Aesthetic Genital Surgery (Feminine)

Why and for who?

The interest for external sexual organs to stand out, ennobled by the art of the most advanced cultures, has now arrived to an exciting stage.  With respect to women, the more determination they have to improve, the more attention they pay to areas like breast reconstruction and the shape of their figure.  In the last decade, attention has shifted to parts of the anatomy which before were reserved for artistic fantasy.  This is due to more permissiveness in general and currents of opinion.

The aesthetic improvement of external genitals promotes the recuperation of signs of youth by filling or lipo-infiltration of the labia, adjustment or tightening of the vulva and vaginal canal, reaffirming its musculature, and even recreating the hymenal membrane, while correcting imbalances of labia minora and clitoris, reshaping its outline and length.

We also correct birth defects such as absence of vaginal cavity, a cavity too short, situations with ambiguous genitalia or intersexuals with inadequate genitalia, or the consequences of endocrine disorders that can cause an enlarged clitoris.

Treatments are also proposed for infections that affect both genders, such as chronic hidradenitis and pilonidal sinus, which are damaging, especially the first, and sometimes massively damaging, folds with hair like inguinal folds and armpits.

In other cases, intervention is essentially to repair any undesired consequences from a previous problem or surgery, such as deformities and contractures, ritual mutilation, trauma or previous surgery for tumor disease.

Recommendations before treatment in female genital surgery

It is helpful to make a written record of questions to avoid forgetting any, because it is important to clarify with the surgeon any questions you may have about the procedure to be performed.

Make preparations with enough time in advance for the list of medicines prescribed in the pre-operative consultation, have looser clothes available that can accommodate your genitals without friction, and the dressing or bandage we apply after the operation.

Who are the most suitable candidates?

The best decision is a result of realistic and balanced deliberation, presenting different alternatives, weighing benefits against drawbacks, understanding the proposed techniques and possible added gestures in the surgery, and respecting the recommended convalescence period.

For best results, this decision making process can be aided by the participation of an experienced psychologist, to whom we can express our expectations, in order to obtain objective and effective advice.  Furthermore, a multidisciplinary approach could be formed, in cases that require it, by obtaining the opinion of a gynecologist. When there are glandular disorders, an endocrinological consultation is essential prior to the procedure.

Do you perform surgery for the redevelopment of sexual identity?

Comprehensive and adequate treatment for gender dysphoria, is subject to international protocols (www.symposion.com/ijt/soc-01/index.htm), involving both hormonal and psychiatric pre-treatment periods of 2 years, essential as a preliminary to any definitive surgery that may be irreversible.

Generally acceptable aesthetic results, can sometimes be controversial.

Treatments that are performed in female genital surgery

1. Labiaplasty:

There are wide variations in both the appearance and size of labia minora, with enlargements that can be from birth, after child birth, or age. The reasons for remodeling are many: discomfort in wearing trousers and swimwear, such as during exercise or sports, and it is not uncommon to get access dyspareunia (from gr. dys: difficult, and pareunos: mating) as in almost 50% of the patients examined. The aesthetic reasons are also important, resulting in high levels of satisfaction, around 95% of the women involved.

There are different techniques, adapted to the type of labia minora excess, which can be further combined with remodeling of the clitoral hood. The most suitable techniques preserve the natural contour and color.

It is usually performed under local anesthesia in association with sedation, as an ambulatory procedure. The period of convalescence, adapted depending on the patient’s job, is usually brief, about 3 days, with immediate revisions at 24 and 72 hours. The resumption of sexual relations is possible at about 4 weeks.

2. Labia remodeling:

Excess tissue causes bumps, especially evident when wearing tight clothes, giving way to irritation from microorganisms. As in the previous case, it can be congenital, or due to age or childbirth.  The reduction is done by making internal semi-lunar reductions in its confluence with the labia minora, which allows for the scar to be properly hidden. Both anesthesia and convalescence period are similar to labiaplasty.

3. Lipoinfiltration of the labia mayora:

By filling of adipose tissue taken from locations where there are surpluses, with the intention of recovering the fullness and youthful tone, as well as correcting the creases from massive weight loss or bariatric surgery.

