Lecture at OGSM 2019

1. D AT O D R A R U K U N A I D U
M D ( U K M ) , F R C O G ( L O N D O N ) , C U ( J C U ) , A M
C O N S U LTA N T U R O G Y N A E C O L O G I S T
H R P B . I S H
AESTHETICS IN
UROGYNAECOLOGY

2. A/P Roy Ng Snr Cons & Head
Urogynaecology & Pelvic
Reconstructive Surg Dept O&G
2
MCH IPOH

3. MCH IPOH

4. CONFLICT OF INTEREST
• I have no monetary support by any drug or medical
instrument company.
• Training support & Trial of CO2 LASER Machine (
Venusys)) use Support for 1 month ( no involvement in any
part of research study)
• Trial with Beladona LASER rejuvenation Machine used as
trial on 5 patients

5. AESTHETICS TRAINING &
KOREAN CONNECTION 2007

6. Factors contributes to interest in FGCS
and Changes in O & G practices
• Decrease Birth rate / Decrease gynecologic pts.
• Long Hours / Low Pay
• Malpractice Insurance
• Many hospital & competitions- looking for alternatives
• Change in socio-cultural, attitudes & norms
• Marital problem or Believe that after tightening, sex will be
improved
• Fashion induce seasonal changes
• Medical reality television and talk shows
• Internet & social media -Accessibility of Pornography
• Search engines direct the searcher to ‘Centres of cosmetic and
aesthetic surgery’
• Development & advance in technology
• $$$$$

7. BUT there are some problem in such field ( FGCS)
• High Cost incurred
• Competition from Beauticians , GP’s, Cosmetics clinics.
plastic surgeon and dermatologist( no man area)
• Not Familiar with Cosmetic Patient
• Not Experienced in Marketing this new services
• Industry driven practices
• Not evidence base practice so far
• Urogynaecologist: traditionally perform pelvic floor
repair +/- complimentary perineorrphy are some what
more exposured to FGCS

8. • Interest in sexual gratification
• Interest in genitalia cosmetic aspect/Obesity/ skin care part.
• Interest in “ well-being”-UI/GSM

9. What Women Really Wants
Is it really beautiful ?/!:
Ideal aesthetic external genitalia
• Motakef classification
• Banwell classification
• None are acceptable to urogynaecologist or
plastic surgical societies

10. 10
Aesthetics Treatment Options in Urogynaecology
Pharmacological
Incisonless
Tissue
Remodeling Surgery
Behavioral
Education
Exercises
(Kegel)
Estrogen
Tightening
sprays and
creams
Laser therapies:
LVT
LVR
GynoPulse
Classical
Lasers:
CO2 surgery
(diode)
Erbium laser
Non-invasive Minimally-invasive Invasive

11. APPLICABLE OF ? AESTHETICS IN
UROGYNAECOLOGY
• Labial hypertrophy/ large labia
• Congenital adrenal hyperplasia
• Clitorial Operations: Phymosis
• Treatment of congenital anomaly: Septum / agenesis
• Transsexualism
• Imperforated hymen
• Pelvic floor repair: anterior(cystocele), posterior
vaginal wall repair(rectocele, enterocele), vault
prolapse, perineorraphy ## complimentary
The goal of urogynaecologist to provide symptom relieve
like prolapse symptoms, urinary, bowel or sexual
symptoms.

12. WHAT IS FGCS
Female genital cosmetic surgery (FGCS) includes several surgical
interventions (such as vaginal rejuvenation, labiaplasty, vulvar
liposculpturing, re-virgination with hymenoplasty, and G-spot
amplification) aimed at reaching better female genital appearance
and/or improved sexual functioning. #1
In a US survey, the American Society of Plastic Surgeons reported a
30% increase in the rate of vaginal rejuvenation procedures (from
793 in 2005 to 1,030 in 2006). #2
# 1. Iglesia CB. Cosmetic gynecology and the elusive quest for the “perfect vagina”. Obstet
Gynecol. 2012;119(6):1083–1084.
# 2. Lowenstein L, Salonia A, Shechter A, Porst H, Burri A, Reisman Y. Physicians’ attitude
toward female genital plastic surgery: a multinational survey. J Sex Med. 2014;11(1):33–39.

13. NEWER APPLICABLE OF AESTHETICS
IN GYANECOLOGY ( FGCS)
• Labia majora /Mons Liposuction
• Labial hypertrophy
• Rejuvenation Vagina
• Urinary Incontinence/ Cystocele (Mild)
• Lipotransfer to pelvis/ pubic hair transplantation/
removal
• Hymenoplasty
• Sexual Improvement/ Gratifications to improve
Sexual Desire
• GSM/ UGA ( Genital Syndrome of menopause)
# Pathogenizing a normality & providing some solution??

