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 Plastic Surgery vs Gynecologic Surgery Approach

Dr. Walden did not address the field of AVS as a whole, but she emphasized the importance of the qualifications of surgeons doing labiaplasties and other AVSs. By "qualified," she meant a doctor who is certified by the American Board of Plastic Surgery and who is familiar with the gynecologic techniques required for operating on the parts of the female genital anatomy targeted in AVS procedures. She acknowledged that gynecologists "certainly are qualified to operate on the female anatomy."[13]

Dr. Walden estimated that she has done 25-50 labiaplasties per year over the past 9 years, for a total of about 225-450 labiaplasties. Nevertheless, she demonstrated only limited knowledge of AVS as practiced by leaders who have been actively working in this subspecialization for at least a decade.

Drawing on the literature, Dr. Walden claimed that wedge excision, such as a V-wedge or W-plasty, are the preferred techniques in labial reduction surgeries. She claimed that the older method of linear excision involving trimming of the outer minoral edge has been largely abandoned.[13] Among gynecologic surgeons who frequently perform AVS labiaplasties, however, linear/curvilinear surgery remains the predominant technique. Whereas plastic surgeons are more likely to do wedge labiaplasties, gynecologic surgeons tend to perform curvilinear excisions.

Dr. Walden's statement that linear techniques cause more scarring than wedge techniques is not supported by evidence based on empirical, observational, or randomized clinical studies. Scarring can occur equally with both techniques, although it is very rarely a long-term problem because suture lines soften with time. I perform a large number of labial revision surgeries and rarely see "scars" of much significance. The more crucial issue is the frequent separation of wedge edges that pull apart or heal jaggedly or asymmetrically.

Furthermore, Dr. Walden insisted that the labial natural edge should be maintained when doing a labiaplasty. This may be wishful thinking and a justification for wedge surgery without actually looking at the broader picture. In my practice, and in almost every gynecologic practice performing labial surgery, an overwhelmingly larger percentage of patients want the dark, irregular edges of the labia removed during labia minora reduction surgery. It is a rarity to have a patient say, "Please keep my dark and irregular edges."

Finally, Dr. Walden said that labial surgery takes about 1 hour to perform. In my experience, the procedure typically requires 2 hours to produce superior anatomical outcomes.[13]

Why These Discrepancies?

One reason for the discrepancy between Dr. Walden's views of labiaplasty and mine involves differences in our training and, subsequently, differences in the AVS techniques typically used by plastic surgeons vs gynecologic surgeons. Although the use of surgery with scissors has diminished today, the success of a procedure depends on the abilities of practitioner. Sufficient clinical experience acquired over time allows a surgeon to refine and improve his or her skills in AVS procedures, such as labiaplasty. Unlike gynecologists, plastic surgeons may lack extensive training in urogynecology and internal vaginal surgery and be unaware of subtle anatomic features of the female genitalia that should be considered when making preoperative surgical plans.

Plastic surgeons have made valuable contributions to the evolving field of AVS. Board-certified plastic surgeons are the undisputed mavens of restoring anatomical form and function, but they typically lack extended training in labial surgery. Except in rare instances, plastic surgery and cosmetic surgery training programs have not had labial and vaginal surgery as part of their curriculum until very recently. Most programs still do not have the faculty to train for this subspecialization. I doubt that Dr. Walden's training program had a distinct concentration on labial and vaginal surgery.

The only genital surgery experience typically seen by plastic and cosmetic surgery residents and fellows occurs in medical school during their two-month ob/gyn rotation, and perhaps during a residency rotation in gynecology where they assist the gynecology resident or fellow. It is exceptionally rare to have a plastic or cosmetic surgery trainee serve as the primary surgeon in a gynecologic residency or fellowship.

Likewise, almost all gynecologic training programs traditionally have not had plastic surgery rotations, and in addition, concepts of aesthetic repairs were not taught. The gynecologic trainee performed a myriad of genital cases repairing pelvic and vaginal prolapse, fixing incontinence, and reapproximating torn labial edges from traumatic deliveries. Residents certainly learned the necessary anatomy, but they were not taught how to make the repairs aesthetically pleasing. These are generalizations, but they are accurate.

Solid training and ongoing full-time experience in gynecologic surgery is generally more advantageous for proficiency in AVS than is training in general plastic surgery. Hands-on experience is the deciding factor that distinguishes an outstanding cosmetic vaginal surgeon from a mediocre or even a good one. Board certification in plastic surgery or gynecology is impressive, but it is not a substitute for an in-depth gynecologic surgical preceptorship and follow-up clinical experience.

Surgeons who perform labial surgeries without well-rounded and recent exposure to clinical and academic research may be unaware of innovative technologies, such as radiofrequency surgery, that have significantly enhanced the safety of many AVS procedures and have allowed extremely refined repairs.[14,15,16,17] Electrocautery, radiofrequency surgery, lasers, scissors, and plasma cutting devices can all give outstanding results, and each has its own inherent strengths and weaknesses.

Surgical tools are essential, but the art and experience of clinical practice are always more important. It is not the wand, but the wizard, that ultimately determines safety and outcome.

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