It is performed under local anesthesia and sedation and it may be associated with other techniques. Sexual relationships are allowed in about 2-3 weeks. Based on the results and what happens over time, it is sometimes complimented by revisions of the procedure.

4. Pubic remodeling due to excess fat tissue, with or without "lifting”:

The bulging pubis, especially evident when wearing clothes, happens even when the patient isn’t overweight, sometimes a side effect of previous abdominoplasty; it interferes with relationships, and even hygiene care.

The reduction in its fullness, under sedation as outpatient surgery with local anesthesia, allows you to quickly restore a morphology more consistent with the feminine form.

When there is also excess skin and soft tissue, it is combined with a “lifting” leaving scars hidden in the folds.

5. Vaginal Rejuvenation:

With multiple child births or over age, a relaxation of the normal tone of the soft structures that form the pelvic floor can be caused, in these cases bulbocavernosus muscle fibers that act as constrictor vaginal surface can be adjusted to improve the intensity during lovemaking. It is performed under epidural anesthesia or general anesthesia, with a medium length stay required.

6. Hymenal membrane recreation:

Done independently from other procedures and as an outpatient procedure, or in connection with the refinements of the above procedure, some women who wish to promote the youthful appearance of their external genitalia may undergo this quick technique under local anesthesia and sedation. Las relaciones, Sexual relations can be resumed after the 4^th week.

7. Enlarged clitoris reduction:

The excessive development of the body and of the clitoris, considering the average size of the clitoris to be between 3.7 and 10 mm, may be present from birth, a side effect from endocrine disorders like adrenal hyperplasia, or be acquired by the administration of steroids.

Its dimensions are re-established under short duration general anesthesia, with respect to the patient’s sensitivity, usually requiring a medium length morning stay.

8. Readaptation of ambiguous genitalia:

The congenital abnormalities in the differentiation of external genitalia cover a wide range of disorders, including the cases of intersexuals.

Specifically customized treatment allows these patients to harmonize their external appearance with their orientation to avoid ambiguous situations.

9. Treatment of vaginal agenesis:

At present, it is possible to treat through various flap techniques, both from vulva and perineum, allowing for some degree of sensitivity, but we propose that which reduces problems in donor tissue areas, moreover, without the annoying problem of hair in the new cavity. As a minor inconvenience, it requires the use of dilators for a period of 3 months

10. Other reparative treatments:

As a result of birth defects or results of previous surgery, from tumor diseases and traumas: burns and accidents, or ritual mutilation, which causes scarring of the vulva, can produce a narrowing of the vaginal opening, and even restrictions on mobility in the lower extremities, affecting the functions of daily life. Corrections are performed by moving healthy tissue sometimes combined with grafts

Frequently Asked Questions

With external genitalia operations, and more specifically labia minora and clitoris, is the function or erogenous sensitivity altered?

The transitional changes, ranging from increased sensitivity and the opposite or numbness are common after most interventions, due to the immediate swelling. After the period of remission and with the absence of complications, the sensitivity is gradually restored. Other more permanent changes are infrequent

Are there any alterations in the urinary capacity?

This function is primarily respected, with the intention of preserving the region intervened, in some cases we apply a transitional bladder catheter, with the more complex and prolonged techniques it is withdrawn about 48 to 72 hours after surgery

When can I resume sexual relations?

In most techniques which reshape the vulva, sexual relations should be avoided until at least the entire course of 4 weeks. In any event, starting relations again will depend on the successful evolution in the postoperative period.

What other problems I can expect?

In most of the remodelings of shorter duration, inflammation of the vulva may extend during through the first 2 to 3 weeks, the pain is usually not severe, and is prevented during the first few days by oral analgesics. The presence of the sutures we use, which are of reabsorbable material in order to avoid additional manipulation and discomfort, usually produces a feeling of tension, which usually stops after scar the maturation process.

When can I return to work?

It depends on the procedures employed, and work activities performed. In some treatments, we recommend a week off work. If your work involves activities with especially intense physical effort, you might add another week.

Can you have more than one procedure done at the same time?