14. MARKETING TERMINOLOGIES:
VULVAL/VAGINAL SURGERIES
I. DLV™ (Designer Laser Vaginoplasty), DLP(Designer Laser Perineoplasty)
1) LRL (Laser Reduction Labioplasty)
LAL ( Laser Augmentation Labioplasty): by filler, fat,
2) LP (Laser Perineoplasty)
II. LCP™ (Laser Clitorial Plasty)
III. PL (Perineal Lipoplasty);
1) Augmentation of Labia majora/minora, Mons pubis, Perineal Body
2) Reduction lipoplasty of Labia majora, Mons
IV. Medical Perineal Skin care
LTC & LVC (laser T-line & V-line cleanup)
Pubic Hair Transplantation
Micropigmentation

15. MARKETING TERMINOLOGIES FOR
SEXUAL GRATIFICATION
I. LVR™ (laser vaginal rejuvenation)/Laser Vaginoplasty
① LPC (Laser Posterior Colporrhapy)
② LAC (Laser Anterior Colporrhapy)
II. LH™ (laser hymenoplasty)
III. GSAV™ (G-spot Augmentation Vaginoplasty)
cf. WLV™ ( Wedding Laser Vaginoplasty)

16. SEXUAL GRATIFICATION

17. Perineorrhaphy
Posterior colporhaphy

18. APPLICATION OF UROGYNAE SURGERY
AS AESTHETICS

19. Fig. 1. Schematic representation of the
mucosal ellipses removed during the cosmetic
mucosal vaginal tightening. The ellipses can
occasionally have slightly different sizes, to
obtain the desired level of tightening.
# Plastic & Reconstructive Surgery. 123(6):212e-213e, June 2009.
Fig. 2. Schematic representation of the
position of the final sutures after a
cosmetic mucosal vaginal tightening.
Lateral colporrhaphy

20. LATERAL COLPORRAPHY

21. Unilateral labioplasty & MUS Posterior colporrhaphy

22. • Quasi-experimental study in Iran
• 86 women(reproductive age)
• Evaluate the effect of selective vaginal tightening on
sexual function using FSFI
• Between baseline and 6-months follow up
# Abedi P, Jamali S, Tadayon M, Parhizkar S, Mogharab F. Effectiveness of selective vaginal tightening
on sexual function among reproductive aged women in Iran with vaginal laxity: A quasi-experimental
study . J. Obstet. Gynaecol. Res. 2014; 40: 526-31.

23. • selective vaginal tightening in women with
vaginal laxity may improve some aspects
of sexual function
• 46.8% of women have dyspareunia most
of the time at 6-month follow up
# Abedi P, Jamali S, Tadayon M, Parhizkar S, Mogharab F. Effectiveness of selective vaginal tightening
on sexual function among reproductive aged women in Iran with vaginal laxity: A quasi-experimental
study . J. Obstet. Gynaecol. Res. 2014; 40: 526-31.

24. NEW METHODS
FOR SEXUAL GRATIFICATION IMPROVEMENT
I. Vaginal Tightening Operation (LVT/LVR), decrease
diameter
II. Intravaginal autologous fat transfer (IVFT), increase
friction
II. Labioplasty by Laser improve self esteem
III. Laser Clitoroplasty for clitorial orgasm potentiation
(Vaginal Relaxation Syndrome)

25. 25
Minimally invasive treatment method
Laser Vaginal Tightening
(LVT/LVR)
Thermal non-ablative irradiation of vaginal wall

26. CO2 LASER VAGINAL REJUVENATION
• CO2 laser to restore
vaginal rugae by vaporizing
tissue.
• Sensation remained intact
using a heat–cold test
• The clinical importance of
the sensation of a smooth
vagina is unclear.
# Ostrzenski A. Vaginal rugation rejuvenation (restoration): A new surgical technique for an
acquired sensation of wide/smooth vagina. Gynecol Obstet Invest. 2012;73(1):48-52ใ

27. EVIDENCE & FACTS LVT
Shrinkage of vaginal canal after intamase laser therapy in 27 patients
Dr Mario Ravera, Santa Cruz, Bolivia (17% shrinkage) Unpublised
The clinical importance of the sensation of a tighter vagina is unclear

