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PST 009: Designer Vagina — Read the Transcript

April 20, 2018

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Hello and welcome. Dr. Stephen Mulholland here from Toronto, Canada. Welcome to our podcast. Plastic Surgery Talk from SpaMedica. We’re going to be talking about a Designer Vagina. What is a Designer Vagina? We’ve had a tremendous technological period of innovation where we’ve focused on this area of women’s health. And you can divide women’s health into transformation of the perineal area, the area that involves the pubis, the labia majora, the clitoral hood, the fourchette around the clitoral hood, and the endovaginal environment of the vaginal canal.

And the external, let’s call it genitalia cosmetic enhancement would consist of mons pubis reduction, mons pubis lift, making the labia majora larger using fat grafting, making the labia minora smaller if they’re protrusive, and then the endovaginal environment. The endovaginal environment has been the biggest innovation through laser and radiofrequency innovation, we have new devices, minimally invasive devices that are inserted in the vaginal canal and almost painlessly can improve the symptoms of vaginal laxity, genitourinary signs of menopause which include dryness, discharge, inflammation and pain and then of course, stress urinary incontinence.

These are three large areas of female health we didn’t have good solutions for, so we can help the stress urinary incontinence, vaginal laxity after multiple parity, multiple childbirth, and with the symptoms of post-menopausal or post-tamoxifen if you’ve had breast cancer, symptoms of dryness, irritation, inflammation. We improved the endovaginal environment with a simple examination, the insertion of a small probe that emits radiofrequency energy or laser energy and restores and returns the vaginal mucosa to a more youthful environment. It tightens the environment of the endovaginal canal, and it improves the integrity of the muscles in the area of the bladder and the urethra, so stress urinary incontinence is improved.

So, we can improve the outside. We can adjust and improve the inside. We can design and tailor the female secondary genitalia characteristics and internal vaginal environment that you want. Hence, a designer vagina. Restoration of the inside and the outside to make a more livable home. The concept of a designer vagina, if you will, has been around quite a long time. Interestingly, it coincides with the growth and proliferation of laser hair removal. In the late 90s and the early parts of the last millennium, we have tremendous devices that can reduce pubic hair and bikini hair and suddenly, we’re looking right at the vagina and the labia like we never did before, and we started to define labial hypertrophy or the inner lips being too large or too small, and the relationships of the labia to the mons pubis because now we had no hair to camouflage things, and so we started to see the growth and popularity of labioplasty, which is making the labia minora smaller. Labioplasty, making the labia majora larger and getting the ideal relationships of the majora to the minora.

In the latter part of the last decade, for the last 10 years, it’s a procedure that’s doubled almost every year. The mons pubis reduction and lifts has become popular, and it’s only been the last four years with the evolution of vaginal lasers and endovaginal radiofrequency devices where the internal restoration of vaginal health has been very popular. This is a procedure that is literally doubling every year because of technology innovation, because of women getting older or more attuned with how they want their private parts to look.

With all these designer vaginas, is this done for cosmetic reasons or functional reasons? And the answer is yes, yes, maybe and both. Many women will present with no functional limitation. They don’t have pain during intimacy. They don’t have discharge or inflammation. They’re not menopausal. They haven’t had tamoxifen for breast cancer. They don’t have vaginal laxity and they don’t have stress urinary incontinence, so they’re not getting any functional improvement, but they have cosmetic concerns. They feel that their labia minora are too large for the majora, and they stick out, they flop, they get in the way. It can happen when you’re riding or exercising. It can sometimes be embarrassing during intimacy, and that is clearly more of a cosmetic reason and perhaps for comfort during intimacy. Fat grafting to the labia majora, same thing, mainly cosmetic. Mons pubic reduction/elevation, usually purely cosmetic.

