What is “designer perineum surgery” ?

It is an aesthetic surgical procedure of the vulva structures, labia minora, labia majora, mons pubis, clitoris, perineum, introitus and hymen. This plastic surgery is to repair or reshape or reduce the vaginal muscles and/or the perineum, and interior/posterior repair, and also reshape the mons pubis. The vaginoplasty surgery tightens the vaginal walls, reinforces the vaginal support (muscles and connective tissue), and tightens the vaginal opening. The latest is Designer Laser Vaginoplasty (DLV). This technique was developed by Dr David Matlock from the United State. It is basically just a modification of traditional perinealrrhaphy, where instead of using a scalpel, laser is used to open up a passage to vagina for a precise surgical incision. The pencil-like tip of laser equipment can take delicate design easily, bloodless, less adhesion, less painful and without scar formation. It has anti-bacterial properties, therefore reduces post operative wound infection and faster recovery. The procedure is done under general, epidural or local anaesthesia which last about 60 to 120 minutes (Matlock 2006) depending on the type of procedure, whether single or combination with Laser Vaginal Rejuvenation (VLR).

Designer Laser Vaginoplasty (DLV) can correct problems ranging from irregularly shaped and sized labia to skin discolouration to restoration of the hymen. Procedures are individually tailored to the patient to address her specific problems and concerns. Laser Reduction Labioplasty can sculpture the elongated or unequal labial minora according to ones specification. Most women they do not want the small inner lips to project beyond the large outer lips. Laser reduction labiaplasty techniques can also reconstruct conditions that are due to the aging process, childbirth trauma, or injury.

1. Laser Perineoplasty is to rejuvenate the relaxed or aging perineum. It can also enhance the sagging labia majora and labia minora. Overall, this labia plastic surgery procedure can provide a youthful and aesthetically appealing vulva.
2. Augmentation Labioplasty can provide aesthetically enhanced and youthful labia majora by autologous fat transplant (removal of the patient’s fat via liposculpturing and transplanting it into the labia majora).
3. Vulvar Lipoplasty can remove unwanted fat of the Mons pubis and upper parts of the labia majora. Liposculpturing can alleviate the unsightly fatty bulges of this area and produce an aesthetically pleasing contour.
4. Hymenoplasty (reconstruction of the hymen) can repair the hymen to restore “virginity”. 
5. Combination of DLV with LVR: LVR and DLV can be performed in combination. They can also be performed with most other cosmetic surgery; the most popular of these are Liposculpturing, breast implants, breast reduction, tummy tuck, nose surgery, and eyelid surgery.

Augmentation labioplasty

Laser Vaginal Rejuvenation (LVR) is a modification of a standard gynaecologic surgical procedure for the enhancement of the sexual gratification. According to Masters and Johnson, sexual gratification for female is directly related to the amount of frictional force generated. LVR can help restore optimum friction during intercourse and also provide aesthetic enhancement of external vaginal structures, resulting in a more youthful look. The vaginal muscles and connective tissues are tightened as well as reducing redundant vaginal mucosa. The procedure enhances the vaginal muscle, tone, strength and control, and effectively strenghtens the internal and external introitus. It can also build up the perineal body.

Why do cosmetic surgery of the vulva?

Designer perineal surgeries benefits these groups of patients with the following: pelvic organ prolapse,  urinary incontinence, ambiguous genitalia (hermaphrodites), wide, absent or stenosed vagina, painful episiotomy wound or  bad perineal scar following vaginal delivery, redundant or stenosed prepuce and enlarge clitoris.

It is increasingly common for gynecological surgery to be performed not just for medical reasons alone but also to enhance sexual pleasure. Other subjective indications include feeling of discomfort when wearing clothing, performing exercises or during sex. Some women claimed that abnormal appearance of their vulva decreases their self-esteem and confidence. Weak perineal muscles reduces vaginal support apparently diminishing sexual gratification.

What is the hype all about?

The aim of cosmetic surgery is to achieve the ideal vulva and vagina! The anatomy of female genitalia is well documented scientifically. Unfortunately, the majority of women do not really know what is normal and what is not. Their knowledge is mainly based on the observation of a child’s genitalia or from the pornographic magazine. The perception of normal perineum is also influenced by cultural taboo (Braun V 2001). Therefore research into socio cultural representations of the vagina may be relevant to consideration of genital appearance.

A wide variation in the genital appearance is to be expected, and as women age there will be changes in the labia minora. Some women are born with a wide vagina. However, a distinction should be made in women who seek labial reduction when there is no suggestion of disease.

