We’re going to talk about vaginal rejuvenation and labiaplasty because they are not the same.
I think the reason we've had a thing that it was a little uncomfortable talking about because we do know there is a lot of controversy out there, we'll probably touch on that first because a lot of patients are petrified to talk about this. They're so ashamed and embarrassed when they come in, but they have reasons to want this done. If you don't understand this or know why it's a problem, just count yourself lucky and move on.
I find the people that are the most judgmental about people doing this surgery are people with completely normal vaginal anatomy, who have never had the experience of extra tissue getting caught during intercourse, or bunching up in yoga pants and truly being physically uncomfortable. We have patients who are horseback riders, or do spin, and do those things a lot. Let alone the psychological impact of it. I cannot tell you how many times we hear from patients that they feel self-conscious during intercourse, even though their partner may assure them that it's not a problem for them, I think most women know a lot of our sexuality is a mental thing- it’s about confidence.
And it is how confident you feel in yourself, so even if somebody's telling you, "You look perfect. This is fine." If you don't feel that way, it definitely translates. So when they come in, they come in with a valid concern, and by exam, a reason to have the surgery.
So when we break things down, there are two ways to look at it. So there's the internal anatomy. You have the vaginal canal, and what we call the introitus, which is the entrance of the vaginal canal to the body. So that's kind of looking from the front onward. If you were looking from this angle, you've got your labia majora, which are kind of the outer lips, and you've got the labia minora, which are the inner lips.
If you're looking in what we call the lithotomy position, or “legs up”, GYN position, then the labia majora tend to be the fuller, kind of outer lips. Then the labia minora are the lips that are in between. And most of the time, they're tucked right between the labia majora. Clitoral hood and the clitoris itself are up at the top. Clitoral hood is the tissue above and around the clitoris towards the top. The outer lips then the inner lips, which are usually hairless and usually more like a wet skin texture, are the labia minora. What happens for women who have excess labia minora, this minora can extend a good two inches outside the labia majora, which is just very uncomfortable for a lot of patients, and a hygiene issue. A lot of patients will get recurring yeast infections or skin fold infections because of the constant irritation of that skin. A lot of patients who come in are like, "Oh my gosh. How long has this been around?" And there's unfortunately a lot of doctors who jumped on the bandwagon, but don't do a lot of these. It's not something a lot of doctors are doing a ton of, and we are doing a lot of these.
Our first one was in 2011 or 2010, and I just think that patients being really educated to making the decision in this, because once you take it away you cant put it back. You want to make sure you're not taking too much tissue below the clitoris so that your clitoris looks like a little penis sticking out. We've seen that from other surgeons, where patients have come in after labiaplasty and nothing has been left under the clitoral hood and everything is removed below, and it looks very deformed and weird.
What is normal?
So looking for your surgeon's experience is one thing, but I think probably the most common thing people ask and something I really do want to go over is, what is normal?
This is the most common question we get, and here's what I will tell those patients that come in. Most likely, if you're doing the surgery because you want to look better in tight clothes, or a bathing suit, or feel more comfortable in intercourse, you probably do have normal anatomy. Nothing's wrong with you, there's nothing abnormal about your body parts, but when it comes to how things look, there's always this bell curve, and it's kind of based on averages and standard deviations. Most people tend to fall within the middle section of a bell curve, so they're the average looking. A much smaller percentage of people are what we would consider superior or aesthetically ideal, and there are a couple people at the far end of what's considered normal that is almost border lining on what's abnormal, but it's not really abnormal. I think the problem with this area for women is that as pubic hair grooming has gotten more aggressive, full bikini waxes, and air brushing in magazine photos, and all this online public nudity. The aesthetic ideal has become the new normal.
So all the people that fall into this part of normal now feel like, "I'm not normal." And they are normal. So plastic surgery can either be about taking something abnormal and making it normal, or it can be taking something that's normal, but less than desirable, and making it more ideal.
We have had patients with what's called a rectocele, where they lose the support between the rectum and the vagina from the muscles stretching out during childbirth, and one of our patients referred to what she called a golf ball in the middle of her legs. It was her rectum prolapsing out of her vagina. That's clearly a functional concern. That's not really about being cosmetic or vain. It's about being comfortable and about feeling like your ass is not going to fall out of your vagina.
