasts. It is the delicate balance between production and degradation of ECM proteins in connective tissue that is critical to the pelvic floor integrity.
Gaining momentum is advent of energy-based devices (EBD) that apply thermal or nonthermal energy to vulvo-vaginal tissue, stimulating collagen regeneration, contracture of elastin fibres, neovascularization, and improving lubrication, and that of electromagnetic fields to restore pelvic floor and sexual dysfunction (in both women and men). These aim to address peri- and post-menopausal symptoms (genitourinary syndrome of menopause, or vulvovaginal atrophy), by stimulating increased proliferation of vaginal epithelium, neo-collagenesis, and increased vascular and neural regeneration – hence moving from pure aesthetics to functional gynaecology applications.
The minimally/non-invasive procedures include EBD such as lasers (Carbon Dioxide (CO2), Erbium:YAG (Er:YAG), Diode, or Low Level Laser Therpy (LLLT)); Radio Frequency (RF); High-intensity Focused Ultrasound (HIFU); Electromagnetic field therapy; Chemical treatments, PRP (Platelet Rich Plasma), and Labial fillers (Hyaluronic acid and Fat grafting).
Globally, laser treatments are among the most popular non-invasive procedures. They allow for delivery of light to the skin in a controlled manner. The wavelengths across the electromagnetic spectrum are differentially absorbed by different tissue chromophores, including haemoglobin, melanin, and water. Two commonly used lasers are CO2 laser and Er:YAG laser, emitting light at wavelengths of 10,600 nm and 2940 nm, respectively. RF devices use thermal energy to directly heat adjacent tissue with target temperatures at or below 45 °C. Heat causes partial denaturation of existing collagen and promotes fibroblast-mediated production of new collagen. When absorbed in sufficient amounts, light energy can induce changes in the skin and mucosal matrix. Thermal energy delivered on vaginal wall stimulates neovascularisation, and collagen formation, and proliferation of glycogen-enriched epithelium leading to improved natural lubrication and urinary continence. Histological assessment demonstrates increased cellular thickness of the stratified vaginal epithelium and visibly greater amounts of collagen and vascular growth in the connective tissue. Visible external changes with these therapies have also been noted.
Distinct characteristics of the target tissue and technical parameters of EBD influence the tissue interactions at cellular level (laser wavelength, energy density, pulse duration, spot diameter, tissue absorption, hydration, and oxygenation, blood supply, degree of keratinization, and insulating properties of adipose tissue). For a given device, degree of ablativeness depends on multiple factors, including fluence, repetition rate, degree of coverage of device, and patient skin types and anatomic sites, whether the treatment is ablative, partially ablative, or non-ablative. Excessive transfer of heat to dermis can lead to adverse effects such as scarring and permanent hypopigmentation. In vaginal tissue, controlled power of the energy source must be used as it varies in its water content and cellular component with age, and under hormonal influence, amongst other factors.
Fractionated lasers have become the cornerstone of laser skin rejuvenation. Fractional CO2 and Erbium Lasers have been popularly used for various indications, for both external and internal genitalia applications using specifically designed probes (either disposable/ reusable) for intravaginal or intraurethral sites. Radiofrequency devices too have etched their mark in this space with successful outcomes. More recently, devices are being designed to accommodate dual mode of energy delivery that allows for a wider scope of clinical application and subjective computing of dose and mode delivery of the energy used.
While a typical cycle of treatment would include at least three sessions, spaced one month apart followed by a touch-up session, home-based easy to use devices using Low Level Laser Therapy (LLLT) are now out in the market that are being used for maintenance therapy to prolong the results achieved. It is important to bear in mind that one size does not fit all. A thorough understanding of interactions between light and biologic tissue is critical for selection of a laser device as well as effective and safe use of the equipment.