High above Sunset Boulevard, in Matlock's plush, 5,000-square-foot office, vaginas are being redesigned, labia modified, vulvae reconfigured. Women are spreading their legs, exposing their personal secrets to the antiseptic trimmings and surgical prunings of a trusty laser, and they are the ad hoc pioneers in a rapidly growing industry. The Laser Vaginal Rejuvenation ad featured a bikini-clad woman writhing in orgasmic delight. The headline read: "You Won't Believe How Good Sex Can Be!" But is LVR truly a way of enhancing sexual gratification or simply a way of selling gynecological surgery while pushing for the perfect vagina? With the reasons for LVR and DLV as diverse as the vagina themselves, the answers are not so cut-and-dried.

Laser instruments

According to Matlock, gynaecology is a super surgical subspecialty as gynaecologists dedicate our entire professional careers to the reproductive tract. But do we ever go back and look at the so called “damage” that result from labor, delivery and childbirth? There can be relaxation of this or that structure and a perceived decrease in sexual gratification.

Sexual gratification is very personal. For women who are “severely damaged”, sex should still be intense and passionate." And herein lays the crux of the problem. No one would disagree that "severely damaged" women are entitled to great sex. While a staggering 30 percent of women will develop some form of pelvic floor disorder resulting in incontinence or compromise of vaginal integrity after birth, about 5 to 10 percent will be so damaged that they are physically and emotionally traumatized. Is this why 40-, 50-, 60-year-old men are courting younger women?

There are over 25 medications for male impotence, and it takes $500 to $600 million to bring one drug into research and development. These are the facts. There is nothing remotely similar for women. There are over 200 prosthetic devices for men in the market but nothing similar for women. If men had babies, and certain body parts are stretched out as a result, they would have been looked at, researched and solved a long time ago.

As cosmetic surgery becomes more widespread, designer vaginas may become as common as the silicon breast -- a sinister prospect that has many women's advocates up in arms. "Women's genitals are fascinating, unique and beautiful," says pioneering sex therapist Betty Dodson, who for decades has helped women discover their genitals, and particularly their clitoris, which she describes as women's "little phallic symbol that terrifies the status quo". She considers LVR and DVR as truly odious procedures except for very extreme cases.

The effectiveness of the procedures is still unclear. Matlock (2006) claimed that he is carrying out numerous studies on the effectiveness of his procedures. The cost for DLV and VLV is estimated to range between USD$3000.00 and USD$20,000 depending on the type of procedure and anaesthesia (Laube 2006).

These procedures are not permanent though, as aging and child birth will destroy the integrity of the vagina. Augmentation labioplasty using autologous fat will only last for few weeks. Like face lift, vaginal cosmetic surgery need to be redone. There is no storng evidence regarding the effectiveness of the procedures and the safety aspect of this technology, only anecdotal claims from customers can be found from the website. To those considering LVR or DLV, these two procedures are not without their risks, among them hemorrhage, infection, loss of sensitivity, lingering pain from nerve damage and sexual dysfunction. To date no related legal action being reported pertaining to these procedures.

There is currently no literature addressing the legal aspect of the procedure. It could level DLV as a form of female genital mutilation. According to the WHO definition, all procedures involving partial or total removal of female external genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons is consider genital mutilation (Convoy 2006). In Arabs countries, hymenoplasty is an illegal procedure. Therefore Matlock could become the Salman Rushdie of the Islamic vagina. However, he claimed that "If I can help a woman in this unfair world, then I'm going to go ahead and do it. I have no problems about doing it whatsoever. The man, he gets to do whatever he wants to do. Is he held accountable for anything? Absolutely not.”

Women have to be clear that the procedure would not improve the sexual libido. Sexual gratification is individualized it could be affected by not only physical problems but also psychosocial. Before offering women the procedure, their sexual life has to be explored, preferably by a psychosexual counselor. Unfortunately women who see the problem as physical may resist referral to psychosexual or other psychological services. Furthermore the availability such services are currently rare and there are long waiting lists (R Bramwell 2007).

Conclusion

To date, there are no robust evidence on the safety, efficacy or cost effectiveness and legality of DLV and VLV. Patient who wish to undergo the procedure need detail counseling regarding the indication, the long term and short term implication especially the safety aspects.

The use of this technology in our society should be made with extreme caution to avoid unethical practicec by gynaecologists as this procedure may be used for the wrong purposes. In the end, the patient should make the final decision regarding their own anatomy.

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