Vaginal Rejuvenation, here in California and worldwide, is a wastebasket term that can mean whatever you wish it to. “Vaginal Rejuvenation.” What’s not to like?! In reality, as the term was originally defined in the early 2000’s by Dr. David Matlock, one of the fathers of female genital plastic and cosmetic surgery, the term referred to a surgical reconstructive tightening of the vagina, using a CO2 laser as a cutting tool, much like a scalpel or radiofrequency needle, with which to precisely perform surgical incisions. It did not refer to the use of either laser or radiofrequency (“RF”) to supposedly tighten the internal vagina or vaginal opening (doesn’t work!). The procedure included a vaginoplasty as well as a perineoplasty procedure, designed specifically to surgically both tighten the vaginal barrel and raise up and re-build the vaginal opening and perineum, as well as aesthetically reconstruct the vaginal opening. What is a Perineopasty? Again, surgical reality can differ amongst different surgeons. In my practice, a perineoplasty is designed to first totally remove all the gritty, adynamic (meaning it cannot stretch and snap back) non-muscular scar tissue from childbirth lacerations and episiotomy repairs from under the skin of the outer vagina, vulvar vestibule and perineum and reaching laterally with several strong, very slowly-dissolving sutures (I use 2-0 Monocryl™) to bring the bulbocavernosis, bulbospongiosis, transverse perinealis and peri-anal musculature together in the midline to fill the defect produced by removing scar tissue and fully re-build and lift the perineum to produce a new perineal body and provide strong firm support elevating the penis (or toy) inserted into the vagina, actually serving to press it more firmly against the internal clitoris and G-Spot during lovemaking. This is called a perineorrhaphy, an integral part of a perineoplasty procedure. The other integral part of a perineoplasty is the aesthetic re-building of the vaginal opening. Part and parcel of a perineoplasty is to remove the tissue between ~ 4 and 8 o’clock (if you are looking at the vaginal opening as a clock face), including removal of local scaring, prolapsed polyp-like hymenal tags, and prolapsed vaginal skin at the opening. In my hands, the opening is then carefully re-constructed using plastic surgery techniques so that it appears much more like its pre-baby appearance.Just performing a perineoplasty can be quite helpful to provide more tightening and pressure at the vaginal opening, but a perineoplasty alone will not eliminate the “…sensation of a wide vagina” and internal laxity producing the lack of coital friction so many women experience, nor will it eliminate the bulge of the recotocele hernia from the bottom of the vagina and the frequent difficulty in evacuating stool that also many women experience. This fix involves a procedure termed vaginoplasty, which basically involves a levatorplasty, a procedure that re-approximates the levator musculature, the Kegels muscles, bringing them, along with the strong fibrous layer (the recto-vaginal fascia) together in the midline to both eliminate the hernia and rebuild the inner vaginal floor to more fully support the vagina and encase an inserted penis or toy in a stronger, tighter vagina, bringing improved sexual pleasure via enhanced friction, and improving the odds of internal, or vaginally activated orgasms. Additionally, the embarrassing release of vaginal wind (like farting through the vagina) is usually relieved. All of these things together, the levatorpasty, vaginoplasty, perineorrhaphy and perineoplasty encompass a true vaginal rejuvenation, more properly called a Vaginal Reconstruction. While most commonly performed in a hospital under a general (asleep) anesthetic, a very very few exceptionally experienced female genital plastic surgeons including Dr. Goodman in California perform their vaginal reconstructive surgery surgery in an in-office surgical suite under a local tumescent anesthetic, with the patient more safely awake. While there are many reasons to use local for vaginal reconstruction, vaginoplasty + perineoplasty, including safety and far easier recuperation, the major reason for local is that the surgeon can actually do a better job of tightening under local rather than general anesthesia. This is because, with an awake patient, Dr. Goodman can both better identify the levator muscle bundles (he can ask an awake patient to squeeze) and put the suture in the proper place. Tightening is improved as well. With an awake patient better muscle re-approximation can be produced. There is no risk of tweaking nerves secondary to overtightening, as the surgeon can get feedback from his awake patient to eliminate overtightening and damaging the nerves within the levator muscle bundles. Recovery (easier under local,) is a 2- month experience. The first week (covered by anti-inflamatory and pain medication) produces most pressure and discomfort. Recovery progresses to almost full normal activities by 1 month, full lifting and straining by 6 weeks, and full penetrative sexual activities by 7-9 weeks. Summarizing, a true and worthwhile vaginal reconstruction or vaginal rejuvenation is a surgical procedure best performed under local anesthesia, encompassing perineoplasty, perineorrhaphy, levatorplasty, and vaginoplasty to both bring the muscles together in the midline, narrow the vaginal barrel, eliminate the hernia, and both elevate and strengthen the tissue of the vagina, vulvar vestibule and perineum to aesthetically produce a relatively new vagina, rejuvenating sensations and orgasmic function for a more enjoyable sexual experience. 43 year old with 2 children concerned about both appearance and vaginal laxity.