There are those women though that have had a number of children with episiotomies or different traumatic transvaginal delivery scenarios or they’ve had pelvic surgery. They might be post-menopausal and they’ve lost the youthful mucosa they had when there was estrogen around, or they’ve got a change in the bladder wall and they’ve got some stress urinary incontinence, so that’s purely functional. Some women just want improvement in pain, discharge, and inflammation. Some want to have less stress urinary incontinence, and some want to feel more firmness or pressure during intimacy after childbirth and episiotomies and that’s for more tightening. We have laxity issues, inflammatory issues, vaginal atrophy postmenopausal, and stress urinary incontinence, so those are purely functional usually.

But then, there’s a huge hybrid group of patients that have both some cosmetic concerns, some sexual functioning intimacy concerns, which you could call functional, and pure functional concerns such as stress incontinence, and by far the most common type of patient we see has combinations of cosmesis and functionality to feel like their vaginal and female health environment is whole and represents that young, sort of active, and fully engaged woman that sometimes these symptoms can detract from. And so, generally, as a cosmetic center, we’re going to treat for cosmetic reasons primarily, but increasingly many of the women present with functional concerns and this treatment is not covered by the managed healthcare system, so it’s become part of the envelope of cosmetic female health that happens to include some functional improvements.

The ideal candidate for designer vagina is a female patient who feels that they have some anatomical arrangement between the labia majora and minora that they don’t like. The majora is not protruding enough, the minora protrudes too far, and they want to improve that relationship, or the mons pubis to the clitoral hood, the clitoral hood to the clitoris needs anatomic adjustment.

The second candidate would be someone that’s perfectly happy with their external anatomy and genitalia, but has some endovaginal concerns. Vaginal laxity, usually after multiple children, vaginal birth, perimenopausal or post breast cancer tamoxifen where there’s signs and symptoms of atrophy, which is dryness, inflammation, pain, or women with stress urinary incontinence.

The final candidate are women that have a hybrid of two, three or four of those symptoms in one presentation. Those are the ideal candidates. Then they have to have realistic expectations. We can’t cure 100% of the problem, but usually we can make 90 to 95% improvement and reduction in all the functional and cosmetic issues that are mentioned, and they have to be accepting of a multi-treatment program, once a month for three months, and generally, to maintain vaginal competency, you need to come back once or twice a year for simple maintenance. We’re talking a fairly simple treatment. The endovaginal takes about eight minutes. It’s done under local anesthesia after an examination, and there’s no pain and discomfort. Very well-tolerated. Realistic expectations. Accept set of symptoms that we can improve, and a commitment to maintenance, just like Botox needs to be done once or twice a year, most of the endovaginal tissues will atrophy or get older and degenerate again if we don’t do some simple maintenance. If they have all those kinds of criteria and accepting of the treatment protocol, most women are extremely happy with the designer vagina program. Even the name though, designer vagina is more marketing hype. It truly is restoring female wellness and health in other areas than just face and body and breast.

What is the age for this designer vagina or female health procedures? Divide it into two groups: the young and the slightly older or not so young. In the young individual, let’s say a pre-childbirth or just after, they’re not perimenopausal, they’re generally not going to have stress urinary incontinence. They’re not going to have the atrophic signs of menopausal vaginal changes. They’re typically not going to have vaginal laxity, or they could be a young mom with a couple of kids and have vaginal laxity issues. The vast majority of young women have postpartum vaginal laxity and concerns about appearance, the appearance of a labia minora, the majora and clitoral hood or the mons pubis, so they’re tentatively going to be externally- oriented, less endovaginal. The older woman tends to be less external- oriented and more endovaginal. They’re going to have incontinence. They’re going to have postmenopausal symptoms, dryness, inflammation, pain, and maybe some laxity issues, but they’re going to be generally content with the external genitalia and the anatomy and more functionally-oriented.

How beneficial are these procedures to a woman’s perception of quality of life? There are very good studies that show the urinary stress incontinence scores improve significantly after the treatment; that the intimacy scores and the confidence during intimacy improve significantly after these treatments; that the sense of intimacy with vaginal laxity symptoms significantly improves after these treatments. So, it’s not a miracle cure, but a very significant improvement in functional quality of life. Cosmetically, for the external treatments, there’s a little more risk because there’s actually surgery involved, but the vast majority of women who have labioplasty, which is a change in the proportion of the majora or minora, are extremely happy because these are treatments that you can’t really treat with any other procedure other than surgical reduction or surgical augmentation.