There is a large majority of people who have this whole persona this kind of procedure is all about vanity and trying to be something they're not. It's not true because there are some patients that come in and they're in this category and we're like, "You know what? You probably shouldn't be doing this." You should probably just be comfortable with where you are, or do a little laser. And they just needed that assurance, yeah.
How are the procedures done?
We can dive into how we do the procedures here? So again, breaking it down. External things, the labia majora, the labia minora, the clitoral hood, we can do under local anesthesia, and I actually prefer to do it under local anesthesia. There's no need to have general anesthesia. It's much more easy for patients to keep their legs in a position where I can really assess how much excess there is from side to side, rather than when people are totally relaxed from their anesthesia. If we're doing anything internally with vaginal tightening you definitely want to do it under anesthesia, you just need it.
When we do them in the office, it is a completely comfortable environment. And I think patients are shocked, by how easy the procedure is because so many people come in, their legs are shaking, they're nervous, we've had people cry during consultations because they feel like they're ashamed or this is not normal, and they walk out at the end of the procedure, and they're like, "Oh my God, I would have done that ten times over again." If they knew how easy it was.
It's about an hour to an hour and a half procedure. We give patients Valium and a pain pill, so you come in, we put our numbing cream for about an hour, most of the time people will end up watching Netflix. I would say seen because it's always behind me, but I've heard most of Breaking Bad, Orange is the New Black, and a lot of Gilmore Girls for the last couple of years because that seems to be very popular with our patients. But most people just end up getting caught up on an episode or two of a show they like and they’re totally zoned out from what we're actually doing.
Vaginal rejuvenation is a little bit opposite in that you do have general anesthesia, so it takes you a couple days longer to get out of that initial down period. There's not really too much discomfort but we are tightening the internal muscles in the vaginal canal. There's not a lot of nerves internally, so people with vaginal rejuvenation often feel very little discomfort, but there's restrictions on heavy lifting and intercourse for about six to eight weeks.
Surgery VS Laser Treatments
Here's what I would say to patients and what I ask people. If you're satisfied with sex, but your partner is potentially not, either because things aren't as moist as they used to be or you're not super comfortable during sex, laser does a great job with slightly uncomfortable vaginal lining, dry vaginal lining, awesome for people going through menopause, awesome for women who are early in their 40s who start to have changing hormones. It plumps a little bit, but there won't be a huge difference in tightening. So what I would tell people is if you can ... I'm going to be very graphic ... with a finger, internally, if you can Kegel and feel muscle all the way around your finger, this is how I examine in the office, then you may not need internal vaginal tightening, and you may see some improvement from the laser. If, however, there's not continuity, you can't feel a ring of muscle between your vagina and your rectum, that's probably been torn during delivery and there may not be a way to get it back to normal. I will also tell patients sometimes, if it feels like things are loose just at the entrance of the vagina, sometimes we can tighten that muscle externally in the office. If it feels loose all the way up to the cervix: That's surgery.
So now we're talking about surgery. This is the vaginal opening, this is the rectum. There is a layer of muscles in between. This is called the perineal body. What happens when somebody has an episiotomy or a vaginal delivery is there's a tear in this muscle. A grade one or two tear is very small, usually easily repaired, and most people don't notice too much of a difference after.
A grade three or four tear can legit go all the way through like that. Even if it's repaired, you have to imagine that when this is sutured up by the OB-GYN, it's not like somebody took a scalpel and made a clean cut through these tissues, they're shredded and torn apart, and it's very difficult to suture them back together and expect them to heal well. So a lot of people either are completely missing support, and it makes this vaginal opening look much, much bigger, and there's almost no separation between the vagina and the rectum, or some people have a thin little strip of muscle that's just not quite what it used to be.
Strip of muscle, but if we go inside about an inch, we can feel there's better muscle, then we can just tighten at the opening to help strengthen this. If there's no separation and we can't feel the muscle in the canal, you've got to pull it in from the sides and basically reconstruct that division and that support. And by doing that, you're rearranging tissue inside there and providing more support
It’s like a tummy tuck but inside the vaginal canal. We're lifting up the extra superficial tissue, we're finding the muscles and bringing them back together where they slid apart, and then we take away anything extra on top and suture it back together.