It depends on what issues are being treated, the complexity each treatment individually and together. After careful study of each particular case, remodeling of the pubis, with "lifting", and even labia correction techniques can be combined. In any case, the inflammatory process will be enhanced and prolonged

What care do I need to take after the operation?

LThe first revision is the day after the surgery, the Potential drains will be removed in the next visit 48-72 hours after the surgery, allowing the patient to begin washing and drying the region intervened. Sutures are usually reabsorbable material but can be revised at 8 or 10 days. In some techniques, dressing is recommended to reduce inflammation, as well as avoiding sport and sex for the first 4 weeks after the surgery.

Most techniques, except for more complex reconstructions, are ambulatory, day surgery procedures, in which post-operative care calls for the abstention from sporting activities and sexual relationships for the first month after surgery

Do you do female genital operations for the redevelopment of sexual identity?

Comprehensive and adequate treatment for gender dysphoria is subject to international protocols (www.symposion.com/ijt/soc-01/index.htm), and requires a period of both hormonal therapy and psychiatric therapy for a period of about 2 years prior to any female genital surgery with irreversible results.  Although the aesthetic results are generally acceptable, they can sometimes be controversial.

What types of anesthesia may be necessary?

Both pubic liposuction and the majority of procedures for labia remodeling, can be performed under local anesthesia and intravenous sedation or epidural. If required, short duration general anesthesia is used

Rehabilitation techniques or pubic "lifting", vaginal rejuvenation and reduction of the clitoris, are preferably done under general anesthesia which lasts about 2 hours, with a morning stay required.

Other, longer interventions like creating a new vagina when there is a deficiency, or restructuring of ambiguous genitalia, are done under general anesthesia and a hospital stay of at least 24 to 48 hours is required.

The final decision on the type of anesthesia is for the medical team to make, although they always consider how it will harmonize with the procedure being done, and adjust it for each patient according to their individual needs

What might the risks be in operations like these?

Every intervention carries some risks that are generally considered common, others which depend on the type of anesthesia used, and finally the specific risks derived from the procedure and the area being treated

• General risks:

Immediately after the procedure (first 24 to 48 hours), bleeding, with or without hematoma (often prevented by drainage), edema or swelling (prevented by cold); some don’t appear until up to three weeks after the procedure, like: seroma or an accumulation of clear liquid, local infection, opening of the wound (dehiscence), loss of skin

Reactions due to intolerance to the suture material or bandages such are adhesives or antiseptics.  Finally the scar, which in most cases is short, can be visible or thickened, evolving during the first 11 months.

• Anesthesia risks:

These range from the effects of local anesthesia (like pain at the puncture site), to the effects from a more invasive epidural or general anesthesia with possible nausea and/or vomiting for the first 12-24 hours.  Having the adequate tools in the operating room can reverse more serious complications, such as intolerance to a medication

• Specific risks:

Changes in the sensitivity of the skin and mucous membranes, which are usually temporary and due to inflammation.  In some cases another intervention may be necessary, depending on the complexity of the problem being treated.  This may be the case with early or late complications such as scar contractures or dissatisfaction with the result.

External Genitalia: Anatomy of the adult female 

The external genitalia is comprised of the vulva, including the labial folds, the cleft or the front part of the limited lateral space, and the erectile bodies.

Labial formations

Mons pubis: Located on front part of the vulva, with a fatty consistency, contains elastic fibers, and is bounded laterally by inguinal folds. The thickness varies widely, depending on surplus fat tissue, ranges from 2-3 cm in normal constitutions, while in obese patient it can be more than 7 cm

Labia majora: Folds of skin, behind the former, consisting of five coats. They measure about 7-8 cm in length and 2-3 cm in width, and is 15-20 mm thick in the middle portion.

Where the two in front, is the arch or anterior commissure, thicker than the posterior commissure, fine and forked, and immediately declines to the vaginal opening, navicular fossa.

Conditions such as multiparity and age can change their appearance, leaving them flabby and perpetually half-open, expanding the pudendal cleft or space defined between them.