We didn’t talk much about the G-Shot or the condensation of sensory nerve endings in the upper anterior vaginal vault, which when injected with PRP or plasma-rich platelets or with Sculptra or HHLs can improve responsiveness during vaginal intimacy. That has a beneficial impact on intimacy, but no other functional impact or benefit, and so the vast majority of patients in some studies show that properly executed, these procedures have very few complications. Properly selected patients have good expectations. Generally, these expectations are met, and their overall sense of well-being improves and therefore, fits the criteria of the kind of procedures that we need to be offering in the world of female health.

Generally, when women are conveying their concerns, there’s a degree of an embarrassment about discussing some of these issues, but most can be compartmentalized, the concerns and the subjective symptoms into endovaginal concerns or external anatomic concerns. Are the concerns with the labia minor and majora? Is it the mons pubis? So, we have a form they can fill out and write down their concerns, and we give them mons pubis, labia minora, the inner lip, labia majora, the outer lip, the clitoral hood, and they can write ‘too much, too little, smaller or bigger’ and what their goals are.

With the endovaginal, it’s really much simpler. Do they have incontinence? And there’s different grades of incontinence. Do they have vaginal laxity and how often does it bother them during intimacy? And then the symptoms of  genitourinary signs of menopause? Do they have pain, inflammation and discharge? It really becomes more of a checklist, so we’ve taken what can be embarrassing to talk about and made a checklist form which by circling and even seeing the paper before the patient, we can have a very good sense of what really bothers them.

The recovery time for laser vaginal rejuvenation, radiofrequency rejuvenation, the endovaginal probes that go inside the vaginal canal, restore the lining, restore health to dryness, inflammation and pain, improve the incontinence and then tighten the vaginal canal, there’s almost no downtime. It’s literally an eight to ten minute procedure done once a month for three months. The results are noticed after the first treatment. There’s no post-treatment instructions, so there’s no pain or discomfort. It’s one of the few plastic surgery procedures where there’s literally no downtime.

With the external and anatomy surgery, labioplasty, labial augmentation, mons pubis reduction, there is downtime. There’s swelling, there’s pain, there’s about two weeks of recovery and then another four weeks until you can engage in high impact aerobic activity or intimacy. So, mons pubis reduction, labioplasty, fat grafting to labia, these procedures are like typical surgeries, like an upper lid blepharoplasty or that type of surgery where you’ve got to have about a six-week recovery for the incisions to heal, for sensitivity to diminish, and to resume your normal active life. The endovaginal treatments, no downtime, very few risks, right back to normal activities.

I often get asked what the G-Shot is, and the G-spot is where the shot is placed. So, what is the G-spot? On the upper, called the anterior vaginal vault, just behind where the clitoral hood and fourchette would be is a condensation of sensory nerve endings, and when stimulated on the anterior vaginal vault in the first two centimeters, there can be a more intense vaginal orgasm during intimacy. That area can be enhanced. As you get older, when the mucosa starts to thin and get what’s called atrophic or older in the perimenopausal or post-Tamoxifen breast cancer patient, or even in an individual who has difficulty with intimacy and responsiveness, the neurovascular bundle, the sensory awareness, can be enhanced by an injection. We can inject simple Juvaderm or Restylane like we would for lip enhancement to add volume to the neurovascular bundle to push the nerves down to get in more of the line of physical manipulation during intimacy. We can also inject growth factors and stem cells to augment the blood supply and the responsiveness of those same nerve endings with what’s called PRP, platelet-rich plasma. So, either gels for physical distention of the area to get more stimulation during intimacy, or growth factors and stem cells to increase the nervous responsiveness of that area, and those shots are injected in the G-spot, hence the G-Shot. A simple injection treatment into a sensitive area of the vagina to make it more responsive during intimacy.

So, thank you very much for joining me on our podcast today on our Designer Vagina. If you’ve enjoyed this podcast, please share it on all your social channels, and join us again on Plastic Surgery Talk for another podcast.

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