Ethics/education
Cosmetic vulvovaginal
surgery
Rufus Cartwright
Linda Cardozo
Abstract
Cosmetic vulvovaginal surgery arouses considerable media interest.
There are significant ethical and technical challenges posed by such
procedures, which may not be justified on medical grounds. Many such
operations are performed without adequate evidence of either safety
or psychosocial benefit. The best established female genital cosmetic
procedure is reduction labioplasty. Women request reduction surgery
for their labia for two distinct indications: aesthetic dissatisfaction or
discomfort. There are a variety of techniques, none of which has high-
­quality supporting evidence. Hymenoplasty is even more controversial
than labioplasty, perhaps because it is seen to perpetuate misogynist
myths about virginity. Despite its persistent popularity there is little
evidence of successful outcomes. Vaginal laxity is a common complaint
among parous women, and has a complex relationship with sexual dys-
function. When a multidisciplinary, conservative approach fails, surgical
intervention, with either perineorraphy or posterior colporrhaphy may be
justified. Recent publications suggest some benefits to sexual function.
Throughout this area, prospective appropriately controlled studies, using
validated patient-centred outcomes are needed in order to assess the
benefits. Until such evidence is available, it will remain difficult appropri-
ately to advise patients requesting surgical intervention.
Keywords gynaecological surgical procedures; hymen; surgery, plastic;
vulva
Introduction
No area of elective gynaecology is currently more controversial
than cosmetic vulvovaginal surgery. Aggressive marketing from
private clinics in both the US and the UK, coupled with media
attention, have lead to increasing numbers of women requesting
vulval and vaginal procedures for aesthetic reasons. Operations
that fall into this category include reduction labioplasty (also
spelt labiaplasty), augmentation labioplasty, vulvar lipoplasty,
G-spot amplification, hymenorrhaphy and perineorrhaphy for
vaginal laxity, sometimes euphemistically termed ‘vaginal reju-
venation’. In this review we attempt to summarize the ethical
and technical challenges posed by these procedures, and suggest
directions for future research.
Rufus Cartwright MBBS is a Senior Clinical Fellow at the Department of
Urogynaecology, King’s College Hospital, London, UK.
Linda Cardozo is Professor at the Department of Urogynaecology,
King’s College Hospital, London, UK.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 18:10
Ethical considerations
Feminist critics of female genital cosmetic surgery have sug-
gested it forms part of a tradition of patriarchal domination
of women’s bodies, aiming to alter them to fit in with a male-
­oriented aesthetic. Under the guise of sexual liberation it is also
said to represent a dangerous medicalization of female sexuality.
A comparison can be also made with female genital mutilation,
which is illegal in most western nations. There are clear distinc-
tions, most notably that female genital mutilation is typically per-
formed without adequate consent upon a minor, and has clearly
established physical harms. However, the similarities with pro-
cedures now being performed in western nations for cosmetic
reasons, have led to the suggestion that any distinction is only a
Eurocentrist fallacy. There is a genuine concern that female geni-
tal cosmetic procedures are not justified on medical grounds, and
are being performed without adequate evidence of either safety
or psychosocial benefit. Although the evidence base for some of
these procedures is minimal, there have been a number of recent
high-quality publications seeking to identify and report appropri-
ate patient-focused outcomes for these operations.
Current evidence
The best established female genital cosmetic procedure is reduc-
tion labioplasty. Women request reduction surgery for their labia
for two distinct indications: aesthetic dissatisfaction or discom-
fort during exercise or sexual intercourse. Recent studies have
used qualitative methods to examine women’s motivations
for requesting surgery, and their expectations about outcome,
with material drawn from either first-hand interviews or media
reports. Women requesting surgery report disabling psycho-
logical distress associated with a perception that their labia are
abnormal in size or shape. They may emphasize sexual dysfunc-
tion or discomfort during other activities as a way of legitimizing
their request for treatment. The invisible nature of the vulva and
vagina in the lay press may mean that women are unaware of the
wide range of normal sizes for labia. The often erroneous percep-
tion of abnormality may arise from comparison with women’s
genitalia as depicted in pornography.
At least six different techniques for reduction labioplasty have
been described. The ‘classic’ labioplasty involves simply trim-
ming and oversewing the free edge of the labium. More complex
techniques, including use of various wedge resections, a z-plasty,
or excision of a central portion of the labium, may help preserve
the neurovascular supply of the labial edge, and may also reduce
this risk of hypopigmentation of the scar line. There are no head-
to-head or controlled trials to support the use of one of these
techniques in preference to the others. The evidence from case
series, mostly using rudimentary or unvalidated metrics of satis-
faction, suggests that these procedures have acceptable aesthetic
outcomes. It is unclear, however, whether reduction labioplasty
relieves associated psychological morbidity or improves sexual
function.
Long-standing taboos against women engaging in pre-­marital
sex persist in some Mediterranean, Middle Eastern, South Ameri-
can and East Asian cultures. Some women request hymenorra-
phy in order to give the appearance of virginity on their wedding
night. By acquiescing to perform such surgery, the doctor is
285 © 2008 Elsevier Ltd. All rights reserved.
