3 Emerging Trends in Non-surgical Aesthetic Gynaecology
The natural processes of aging, childbirth, and hormonal changes can result in vulvovaginal laxity (VVL) and mucosal atrophy, which can have a negative impact on a woman's quality of life. With the emergence of minimally and noninvasive genital rejuvenation procedures, it is crucial for dermatologic surgeons to be knowledgeable about these procedures due to their increasing popularity.
Reasons for seeking genital rejuvenation procedures range from cosmetic purposes to addressing functional problems such as painful intercourse, urinary incontinence, and vulvar irritation. In the past, invasive surgical procedures were commonly used to address VVL, but newer technologies now offer less invasive options. Studies have shown that women are interested in nonsurgical tightening methods.
In this blog, we will discuss the anatomy of the external female genitalia and provide an overview of minimally and noninvasive genital rejuvenation options relevant to dermatologists.
Anatomy
To effectively administer rejuvenation therapies for the external female genitalia, it is crucial to have knowledge about its anatomy.
Before starting any treatment, it is essential to differentiate between laxity of the vagina and the protrusion of genitopelvic structures into the vaginal canal, which can indicate pelvic organ prolapse. However, the effectiveness of nonsurgical approaches in improving prolapse is currently uncertain based on available data.
Structures
The vulva is comprised of various structures including the mons pubis, labia majora, labia minora, clitoris, vaginal introitus, and urethral orifice.
The mons pubis is a triangular area covered in hair located above the pubic bones. The labia majora are symmetrical skin folds extending from the mons pubis to the perineum. They contain hair and numerous glands. Inside the labia majora are the labia minora, which form two folds. The anterior folds merge to create the clitoral hood, while the deeper folds attach to the clitoral frenulum. The labia minora join together posteriorly to form the vaginal fourchette. The clitoris is an innervated erectile organ situated at the junction of the labia minora. The vaginal introitus, or opening, is located between the labia minora in the vulvar vestibule. It is surrounded by the hymen, which is eventually replaced by caruncles after rupture. The Bartholin glands open on either side of the introitus. The urethral orifice is found just before the vaginal introitus, and Skene glands are located on its posterior surface. The vaginal wall is composed of three layers: the superficial layer consists of nonkeratinized stratified squamous epithelium, followed by the muscularis composed of circular and longitudinal smooth muscle, and finally the outer adventitia layer which is adherent to the muscularis.
See below the figure for an illustration of the vulvar anatomy. (From Vanaman, 2016, taken from UpToDate)
Vasculature
The blood supply to the vulva, which includes the external female genitalia, is primarily provided by the pudendal artery. However, the mons pubis, a fatty area over the pubic bone, receives its blood supply from the inferior epigastric artery, a branch of the external iliac artery. The vagina, on the other hand, receives its main blood supply from the vaginal artery, which is a branch of the internal iliac artery. Additionally, some branches of the pudendal arteries also contribute to the blood supply of the vagina.
The innervation of the anterior (front) vulva is provided by the ilioinguinal nerve along the midline, over the mons pubis, and the genital branch of the genitofemoral nerve on the lateral side. The posterior (back) vulva is innervated by the pudendal nerve and the posterior cutaneous nerve of the thigh. As for the vagina, most of its innervation comes from the autonomic nervous system. However, the distal (lower) part of the vagina receives innervation from the pudendal nerve.
See below the figure for an illustration of the vulvovaginal vasculature. (From Vanaman, 2016, taken from UpToDate)
Non-surgical Female Rejuvenation
Ablative Lasers
Vulvar and vaginal mucosal atrophy, commonly known as atrophic vaginitis, is a common consequence of menopause. The decrease in estrogen levels during menopause leads to changes in the vulvovaginal tissue, resulting in symptoms such as itching, dryness, burning, painful urination (dysuria), and painful intercourse (dyspareunia). To address these symptoms and improve quality of life, research has focused on nonhormonal and long-lasting treatments for vulvovaginal atrophy.
Carbon dioxide (CO2) lasers have been historically used to address cosmetic concerns in the vulva and perineum, but they were associated with patient discomfort. However, more recently, fractional ablative CO2 lasers have been used to treat vulvovaginal atrophy. A study involving postmenopausal patients who received a single treatment with fractional ablative CO2 laser found that it restored the vaginal mucosa to a premenopausal state by increasing epidermal thickness, glycogen levels, and promoting a rich dermal vascular supply.
Loss of vaginal rugae (folds) with aging and menopause may contribute to decreased sexual satisfaction. Fractional CO2 laser has been used to restore vaginal rugae, potentially improving sexual function. However, larger studies are needed to establish the safety and effectiveness of this application.