28. Study Design Results
# Salvatore
et al. 2015
• Prospective study
• n=77
• VVA symptoms
• Fractional microablative
CO2 laser for 3 section
every 4 wks
• 12 wks follow up
★ Sexual function: FSFI,
SF-12
★ VVA symptoms: VAS
★ Sexual satisfaction:
VAS
★ QOL
• Significant improvement in FSFI
score(total, each domain) (p<0.001)
• Significant improvement of overall
satisfaction with sexual life (p<0.001)
• Significant improvement in each VVA
symptoms (p<0.001)
• Significant improvement in QOL (p<0.05)
# Salvatore S., Nappi RE., et al. Sexual function after fractional microablative CO2 laser in women with
vulvovaginal atrophy. Climacteric 2015; 18: 219-225.
Sexual function after fractional microablative
CO2 laser

29. Laser Vaginal Rejuvenation
( surgical )

30. Laser Vaginal Rejuvenation (surgical)

31. Laser cliteroplasty
(surgical)

32. LRL INSTRUMENTS & DESIGN 1

33. LRL INSTRUMENTS & DESIGN 2

34. Intravaginal Fat Transfer (IVFT)
IVFT reduce internal vaginal
diameter
Potentiate sexual contact in vagina/
Improve sexual gratification
Application in Relaxed vagina
Advantage
• Natural sensation
• simple procedure
• rapid recovery
• rapid assumption of sexual
activity
• no definite complication
May need to repeat every 6 months

35. Intra vaginal Fat Transfer (IVFT)

36. TREAT OF URINARY INCONTINENCE

37. Laser irradiation of urethra and sphincter surrounding
Non-ablative thermally processed mucosa causing
collagen remodeling and neocollagenesis
Laser Therapy for SUI (Non surgical method)
So far no evidence to show laser therapy is beneficial to treat urinary stress
incontinence

38. ONGOING
No. 358-Intravaginal Laser for Genitourinary Syndrome
of Menopause and Stress Urinary Incontinence.
Walter JE, Larochelle A. No. 358-Intravaginal Laser for Genitourinary Syndrome of Menopause
and Stress Urinary Incontinence. J Obstet Gynaecol Can. 2018 Apr;40(4):503-511.

39. TREATMENT OF GSM/UGA

40. LASER THERAPY FOR VAGINAL ATROPHY
Vulvovaginal atrophy:
• Lubricants and moisturizers
• Vaginal estrogen
• Vaginal dehydroepiandrosterone
• Ospemifene(SERM)
• Alternative and complementary
supplements
• LASER
# Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American
Menopause Society.: 2013. Menopause 2013; 20(9): 888-902.
Transforming growth factor-β : key
element in inflammatory response and
in the fibrogenic process —> produce
collagen and extracellular matrix

41. GSM(Vaginal Atrophy) : Microscopic Structure
Before treatment
After treatment ? Laser growth
factor stimulation or routine
repair after thermal injury ??
# Zerbinati N., Serati M. et al. Microscopic and ultrastructural modifications of postmenopausal
atrophic vaginal mucosa after fractional carbon dioxide laser treatment. Lasers Med Sci
2015;30:429-436

42. LONG-TERM EFFECTS
OF VAGINAL ERBIUM LASER IN THE TREATMENT
OF GENITOURINARY SYNDROME OF MENOPAUSE.
• Vaginal erbium laser treatment induced a significant
(p < 0.01) decrease in VAS for both vaginal dryness and
dyspareunia, as well an increase in VHIS (p < 0.01) up to
the 12th month after the last laser treatment.
• The values returned to levels similar to the baseline
after 18 and 24 months.
CONCLUSIONS: These results suggest
that vaginal erbium laser may be effective and safe for
the treatment of genitourinary syndrome of menopause.
# Gambacciani M, Levancini M, Russo E, Vacca L, Simoncini T, Cervigni M. Long-term
effects of vaginal erbium laser in the treatment of genitourinary syndrome of menopause.
Climacteric. 2018 Apr;21(2):148-152.

43. ONGOING STUDY ON EFFECTIVENESS
OF LASER ON GSM

44. CURRENT CONSENSUS

45. PROFESSIONAL VS. POPULAR
“Vagina rejuvenation”
= 7 items found
“Laser labia rejuvenation”
= 0 items found
“vagina rejuvenation”
= 594,000 items found
“Laser labia rejuvenation”
= 106,000 items found

