Frequently Asked Questions about Genital Plastic/Aesthetic Surgery, from Dr. Michael Goodman

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  • Genital Plastic/Cosmetic Surgery FAQs

1. What is the normal size of a woman's labia? 

Like breasts and noses, labia come in an amazing array of shapes, sizes, and colors. And, like these other organs, there is a wide range of normality. No two women’s labia look exactly alike and, usually, the two sides are not exactly the same in an individual woman. Many women have petite labia, while others are more “…well endowed…” The “average” width of a woman’s labia is ~ 1 inch. Obviously, many women are smaller, or larger. Some women’s labia begin in multiple folds from a generously endowed clitoral hood; others hoods are more spare, and there is only one fold. Sometimes the labial edges are pink, sometimes tan, ofttimes considerably darker. Sometimes thick, at times thin, frequently folded on itself. Sometimes the labia end well above the base of the vaginal opening, frequently the labia trail well below the opening(the “introitus.)
It’s all “normal.” But, just because it’s “normal” (like very small breasts, or breasts that have lost their shape after bearing children) doesn’t mean that a woman is satisfied with the appearance and might, exactly like having breast size augmented or reduced, wish to change the appearance and size to one that better suits her desires.

2. What is the "G-Spot" and what is the difference between clitoral and vaginal orgasms?

The “G-Spot” is less of a “spot” than an area below the upper vaginal wall, about 1 inch or so up in the vagina from the urethral opening. It is directly below and to either side of the urethra, the tube that empties urine from the bladder to the outside. It is not a constant anatomical structure, and varies somewhat in size and position in different women. It is actually the “roots” of the clitoris. The clitoris, clitoral hood, and the outer portion of the vagina as well as the urethra and labia are in reality a “unified” structure that together play important roles in sexual response, and respond to sexual stimulate in a unified manner.
The “thicker” the “space” directly below the urethra, the more likely a woman is to have vaginal spread from her orgasm, originating in the body of the clitoris, below the clitoral hood. “Vaginal orgasm” occurs when the orgasm originating in the clitoris (analogous to the male penis) spreads down through the crus and crurae (the “base” of the clitoral body) into the G-spot area. Of course, the uterine contractions that frequently accompany orgasm, especially if your partner ejaculates into the vagina- prostatic fluid contains prostaglandins, which stimulate the uterus- helps… Pressure against the “G-spot,” whether by finger(s), toys, or the direct stroke of the penis, “kneading” the clitoral body against the pubic bone help with this orgasmic spread.
Childbirth, especially with tears, and loss of muscular strength, loosens the vaginal opening, leading to less clitoral and G-spot pressure, and weakens the “gripping” muscles of the pelvic floor. This is why vaginal tightening operations that elevate the perineum (re-establishing the anatomical curve often lost secondary to childbirth) and repair separated musculature, especially with added pelvic floor physical therapy, are so effective.


3. Explain the surgical techniques for labiaplasty.  Is one better than another?

Although there are other techniques, the most frequently utilized technique (mostly because this is the technique utilized by a leading surgeon who has trained many other genital cosmetic surgeons) is a linear resection, closely followed by the “modified V-wedge,” and more distantly by the “inferior flap amputation/superior flap rotation” technique. Most novices start out with this technique.
In the “sculpted linear resection” technique, the bulk of the labia are removed via a vertical incision, essentially amputating a large portion of redundant labum, carefully re-approximating the inner and outer cut edges. This gives the socalled “Barbie” and “rim” looks.
The “modified V-wedge” is performed by removing a central V-shaped wedge of labum and re approximating the more modestly-sized upper and lowermost edges of labum, giving a more “natural” edge, preserving the labial architecture. The “flap” technique is similar, except that here, the lower half of the labum is resected, and the upper portion is brought down and sutured to the lower edge, minimizing size and re-shaping the labia.
Which technique is best for you depends on your individual anatomy, your cosmetic desires, and your surgeons training. Ideally, it is best to have a surgeon who is skilled in more than one technique. “If all you have is a hammer, everything looks like a nail…” If your surgeon knows only one method, you may not get the most ideal results for your anatomy.
One technique is really no better than the other. Do what your surgeon is skilled in. The advantage of the linear resection is that more tissue can be removed, and that your labia end up “pinker”, as your natural edge (which may be dark colored) is removed, leaving the more pinker skin color of the inner part of your labia. The downside is that this technique is more likely to have a complication of post-operative edge sensitivity, less “feeling,” and can, especially in less experienced hands, can result in too much labia being removed, with greater risk of discomfort and deformity.
The advantages of the wedge are more “natural” looking labia and less potential for loss of sensation and pain; disadvantages include the risk of separation of the edges, and sometimes having less tissue removed than you’d hoped for.
Again, the best is if your surgeon knows 2 or 3 different techniques. Then (s)he can tailor surgery exactly for your anatomy and your individual cosmetic choice.


