5 Key Procedures of Non-surgical Aesthetic Gynaecology
In today's age, driven by the powerful influence of social media and a widespread obsession with attaining the "ideal body," there has been an expanding interest in achieving the "perfect genitalia." As a result, the field of cosmetic gynecology has emerged, encompassing various medical specialties like gynecology, urogynecology, urology, plastic surgery, and dermatology.
This field addresses both the aesthetic aspects of external genital appearance and functional concerns related to sexual well-being and quality of life. These concerns stem from issues such as aging-related changes, pigmentation disorders, vaginal atrophy, laxity, and stress incontinence. Various aesthetic and surgical approaches, such as peels, platelet-rich plasma, energy-based devices, and surgeries, have been proposed.
This blog discusses the anatomy of external genitalia, as well as various non-surgical approaches to vaginal rejuvenation.
Anatomy of Genitalia
Having a basic understanding of the external genitalia's anatomy is crucial when considering any cosmetic procedure.
In females, the external genitalia (vulva) consists of several parts, including the mons pubis, labia majora, labia minora, vulvar vestibule, external urethral meatus, hymen, ostia of accessory glands (Bartholin's, Skene's, and vesitubular glands), and the perineum. The mons pubis is a fatty tissue area located in front of the pubic bone. The labia majora are skin folds extending from the mons pubis to the posterior fourchette, while the labia minora are thinner folds positioned inside the labia majora, containing less subcutaneous tissue. Unlike the labia majora, the labia minora lack hair follicles and include a clitoral hood and frenulum on their anterior surface. The external urethral opening is situated 2.5 cm behind the clitoral glans and in front of the vaginal opening. Analogous to the male penis, the clitoris is the female sexual organ, positioned near the front juncture of the labia minora, above the urethral and vaginal openings. The clitoral body is about 2.5 cm long and connects to the pubic bone via a suspensory ligament.
See below the figure for the important features of the external genitalia. (Taken from Jindal et al, 2022)
Non-surgical Vaginal Rejuvenation Procedures
The reduction of estrogen production as females age triggers noticeable metabolic and tissue transformations, particularly within the genital tract. These changes involve thinning of the vaginal epithelium, increased looseness of vaginal walls resulting in loss of texture, leading to a paler, drier, and more delicate appearance upon examination. This collection of symptoms is referred to as the genito-urinary syndrome of menopause (GSM). Vaginal rejuvenation is pursued for various reasons, including vaginal laxity syndrome, GSM, and vulvodynia. Vaginal laxity syndrome pertains to excessive vaginal wall laxity, causing feelings of looseness, diminished sexual pleasure, and potentially linked to incontinence. One common motivation for vaginal rejuvenation is enhancing sexual enjoyment. Vulvodynia, a complex chronic pain disorder, affects a significant proportion of women, ranging from 4% to 16%.
Traditional applications of lasers encompass hair removal, pigmentation correction, and addressing skin laxity, similar to their use on facial and other bodily regions. Hair removal techniques employing intense pulsed light (IPL), diode (810 nm), alexandrite (755 nm), or Nd:yag (1064 nm) lasers are effective for reducing hair growth on the pubic area, labia majora, and bikini area. In contrast to lasers, IPL employs a polychromatic, non-coherent, and non-collimated light with wavelengths spanning 420–1400 nm and diverse pulse durations. Skin's primary chromophores, including hemoglobin, melanin, and water, exhibit a broad absorption spectrum, allowing IPL to address various conditions ranging from pigmentation irregularities to hair reduction.
2. Energy Devices
Various energy sources have been employed in their non-ablative form to induce vaginal rejuvenation, targeting both mucosal revitalization and sub-mucosal tissue tightening by promoting neocollagenesis. Recent advancements have introduced specialized tools for delivering non-ablative lasers and other energy sources in a precise circumferential manner within the vagina, avoiding ablation.