46. PUBMED
1: Park TH, Whang KW. Vaginal Rejuvenation with Gore-Mycromesh. Aesthetic Plast Surg. 2015
Aug;39(4):491-4.
2: Moore RD, Miklos JR, Chinthakanan O. Vaginal reconstruction/rejuvenation: Is there data to
support improved sexual function? An update and review of the literature. Surg Technol Int. 2014
Nov;25:179-90.
3: Park TH, Park HJ, Whang KW. Functional vaginal rejuvenation with elastic silicone threads: a 4-year
experience with 180 patients. J Plast Surg Hand Surg. 2015 Feb;49(1):36-9.
4: Puppo V. Can female genital cosmetic surgery be considered or classified as female genital
mutilation type IV?. Reply to: A. Ostrzenski: Vaginal rejuvenation (restoration): a new surgical
technique for an acquired sensation of wide/smooth vagina. Gynecol Obstet Invest 2012;73:48-52.
A rebuttal. Gynecol Obstet Invest. 2013;75(3):215-6.
5: Ostrzenski A. Vaginal Rejuvenation (restoration): A new surgical technique for an acquired
sensation of wide/smooth vagina. Gynecol Obstet Invest. 2012;73(1):48-52
6: Mirzabeigi MN, Jandali S, Mettel RK, Alter GJ. The nomenclature of "vaginal rejuvenation" and
elective vulvovaginal plastic surgery. Aesthet Surg J. 2011 Aug;31(6):723-4.
7: Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. ACOG
Committee Opinion No. 378: Vaginal “Rejuvenation" and cosmetic vaginal procedures. Obstet
Gynecol. 2007 Sep;110(3):737-8..

48. # Committee on Gynecologic Practice. American College of Obstetricians and Gynecologists. ACOG
Committee Opinion No 378: vaginal “rejuvenation” and cosmetic vaginal procedures. Obstet Gynecol.
2007;110(3):737–738.

49. Similarly, in a 2013 ethical opinion paper on FGCS, the Royal College of
Obstetricians and Gynaecologists (RCOG) underlined that presenting FGCS
procedures as an unproblematic lifestyle choice is inappropriate because it
misinforms women about the actual efficacy of these procedures. #4
Moreover, the Royal Australian and New Zealand College of Obstetricians and
Gynaecologists (RANZCOG) and the Society of Obstetricians and Gynecologists
of Canada (SOGC) took a public stand against FGCS. #5,6
#4. Royal College of Obstetricians and Gynaecologist. Ethical considerations in relation to female
genital cosmetic surgery (FGCS). RCOG Ethics Committee, 2013. Accessed June 26, 2017.
#5. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. RANZCOG
College Statement: C-Gyn 24. Vaginal “Rejuvenation” and Cosmetic Vaginal Procedures; 2008. .
#6. Committee Clinical Practice Gynaecology, Ethics Committee, and Executive Council of the Society
of Obstetricians and Gynaecologists of Canada. Female genital cosmetic surgery. J Obstet Gynaecol
Can. 2013;35(12):e1–e5.

52. LOCAL DATA (DEC 2017)

53. RETHINKING THE TECHNO VAGINA: A CASE SERIES OF
PATIENT COMPLICATIONS FOLLOWING VAGINAL LASER
TREATMENT FOR ATROPHY.
Case 1: Is a 65-year-old woman with GSM and
moderate vaginal stenosis who had two vaginal wall lacerations
after resumption of intercourse.
Case 2 : Is a 61-year-old woman who had persistent dyspareunia
following vaginal laser treatments.
Case 3: Is a 68-year-old woman who reported worsening
dyspareunia and had a fibrous band mid vagina that impinged on
the canal.
Case 4: Is a 55-year-old woman who complained of dyspareunia
and insertional pain, after her laser. Assessment and follow-up
treatment are presented.
Gordon C, Gonzales S, Krychman ML. Rethinking the techno vagina: a case series of patient
complications following vaginal laser treatment for atrophy. Menopause. 2019 Jan 14. doi:
10.1097/GME.0000000000001293. [Epub ahead of print]

54. CONCLUSIONS
• As Urogyanecologist our aim is to restore abnormality & improve
the quality of life of patients with POP, UI & Sexual dysfunctions
• Urogynaecologist are somewhat doing some form of FGCS in some
sense, usually as complimentary procedures
• FGCS is not a new kid, but a rebranding of procedures currently
carried out by urogynaecologist
• FGCS for non indication is difficult to justify with current
evidence & positional statements by many authorities
• The current evidence does not support for FGCS, as there are very
limited evidence
• More research are need to justify its use
• Currently some well design research are in progress & hopefully
some supporting evidence will be available

55. CONCLUSIONS
• FGCS in current practice is pathoginizing a normality of a female
genitalia
• FGCS can be constitute to FGM ( Female Genital Mutilation)
• ?? Should we use Medical terminology for “ Vaginal rejuvenation”
instead.
• Some evidence that vaginal LASER can improve vaginal atrophy and
sexual function in short term but lack of RCT
• Little evidences of efficacy and safety of LASER in long term
• We should only accept new Technique/ Technology after a robust
testing & research
• Many organization is ongoing process for recommendation of do’s &
don’t’s with FGCS
• Guideline by professional organization is advocated
• Every thing is not $$ but also need to some ethics as doctors