As one advances in their practice, they will appreciate the fact that offering the same client different modalities may in fact yield far superior results, as would a combination therapy using adjuncts in addition. It is not uncommon to see experts offering a bespoke treatment to clients that include a host of add-on therapies such as cell-based therapeutics (PRP, Stem cells), Hyaluronic acid, cosmeceuticals, add-on Bio-identical hormones, carboxytherapy, etc.
Though the initial indications were listed for the peri-/post-menopausal women for either vaginal atrophy and/or urinary incontinence, today, these EBD’s are more popularly being used as preventive measures in the younger women in the reproductive age group for functional reasons, especially in the post-natal period for the same indications, and also in those affected by chronic debilitating conditions such as Lichen sclerosus, scars, hyperpigmentation, vulvodynia, skin laxity post weight loss, side-effects following chemotherapy or hysterectomy, etc. Further, the experts use it to craft their cosmetic work during invasive procedures such as during labiaplasty and vaginoplasty, fat-grafting procedures or simply to replace the invasive procedures with the non-invasive, such as in non-invasive labiaplasty.
EBDs are also being used to augment results of other procedures that address sexual dysfunction or enhancements such as G-spot or O-spot augmentation. One of the latest innovations of laser device is that of CO2 laser that not just offers applications for female genital rejuvenation but also extends an arm for in-office minor surgical and hysteroscopic procedures.
Mini-liposuction followed by fat-grafting too has made its way into the armamentarium of services offered in this field. The scope of services hence sees an overlap essentially not just to urogynaecology, but also to associate fields such as urology, plastic surgery, and cosmetic dermatology.
One of the biggest changes in the past decade has been more openness about procedures, which has helped turn the cultural tide. As a result, there have been considerable investments in new technologies. Cosmetic Gynaecology Market drivers include changing women’s lifestyle, increasing adoption of non-invasive gynaecological procedure, growing medical tourism across borders, and surging demand for EBD treatments. The market restraints include social stigma associated with gynaecological treatments, stringent safety regulations for EBD procedures.
Recently, much uproar was created by the FDA published warning with the use of EBD and their false marketing promises. However, this was based on their adoption of the MAUDE database report that has failed to provide specifics regarding the quality, the quantity, and the nature of these reports. The MAUDE system does not track the number of procedures performed. It only offers an insight into the issues of reported events and has its limitations at that. The devices are exceptionally safe when properly used by trained providers, at proper settings, for clinical conditions they were designed for. These devices are also are ranking high in consumer satisfaction.
To still remain in denial of cosmetic gynaecology’s essence in one’s practice would be to deny oneself the privilege of reaping the benefits of pure self- and patient- satisfaction in this era. In the words of Dr. Marco Pelosi III, MD, Founder of the ISCG (International Society of Cosmetic Gynaecology), “Conventional Gynecology is stuck in the Stone Age. It offers nothing for the true needs of the 21st century woman”.
Moving forward, this field is here to stay and has carved its niche. Early adopters across the globe wear their label with smile as they take pride in not just addressing to normalise the health of their patients, but to actually help women optimise their health and overall well-being. Furthermore, those that initially were sceptical, now have positively skewed their interests towards this field as they are seeing more and more feedback from patients who can’t stop bragging about its positive life-changing effects.
With the rapid pace of change occurring in this field, it is important to have readily available resources and innovations that are critical to the advancement of the specialty. It is of tremendous benefit to be able to provide patients with a variety of options with the best possible solution to their functional and aesthetic needs. It is up to each of us to be our own investigator and our own judge of what is appropriate in our practice. That requires ascertaining whether a given procedure or technology has been truly validated as safe and effective. Any decision made by a competent woman regarding her own body and medical treatment should be respected. As for any new specialty, standards need to be set, and long-term studies undertaken.
With cosmetic gynaecology expected to continue to grow in popularity, providers must be prepared to respond to questions about vaginal rejuvenation and must possess a strong working knowledge of cosmetic gynaecology and be willing to discuss the benefits and risks. The field has established itself as a big practice changer, and it is!