See below the figure of a patient with significant VVL before treatment with ablative CO2 laser, after treatment, and eight weeks after treatment, from left to right. (From Vanaman, 2016, taken from Red M. Alinsod, MD)
Radiofrequency
The use of monopolar radiofrequency (RF) in dermatology has been successful in skin rejuvenation since 2003. It delivers thermal energy to the deep dermis, promoting lifting and tightening while avoiding damage to the epidermis and neurovascular structures. The treatment initially causes collagen fibril contraction, resulting in immediate tissue tightening. This triggers a wound-healing response that leads to long-term production of new collagen, improving the appearance of wrinkles and further tightening the tissue.
One study involved 30 premenopausal women with vaginal laxity who underwent a single RF treatment to the vaginal introitus mucosal surface using a device that does not require anesthesia. The treatment resulted in significant and sustained improvements in laxity, sexual function, and sexual distress even after 12 months of follow-up. No significant adverse events were reported, except for mild vaginal leukorrhea and abdominal discomfort, which resolved spontaneously.
See below the figure of a patient with significant VVL before treatment with transcutaneous temperature-controlled radiofrequency (left) and four weeks after third treatment (right). (From Vanaman, 2016, taken from Red M. Alinsod, MD)
Injectables
Injectables, specifically hyaluronic acid and autologous fat, are sometimes mentioned and promoted as minimally invasive approaches to female genital rejuvenation, although they are less commonly used compared to other methods. These injectables are used to enhance and rejuvenate the female genital area.
1. G-spot Amplification
One technique used to enhance female sexual gratification is the amplification of the G-spot through the injection of hyaluronic acid fillers. This procedure aims to increase friction during intercourse, which can decline in conditions such as vaginal laxity (VVL) and menopause. Other filler substances like collagen, autologous fat, silicone, and calcium hydroxylapatite have also been used for this purpose with varying degrees of success.
However, there are potential risks associated with this procedure, including bleeding, infection, and urinary complications. The most serious adverse event reported is the intravascular injection of fillers, which can lead to complications such as nonthrombotic pulmonary embolism. Fatal pulmonary embolism has been reported in a case involving the injection of polyacrylamide hydrogel into the vaginal wall to achieve tightening. The safety and efficacy of G-spot amplification have not been firmly established, but the procedure remains popular among certain patients.
2. O-shot
The O-shot, also known as the "orgasm shot," is a controversial rejuvenation procedure that involves injecting platelet-rich plasma (PRP) into the clitoris and upper vaginal wall. PRP is derived from a patient's own blood and contains chemokines, growth factors, and cytokines that are thought to play a role in tissue repair and inflammation. While PRP has been used in other medical disciplines, such as maxillofacial and musculoskeletal applications, studies have not consistently demonstrated its efficacy.
The O-shot procedure is marketed as a minimally invasive method to improve sexual gratification and address urinary incontinence. Practitioners claim that PRP stimulates stem cells and promotes the growth of healthy vaginal tissue. However, there is a lack of peer-reviewed studies in the literature examining the safety and effectiveness of the O-shot procedure.
3. Fat Transfer
The aging process affects the labia majora, leading to decreased volume, wrinkles, loss of elasticity, and changes in color. Volume loss in the labia majora can cause discomfort, dryness, and cosmetic concerns, as it may expose the labia minora. Surgical methods such as fat grafting and autologous fat injection have been described as options to address these issues.
However, a potential complication of these procedures is the development of palpable fatty cysts, although they tend to resolve on their own within six months in most cases. Other reported adverse outcomes include increased perspiration and the appearance of an exaggerated vulvar outline, commonly referred to as a "camel toe," which may be visible through clothing.
Conclusion
Recent studies have highlighted the significant impact of vulvovaginal laxity (VVL) and vulvovaginal atrophy on women's quality of life, which has led to the development of nonsurgical and minimally invasive options for genital rejuvenation. These procedures aim to address cosmetic concerns, discomfort, and sexual dissatisfaction in women. Additionally, nonablative and radiofrequency (RF) techniques have shown effectiveness in treating stress urinary incontinence associated with VVL.
Dermatologists, who are well-versed in addressing skin aging through nonsurgical methods, may be less familiar with how these principles are applied to the treatment of VVL and vaginal atrophy. The growing demand for female genital rejuvenation necessitates that dermatologic surgeons become knowledgeable about office-based nonsurgical devices and procedures that can effectively and safely address these concerns.
See below the table summarising the devices marketed for female genital non-surgical rejuvenation. (From Vanaman, 2016)
Reference:
Emerging Trends in Nonsurgical Female Genital Rejuvenation (2016)
Nonsurgical Vulvovaginal Rejuvenation With Radiofrequency and Laser Devices: A Literature Review and Comprehensive Update for Aesthetic Surgeons (2018)
Genital Rejuvenation: The Next Frontier in Medical and Cosmetic Dermatology (2018)
Genital Beautification and Rejuvenation with Combined Use of Surgical and Non-surgical Methods (2021)
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