COMMENTARY

Aesthetic Vaginal Surgery Today: A Collegial Rebuttal to Drs. Iglesia and Walden

Red M. Alinsod, MD

Disclosures

August 07, 2013

In This Article

The Example of Labia Minora Plasty

Labia minora plasty, or reduction surgery of the labia minora, is the standard surgical therapy for hypertrophic, asymmetrical, or irregularly shaped minora tissue.[11] Labia minora plasty is one of the most popular and fastest-growing AVS procedures in the United States today.[4,11,12]

Earlier this year, 2 separate interviews with opinion experts, Cheryl Iglesia, MD, a pelvic medicine and reconstructive surgeon, and Jennifer Walden, MD, a plastic surgeon, were published on Medscape Ob/Gyn & Women's Health[4] and Medscape Plastic Surgery,[13]respectively. Drs. Iglesia and Walden both correctly view labia minora plasty as an elective procedure for functional and aesthetic indications.[4,13]

Dr. Iglesia stated that AVS procedures are heavily marketed without sufficient data to support safety and benefit. She also admitted that some of the very conditions treatable with AVS may be functional problems associated with weak pelvic floor muscles. Dr. Iglesia acknowledged that some women might experience reduced sensation during sexual activity owing to laxity of connective tissue and weak pelvic floor muscles.[4] Reduced sexual pleasure due to a "loose vagina" is a common complaint of many women following childbirth or aging, and it sometimes occurs with pelvic floor defects, such as prolapse.[9,12]

Dr. Iglesia cautioned that doctors must determine whether there are "real prolapse and medical indications for reconstructive surgery." She clearly stated that women undergo labia minora plasty "to improve the appearance of the labia minora...mostly for aesthetic reasons but sometimes for functional reasons," such as irritation when doing physical exercise, chafing, or obstructed urination. Refreshingly, she also stressed that she respects a woman's right to undergo cosmetic procedures solely for aesthetic reasons.[4] However, in academia and some segments of the general ob/gyn community, there is often a belief that one set of indications, functional issues, warrants surgical intervention, whereas the other, aesthetic concerns, does not.

Where Do We Draw the Line?

Does a functional indication make an elective procedure more "legitimate" than an aesthetic indication? Unfortunately, clinicians making assumptions about "a patient's right" to undergo any type of aesthetic surgery often lack hands-on experience in performing cosmetic procedures. Experienced doctors who have treated patients requesting AVS understand that overlapping functional and aesthetic causes often drive women to seek these surgeries. The sometimes artificial division between cosmetic and functional reasons obscures the real issue: a woman's right to personal choice, regardless of her reasons for having the surgery. The surgeries are elective, much like breast enhancement and liposuction.

Similarly, the line between conventional pelvic reconstructive surgery and AVS procedures can be quite thin, even nonexistent in some cases. Pelvic prolapse may be unexpectedly diagnosed in older women seeking vaginal tightening to alleviate diminished sexual sensation caused by weakened pelvic floor muscles. Prolapse can be repaired by traditional pelvic reconstructive surgery. Vaginal tightening is achieved using modifications of conventional pelvic floor operations. Dr. Iglesia failed to mention that just as weak pelvic floor muscles are sometimes responsible for both prolapse and laxity of the vaginal opening and canal, combined reconstructive and AVS surgeries to correct weakened pelvic floor muscles may improve symptoms caused by prolapse and also repair and improve the appearance of a sagging, patulous vagina.[2,7,9,10]

Dr. Iglesia pointed out the potential pitfalls of what she called misleading advertising, sometimes appearing on gynecologists' Websites, which she claimed offers "either no or very low-quality data to support the marketing claims." She contended that there is no evidence to support the efficacy of AVS procedures in improving urinary incontinence or to justify the benefits of vaginal tightening procedures to enhance a woman's sex life.[4] It is true that AVS does not help incontinence, and it is misleading to say so. Ironically, the same studies on which Dr. Iglesia drew to find complication rates also provide evidence of high rates of patient self-reported satisfaction after vaginal tightening procedures. In my own practice, I frequently perform concomitant surgeries for vaginal tightening and prolapse repair along with incontinence slings that together lead to notable improvement in quality of life.[14,15,16,17]

Emerging clinical data on AVS procedures, such as labia minora plasty, reveal that the risk for many complications is minimized if the correct procedure is performed using the most appropriate surgical technique.[14] Admittedly, additional studies are urgently needed. However, analysis of the evidence to date may be skewed if critics do not differentiate between patients treated by skilled vs unskilled surgeons. Gynecologists who actually perform AVS (and who do not just make referrals) have a different perspective on these procedures than those who observe from the sidelines or who simply browse the literature.

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