This process hinges on selective photothermolysis, utilizing water within the vaginal wall as a chromophore, akin to its use in skin rejuvenation. The Er:Yag and CO2 lasers function based on water absorption. Absorbed laser energy generates heat, stimulating the production of heat shock proteins in fibroblasts. This leads to collagen synthesis, potentially elastic fiber synthesis, resulting in tightening, epithelial regeneration, and neovascularization. Gradual temperature elevation to 60–63 degrees Celsius minimizes the risk of burns, as this range optimally induces collagen fiber shortening and neocollagenesis. Er:Yag laser exhibits higher water absorption than CO2 laser. Non-ablative smooth mode of Er:Yag can achieve vaginal tightening by gently heating vaginal tissue, shortening collagen fibers.
Vaginal canal tightening can also be achieved using energy-based devices like radiofrequency (RF). Recent research indicates that RF increases small nerve density in the papillary dermis and promotes elastin and collagen production, with a unique impact on vaginal tissue. High-intensity focused ultrasound (HIFU) energy functions through focused thermal effects, resulting in cavitation, apoptosis, and thermal coagulative tissue damage. Originally used in oncology, HIFU has transitioned to aesthetics, including vaginal tightening and addressing stress incontinence. Vaginal HIFU devices use transducers similar to those employed in facelifts, emitting mechanical waves that cause water molecule vibration, thereby elevating tissue temperature and inducing neocollagenesis in reticular dermis layers. A comparative study indicates that RF has a more diffuse impact on tissue, whereas HIFU induces more focused collagen induction.
The "O shot," or Orgasm shot, involves injecting platelet-rich plasma (PRP) into specific areas including the clitoris, vagina, pubocervical fascia, and Skene's glands. When platelets release growth factors through degranulation, they stimulate processes like neo-angiogenesis, fibroblast growth, and neuronal growth. This leads to improved blood vessel formation and nerve supply in the clitoris and vagina, enhancing sexual responsiveness and sensitivity by increasing blood flow.
Platelet-rich plasma is also employed for regenerating vaginal mucosa, muscles, and skin. Following PRP injection, the skin becomes more resilient and firm, contributing to a more youthful vaginal appearance. Additionally, the supportive ligaments and muscles become stronger, aiding in the reduction of urinary incontinence symptoms.
4. Botulinum Toxin
Botulinum toxins, which are protein-based neurotoxins produced by certain bacteria from the Clostridium genus, act by blocking the release of acetylcholine, a neurotransmitter, resulting in muscle paralysis. They have been employed to treat challenging cases of vaginismus and vulvodynia. Vaginismus involves involuntary perineal muscle contractions during sexual intercourse. Various doses of botulinum toxin, ranging from 100 to 500 units, have been used based on vaginismus severity. Injected into the levator ani muscles under sedation, these doses have shown positive results.
Vulvodynia is characterized by persistent burning pain in the vulvar area lasting at least 3 months, without significant dermatologic or neurologic findings. Injecting 20 to 40 units of botulinum toxin into the vestibule, perineal body, and levator ani muscles has been found effective. Sessions can be repeated after 2 weeks if pain persists. Meta-analyses indicate that botulinum toxin is a valuable option for patients who do not respond to standard treatments.
Adipose-derived stem cells (ADCs) are a plentiful and enriched source of stem cells. When used in autologous fat transfer, the risk of rejection is extremely low since the cells come from the individual's own body. This source of stem cells includes various components, primarily the stromal vascular fraction (SVF), which encompasses ADCs, along with extracellular matrix (ECM), endothelial cells, and other immune cells.
Autologous fat transfer is a technique utilized to enhance genital volume, rejuvenate the vulvar skin, and improve vaginal walls through lipofilling. Lipofilling involves increasing the thickness of labial folds by repositioning fat, effectively reducing vaginal diameter.
Cosmetic gynecology—An emerging field for the dermatologist (2022)
Cosmetic gynecology-a systematic review and call for standardized outcome measures (2020)
A mini-review of aesthetic gynecology and leading gynecology associations’ approaches to this issue (2018)
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