 Ethics/education
perpetuating misogynist myths about virginity. The free borders
of the hymenal remnants or hymenal tear are incised. Then the
remnants, or edges of the tear, are approximated using either
a purse-string or interrupted sutures of Vicryl 3.0. This aims to
achieve at least partial occlusion of the introitus. In countries
where catgut sutures are still available, these may be used in
preference. When insufficient hymenal remnants are available to
make a satisfactory membrane, then a small flap of vaginal skin
can be lifted from the posterior vaginal wall, and approximated
to the anterior wall as a band across the hymenal ring. When
the procedure is performed in the days immediately before the
wedding, some authors have also recommended incorporation
of a gelatin capsule containing a blood-like substance, in order
to simulate post-coital bleeding. In the only reported case series,
half the women were followed up after the wedding night, all
reporting a satisfactory outcome.
Vaginal laxity is a common complaint amongst parous women
Although reduced sexual sensation is the most common specific
symptom, it is not clear that laxity is directly related to sexual
dysfunction. Related symptoms include pelvic discomfort, inabil-
ity to retain tampons, vaginal wind and entrapment of bathwa-
ter. There is very limited evidence that surgical repair improves
any of these symptoms of laxity. In the absence of objective pro-
lapse ‘vaginal rejuvenation’ procedures may include posterior
colporrhaphy or perineorrhaphy, either of which may risk bowel
symptoms and dyspareunia. Given the uncertainties, a multidis-
ciplinary evaluation is mandatory before considering surgery.
Psychosexual counselling may be helpful, with consideration of
partner issues, including erectile dysfunction. Women may also
benefit from a trial of topical oestrogens and a course of super-
vised pelvic floor muscle training. Only if these measures fail
should surgery be undertaken. Few series of such procedures
have reported outcomes related to laxity. In one series of 80
women having combined posterior colporrhaphy and perineor-
rhaphy for symptomatic prolapse, the incidence of symptomatic
vaginal laxity had significantly decreased at 5-year follow-up
from 25% to 8%. In another series of 51 women having the
same procedure specifically for vaginal laxity and reduced sexual
function, 94% of patients reported greater vaginal tightness at
6-month follow-up, with 74% having their expectations for the
procedure fully met.
Directions for future research
There are very significant gaps in our understanding of these
types of procedures. Given the political and ethical controversy,
the onus remains on the surgeons who perform such surgery to
demonstrate both safety and efficacy. Even for the most stud-
ied procedure, reduction labioplasty, we have only Level 4 evi-
dence of success. In order to understand the psychosocial risks
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 18:10
and benefits of these procedures, future studies should co-opt
validated patient-centred outcome measures from both aesthetic
plastic surgery and urogynaecology. The dimensions that could
be assessed include anxiety and depression, body image, sexual
function and global satisfaction. The priority for research should
be to assess improvements in each of these dimensions, either
in head-to-head studies of surgical interventions, or in compari-
son with psychosexual counselling. For the more commonly per-
formed procedures, it is important to identify patient subgroups
that might be at risk of persistent aesthetic dissatisfaction and
psychological morbidity, despite excellent anatomical correction.
Conclusions
Media interest in cosmetic vulvovaginal surgery is ­disproportionate
to its popularity. Although there is a dearth of evidence of efficacy
and safety, recent publications have begun to explore patient-
centred psychosocial outcomes for these procedures. Until con-
trolled trials with appropriate validated measures are reported it
will remain difficult adequately to advise women of the risks and
benefits. In the absence of clear evidence, surgeons must tread
cautiously, choosing to operate only as a last resort. ◆
Further reading
Alter GJ. A new technique for aesthetic labia minora reduction. Ann
Plast Surg 1998; 40: 287–290.
Bramwell R, Morland C, Garden A. Expectations and experience of labial
reduction: a qualitative study. BJOG 2007; 114: 1493–1499.
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: 737–738.
Liao LM, Creighton SM. Requests for cosmetic genitoplasty: how should
healthcare providers respond? BMJ 2007; 334: 1090–1092.
Lloyd J, Crouch NS, Minto CL, et al. Female genital appearance:
“normality” unfolds. BJOG 2005; 112: 643–646.
Logmans A, Verhoeff A, Raap RB, et al. Should doctors reconstruct the
vaginal introitus of adolescent girls to mimic the virginal state? Who
wants the procedure and why. BMJ 1998; 316: 459–462.
Pardo JS, Solà VD, Ricci PA, et al. Colpoperineoplasty in women with a
sensation of a wide vagina. Acta Obstet Gynecol Scand 2006; 85:
1125–1127.
Rouzier R, Louis-Sylvestre C, Paniel BJ, Haddad B. Hypertrophy of labia
minora: experience with 163 reductions. Am J Obstet Gynecol 2000;
182: 35–40.
WHO study group on female genital mutilation and obstetric outcome,
Banks E, Meirik O, et al. Female genital mutilation and obstetric
outcome: WHO collaborative prospective study in six African
countries. Lancet 2006; 367: 1835–1841.
286 © 2008 Elsevier Ltd. All rights reserved.