Inside the Vagina & VaginaL Laser Treaments
So there are basically four parts of the vaginal canal. There's the front part that goes up against the bladder, the back part that goes against the rectum, and the sides. I tighten along the sides and back. I do not tighten along the top where the bladder is. Like you said, I'm not a urologist, that's not the goal of my surgery. There are suspension procedures and normal procedures covered by insurance that are better if urinary incontinence is your main concern. Many of our patients have a little vaginal laxity and a little incontinence, but they're not going to go have a major surgery, they don't want the mesh.
And that's where the vaginal laser can also come in and do a really nice job. Our nurse practitioner Katie does those, and she has several patients who now come in, once every six months or so, just for a little touch up, and it keeps their incontinence under control. It's a ten minute procedure, and it's no downtime besides about 24, 48 hours of no intercourse.
Yeah, I have had the internal laser done. I try all sorts of things at this practice just to make sure I know what it's going to feel like and what it does and doesn't do, and I will tell you, it felt very much like absolutely nothing getting it done. I kept bracing myself, ready for something, and there was nothing. So that part was very easy, and for the next couple of days, it was just mildly irritated, uncomfortable, but I worked and I took care of the kids, I didn't take anything or anything.
I would say vaginal laser is for urinary incontinence, moisture, slight plumping. Vaginal surgery is more for tightening and getting things back to the way they felt before kids. And the labiaplasty is external.
So a little bit about labia majora. Some patients will come in complaining about looseness in the outer lips, and this is a tricky territory for me. Deflation, where they just seem wrinkly and deflated. So there are a few things that we can do to the outer lips. We can remove skin, but it works better for some patients than others, but if you have a very large labia minora and a loose, deflated labia majora, taking away that majora skin is just going to make that minora look bigger or more prominent. And a lot of our patients that want extra tissue removed in the area, it's because they want things a little smaller, so when we plump up with fat or do something to reduce wrinkles, some people feel like it's just trading one problem for another. It is a tricky one. So I tread lightly when it comes to the labia majora. I will do some skimmer section, I will do some laser to reduce wrinkling, I will do some mild plumping with fat, but that's one where I really want to talk to a patient individually.
Is age a factor in getting a labiaplasty?
The time in women's lives when this growth tends to happen tends to be right during or after puberty, some women notice some changes in their 20s or 30s associated with pregnancies or birth control, and then a lot of women notice changes after menopause, so it's clearly very hormonally mediated. I have had a boatload of patients that are about fifteen or sixteen years old. They're mature with sexual development, they've had their period for several years, this tissue is not going away, it's not getting better, and it can be doubly traumatic for a teenager who feels very different than her friends in a bathing suit, in a locker room. So I have done several patients who are fifteen, sixteen years old. My youngest patient was twelve. These are not the typical cosmetic concerns. These are deformities.
Support from parents, puberty, emotional development absolutely need to have happened, but the younger they are, it is more emotional, but I would say we don't do a lot of young patients unless its medically necessary.
The majority of our patients are somewhere in their mid to late 20s, or there's another age group within their 40s that are doing this after their kids are grown and they feel like it's the right time to do something for them.
A lot of people worry about risk of sensation loss. There's almost no risk of sensation loss when this procedure is done correctly. The nerves for that tissue come from way deep underneath, and we're working very superficially. So if you go to somebody who knows what they're doing, there's almost zero risk of change in sensation at all.
Can you undo surgery?
IF you have another baby, you could undo it. So that suture repair will hold. That muscle may stretch and tear again, but it may be perfectly fine. Just like we talked about last week with tummy tucks, we have three patients who have had tummy tucks and then had babies and all of them are fine, the muscle repair held, so it's possible that for this it could, but I, more strongly than any other surgery, really do encourage people to know they are done having kids before doing this surgery.
Labiaplasty, you can have a complete normal pregnancy afterwards. If you're going to tear, some people tear their labia during delivery anyway, it is a little more likely to tear along the incisions, but it's definitely not a guarantee, and it's probably someone who would have torn anyway.