(aka Unintended Avoidable Genital Mutilation) and poor results from Vaginoplasty
Speaking for many of my colleagues and for myself as an experienced women’s genital plastic/aesthetic surgeon who has performed more than 800 aesthetic/functional labiaplasties and more than 200 aesthetic/sexual vaginal tightening procedures (combination of modified posterior repair/vaginoplasty/aesthetic perineoplasty), I continue to be dismayed by the unintended avoidable mutilation of the labia of patients. We see these women in consultation for possible re-operation or as expert witnesses involved in medical legal actions resulting from botched labiaplasty procedures. On many patients we note the lack of vaginal tightening, aesthetic appearance and/or increased muscular strength encountered in posterior repairs performed by general gynecological and urogynecological surgeons untrained in the procedures of aesthetic labiaplasty, perineoplasty, and vaginoplasty operations. (More below on the reasons that general gynecologists are untrained in these procedures.) Invariably, these operations with poor results were performed by general gynecologists, untrained in the plastic and aesthetic procedures of labiaplasty or vaginoplasty.
In all fairness, no one knows how many successful surgeries (labiaplasties, vaginal tightening surgeries) are performed by general gynecologists, as there is no reporting mechanism for these surgeries. The professional organization purporting to represent Ob/Gyns — the American College of Obstetrics and Gynecology or “ACOG — has made its position clear in a “Committee Opinion” released in 2007 and reconfirmed in 2012: they do not support these aesthetic and restorative surgical procedures, nor do they encourage the teaching of these procedures either in gynecological residency or via stand-alone training programs. “Official Gyn-dom” does not want women to have a say in how they wish to model or remodel their own bodies.
The outcomes that we experienced female genital plastic/cosmetic surgeons see from general gynecologists are the many botched and mutilated women who present to us for revision or when their attorneys are bringing legal action and want our opinions. These are women who brought their labial (and frequently clitoral hood) hypertrophy to their family Ob/Gyn and that physician said to themselves, “How hard can it be? I just pull on the labia, place a clamp on it, and cut off the excess,” and says to the patient “Sure. No problem, I can do it!” This response is despite being untrained in plastic technique and aesthetic surgery, untrained in how to sculpt a clitoral hood or the rules necessary to avoid harm, and untrained in the choice of several surgical techniques available. While these gynecologists certainly know the anatomy, and have been trained in general excisions and cancer operations, they have received no training whatsoever in micro-plastic technique or working with small-caliber instruments, sutures and needles, and no training on how to determine tissue planes in the area, how to deal with folds or the clitoral hood. The resulting surgery often ends up being a simple resection bordering on amputation and leaving no labia at all, with extra hood tissue hanging from the top. The surgeon has performed an avoidable unintended genital mutilation. The patient sees it as a botched labiaplasty.
What about sexually mandated vaginal tightening operations? General Ob/Gyns are trained in their residencies to do what is called a posterior repair (aka posterior colporrhaphy) which includes a perineorrhaphy, or a repair of the perineal incision necessary when doing this site-specific repair. The term site-specific is important, as it describes a procedure (posterior repair) which is ONLY an operation designed to reconstruct a vaginal floor hernia that causes defecation difficulties, and then to sew it up. This bears little resemblance to the functional and aesthetic operation of vaginoplasty and perineoplasty (sometimes termed vaginal rejuvenation). A vaginoplasty is an operation that takes into account the goal of overall vaginal tightening. It specifically re-approximates the levator muscles throughout their course through the outer half of the vagina, along with removing scarred and inflexible vaginal skin and all of the deep non-functional scar tissue from the outer third of the vagina and vaginal opening. It adds deep sutures to re-approximate the viable tissue and rebuilds the perineal body to strengthen the perineum and aesthetically re-construct the introitus (opening) to appear more similar to its appearance pre-childbirth(s). This operation is not taught in routine Gyn residency training. The whole idea of a woman rejuvenating the appearance and function of her vagina, perineum and opening for sexual and self-esteem reasons appears, unfortunately, to be anathema to ACOG’s philosophy and goals. Additionally, a true perineoplasty is a plastic operation that takes into account muscle re-connection, tissue bulking, and aesthetic reconstruction. It is distinct from the perineorrhaphy gynecologists learn in their residency.
So, what happens in the real world? The organization that represents traditional Ob/Gyns (ACOG) has come out with “Committee Opinions” that discourage genital plastics, and that say there is no evidence-based research on the topic. These opinions are just that: opinions of the ACOG Committee (conservative non-community academic types) who, because they are neither trained nor savvy in this new field of surgery, condemn it. In truth, there are over ten peer-reviewed, evidence-based studies (prospective and retrospective) supporting the positive outcomes of women’s genital plastic/cosmetic surgeons when performed by well-trained, high-volume plastic and cosmetic gynecologic surgeons. This data does not include the botched surgeries performed by untrained ACOG Fellows and is not recognized by the out-of-touch officialdom of an unresponsive conservative national organization.
Very unfortunately, this head-in-the-sand response to the revolution in women’s empowerment has led directly to botched labiaplasties and avoidable unintended genital mutilations performed by otherwise competent gynecologists who, unfortunately, are not knowledgeable enough to “know what they do not know.” Women have come to them to take charge of their bodies and tighten and remodel as they please, with disastrous results.
Bottom line? Your patient’s vagina and vulva are treasured assets. They should not be trusted to a general Gyn who cannot prove that they have either taken a specialized course in genital plastics or have performed (and can show the patient before and after photos to prove it) at least 25 procedures (over 100 is best). The patient’s first procedure is the very best chance to do things professionally and avoid poor results at best, and mutilation at worst.