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

Red M. Alinsod, MD


August 07, 2013

In This Article

AVS From the Gynecologic Surgeon's Perspective

The world of AVS looks quite different to gynecologic surgeons, such as myself, who daily perform a wide array of AVS procedures. The data collected by experts in our field reveal that AVS, when done by expert clinicians, overall produces favorable anatomical and aesthetic outcomes. These outcomes also include a remarkably low complication rate and a consistently high level of patient self-satisfaction with the anatomical modifications from the procedure.[15,16]

Dr. Walden, a plastic surgeon and advocate for AVS, also discussed a woman's right to have elective procedures for functional or aesthetic reasons, or both. Reflecting the perspective of many (perhaps most) female aesthetic gynecologic surgeons, Dr. Walden correctly noted that labial reduction surgery is not a form of genital mutilation or a technique intended to make women more subservient by changing their vulvar anatomy.[13] Her view resonates with person-centered medicine, an emerging paradigm shift in healthcare in which providers are respectful of and responsive to individual patient preference.[18] Patient choice is key.

As in the case of other cosmetic surgeries, AVS procedures are a matter of personal choice. They are elective in nature. The state of the field today is reminiscent of cosmetic plastic surgery in the 1990s, when patients started requesting surgery to cosmetically alter their physical features and thus help boost their self-confidence. To some extent, the current controversy over AVS in repairing a postnatal sagging vaginal canal, or in reducing the size of excessively protruding and irritating labia minora, parallels the debate over the ethics of cosmetic plastic surgery in its early years.

Marketing Issues and Other Concerns

Dr. Walden, who performs labia minora plasties, echoed Dr. Iglesia's complaint about seemingly questionable marketing practices by some surgeons practicing AVS. Dr. Walden worried about marketing ploys of "designer vaginas" that appeal "to people's emotional senses and to the unrealistic." According to the ACOG Committee, AVS is marketed or franchised as a means to improve the appearance of the vulvar area or to enhance sexual gratification.[13]

Dr. Iglesia was also critical of the marketing aspects of AVS. She demanded that patients receive full disclosure of the risks associated with AVS procedures before they undergo these procedures.[4] This is certainly a reasonable request.

Concerns about AVS are valid. After all, women still risk being objectified by society, and surgeries can result in complications. However, the debate over AVS should be guided by evidence-based knowledge rather than by unproven speculation. The surgical risks identified by the ACOG Committee in its 2007 report have not been systematically evaluated, let alone updated. The Committee members did not provide clinical data to support their opinions, perhaps rightfully so, because it was a "Committee Opinion." Everyone has an opinion.

Currently, only a handful of qualified surgeons with acceptable levels of skill and experience are performing these procedures regularly. Of this group, a small number has published credible, peer-reviewed studies. Clinical data remain limited, but a growing number of studies from both gynecologists and plastic surgeons has shed new light on the safety and efficacy of core AVS procedures, such as labia minora plasty; vaginal tightening; and combined aesthetic/functional surgeries involving vaginoplasty, perineoplasty, and colporrhaphy.[14] Most of these studies are found not in ob/gyn journals, but rather in plastic surgery and cosmetic surgery journals.

On the basis of personal experience, I have noted a lack of interest in AVS from mainstream ob/gyn journals and organizations whose management has little to no experience in addressing critical issues in elective AVS. Cosmetic and plastic surgeons, not gynecologists, have taken the lead in mainstreaming AVS. As in breast augmentation and liposuction, which were invented by gynecologists, labial surgery is likely to also become the domain of the cosmetic and plastic surgeon.

It is very telling that cosmetic surgery and plastic surgery organizations encourage and stress the need for training and learning the skills to perform AVS. No ACOG Committee or publication has mentioned or recommended the training of its members in this field.

Dr. Iglesia reminded us of the importance of open exchange between doctor-researchers in scientific biomedicine.[4] In reality, however, most doctors, regardless of their specialization, directly or indirectly market their services to prospective patients. A review of the literature on AVS published in the past 5 years suggests that leading experts in the field follow a highly ethical code of conduct. Many leaders in AVS, including members of the Congress on Aesthetic Vaginal Surgery, have called for uniform, evidence-based practice guidelines. Some AVS specialists are proposing practice guidelines to prioritize surgical techniques for specific anatomical defects, thereby optimizing anatomical and functional outcomes for patients. This action is being taken outside of ob/gyn's parent organization, ACOG, which has shown minimal interest in advancing this arena. This is a fluid but coalescing field.

As Drs. Walden and Iglesia both point out, AVS carries a risk for potential complications, such as pain, pain with intercourse, scarring, incomplete tissue healing, and sexual dysfunction.[4,13] All surgeries have inherent risks, however. In the case of AVS, the risk for complications is mitigated or almost eliminated if the procedure is performed by a surgeon with proven competence in performing specific AVS operations.

Although complications of AVS have been reported in the literature,[2,11,15,16,18,19,20] adverse events are usually linked to a lack of adequate surgical mentoring.[14,15,16,17] Surgeons qualified to serve as preceptors in AVS may be trained in either gynecology or plastic surgery, as long as their training is adequate. Both of these medical specializations offer unique perspectives and skill sets for AVS.

AVS, including labiaplasty, is rightfully within the domain of ob/gyn. Aesthetic restoration is the domain of cosmetic and plastic surgery. By not paying attention to new developments in aesthetic genital surgery, the ob/gyn specialty has abdicated its ability today to help chart the direction of this field. Gynecologists are unwittingly taking a back seat to the entrepreneurial practices of plastic and cosmetic surgeons.


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