Labia minora:  Flat, membranous skin folds, behind the labia majora, according to Testut the average length is 30-35 mm, 10-15 mm width, and thickness 4-5 mm, but subject to great variability in their morphology and dimensions, due to age, for this reason they overtake the labia majora in newborns, which later reverses; of individual variability, and may be hidden by the majora, they descend to their open border, where they show themselves and appear more pigmented:, also due to racial variations, in certain ethnic groups they reach 15-20 cm. Their extreme fronts are divided into secondary sheets, comprised of the ones that meet behind the clitoris, thus inserting into the frenulum of the clitoris; and those which come together in front, much longer, forming a semicircular shell, the clitoral hood or prepuce, a fold which is poorly developed in Europeans, and more pronounced in Asians and Africans

The subsequent convergence between the two labia minora, less obvious and sharp, where it merges with the labia majora, is a fold of skin called the pudendal frenulum of the labia minora or fourchette, evident in young women, but often torn in childbirth

Interlabial space or vulvar canal 

The labia  to delimit the hole which accesses the genital tract, when in repose or closed, it is reduced to a mere slit, but when separated a space is exposed of 6-7 cm in length, 20-25 mm in width, with infudibulum morphology or funnel, getting smaller from front to back.

Vestibule, triangular area confined laterally between the labia minora, continued by the mucous membranes of the clitoris in front, urethral opening of 3-4 mm in diameter, situated 2-3 cm behind, and below that the vaginal orifice which adopts an oval shape during maternity, except in cases where there is still an incomplete mucosal septum inserted between vulvar and vaginal canals, called the hymen, it has a variable shape: semi-full moon shaped, round or lip shaped, where a perforation is found, which is barely 1 mm in width.

An imperforate hymen accumulates menstrual bleeding in the vaginal cavity or hematocolpos.

A complete congenital absence has also been described. En postparto, pueden persistir unos vestigios redondeados denominados carúnculas mirtiformes. After a woman gives birth, she may be left with remnants of the hymen, called carunculae myrtiformes.

Adjacent to the urethral orifice, there are two separate yuxtauretral drainage openings or Skene's glands which are considered rudimentary female prostate. Also on each side but posterior and lateral in position, are the Bartholin vestibular glands, 12-15 mm in length, lubricators during the sex life, and atrophic afterwards.

 In cases of infection or bartholinitis, they can be enlarged up to 5 cm.

Erectile bodies

(Capable of swelling or increase in volume)

The clitoris, homologous to the penis, attached by a suspensory ligament, but lacking corpus spongiosum and completely separate from the urethral orifice. Composed of a hidden portion, two roots or lateral halves inserted into pubic ischium branches, comparable to the corpus cavernosum of the penis, ascending and converging in the midline, ending in an open cylindrical portion, the extreme or glans

Its dimensions in repose according to Testut, although variable are: roots 30-35 mm, body 25-30 mm, and diameter of the glans 6-7 mm. More recent studies, the first held with 200 women and the second with 50 women, expand the variability of the measurements to range from 3 to 10 mm

Vestibular or vaginal bulbs, two elliptical formations, beside the urethra and vaginal opening, homologous to the urethral bulb and corpus spongiosum counterparts in men, covered by vulvar constrictor muscle fibers lateral, beside the vaginal orifice, with normal dimensions: length 30-35 mm, width 12 -15 mm and 8-10 mm thickness, interconnected by veins to the glans, or clitoris

Among the muscles of the perineum (the set of soft parts which close the pelvis, traversed by rectum, urethra and genitals) anterior or genital, which contribute particularly to sexual function are: ischiocavernosus, or isquioclitorídeo, with an oblique direction going forward, is inserted into the root of the clitoris, with double action: it causes a drop and application of the clitoral glans over the bask side of the penis, and compresses the corpus cavernosum of the clitoris.

The bulbocavernosus muscle surrounds the orifices of the vagina and urethra, with a double arch formation of average concavity, with multiple functions: it erects when the dorsal vein of the clitoris is compressed, and it is also mobile, descending to touch the penis, it compresses the vaginal bulb and pushes blood to the vestibule, draining the Bartholin gland, and it is a superficial constrictor for the inferior vaginal orifice, applying pressure to the penis. Spasmodic contraction is known as vaginismus.