4. What are the risks of genital plastic/cosmetic surgery?

All surgery carries known risk; the bar is set higher for elective cosmetic/plastic procedures.
Risk consists of known possibilities for a given procedures, but is very much a function of experience and aptitude as well. Simply put, risk for a complication or a less-than-satisfactory outcome exponentially increases especially with novice surgeons (less than 25 procedures) and surgeons who know only one procedure (“one-trick ponies…”).
That said, here are the risks of genital plastic/cosmetic surgery procedures:
Labiaplasty and Clitoral Hood Reduction: Poor, or protracted healing process; incision separation, ongoing pain with sexual intimacy; cosmetic results not up to expectations.
Vaginoplasty/perineoplasty (“vaginal rejuvenation”): Poor or protracted healing; over- or under-tightening (if over-tightened,, expect a 1-3 month time-frame of progressive stretching exercises to put things right.); injury to bladder or bowel; infection/abcess; results not up to expectations… (Remember. A pelvic floor exercise program facilitated by your surgeon is mandatory if you are to reap maximal benefits from your costly surgery; beware of the surgeon who does not offer you this advantage..!)
Who to be aware of (risk-wise): Surgeons who do all their cases using only one approach; surgeons who have performed less than 25-50 procedures; surgeons who tell you “…No problem… we’ll just trim a little off…” or tell you that they will bill insurance for your cosmetic/plastic work (usually only novice surgeons do this, as a way of getting patients when they are starting out; it’s Insurance Fraud as well, and you could end up holding a very expensive bag with the insurance company..!). Also, be aware of surgeons who appear to not take into account the very sexual nature of these procedures, and do not quiz you about this aspect. Trust your intuition!!


5. Why are writers for women's magazines and many Gyns and University types against this type of surgery?

AHhhh… First, you must understand that the vast majority of writers for women’s magazines are “free-lancers” who would sell their souls to the devil for a buck! Most either have a pre-conceived bias one way or the other, and selectively write to prove their point, or fabricate what will appeal to the magazine they hope to sell their work to… Bad news, conflict, and controversy sells..! Very little honest and investigative journalism here.
It’s a very interesting situation: The very same writers who shout for autonomy and women’s rights, become parental, judgmental and puritanical (very similar to many of your Gyns and primary care practitioners when it comes to genital plastic/cosmetic procedures.
I see the exact same thing here as I’ve observed in the past with breast augmentation in the 1960s and 70s, liposuction in the 70s and 80s, and advanced operative laparoscopy in the 80’s. In fact, when a small group of U.S. Gyns (myself among them) began to perform minimally invasive endoscopic surgeries “through the ‘scope,” including tubal, ovarian and uterine surgery (this was in the days prior to “Lap Cholycystectomy”, laparoscopic appendectomy, and so many other minimally-invasive surgical procedures considered “standard” today), we were laughed at, and called “surgical gymnasts” by “..the medical establishment.”
It helps if you understand that doctors in a position of medical political power, especially in a University setting, universally “pan” any procedure that they themselves have not discovered or that they are not good at. And, since ALL of the advances noted above (virtually all plastic procedures, the entire field of minimally-invasive surgery, and now female genital plastic/cosmetic surgery) start in the community, jealousy, snobbery, and, in the case of writers, the desire to “make a buck,” takes precedence.


6. What is "Laser Vaginal Rejuvenation" and "Designer Laser Vaginoplasty?

“LVR” and “DLV” are patented, marketing terms only, devised by a very skilled and clever plastic/cosmetic Gyn in Los Angeles (David Matlock M.D.), as a marketing tool to set apart the work that he does so well. Dr. Matlock teaches his techniques to other surgeons from around the world, for a very significant fee. When they have completed his 3 day course and paid the fee, they are allowed to use these terms and advertise on websites sponsored by him.
“DLV” is actually Dr. Matlock’s patented term for labiaplasty; “LVR” is his term for vaginoplasty. By using a laser (which is only a tool, not a technique,” similar to an electrosurgical or radiofrequency electrode, scalpel or plastic surgery scissors: it is a only one of the several tools that can be safely and effectively utilized to perform the surgery) they can set themselves apart advertising-wise. Much more important that the specific tool however, is the surgeon’s experience and the hand that is wielding that tool! (And physicians utilizing a laser need to charge more to pay for that expensive toy!)


7. How does vaginoplasty and perineoplasty (sometimes nicknamed "Vaginal Rejuvenation") porentially improve sexual function?

Several ways:
1) By repairing, elevating, and strengthening the perineum and “perineal body” (the area just outside of and below the vaginal opening) and, if indicated, bringing the pelvic floor muscles into better apposition, both the “angle of attack” and the tightness of the vaginal opening are changed, leading to better “gripability” of the penis at the opening, and more pressure of this thrusting organ against the clitoral complex. (**But remember, a series of pelvic floor physical therapy sessions to bring you better ”in touch” with, and build up your muscular strength in this area will significantly enhance your post-surgical results (and sometimes eliminate the need for surgery at all…) Any surgeon who does not evaluate your muscular strength and offer you the adjunct of pelvic floor P.T. is not doing his/her job well (I always include P.T. in my post-op plans and, if not covered by your insurance, pay for the first 2 P.T. sessions!)
2) Frequently, after childbirth (especially big baby; long & difficult delivery, etc.), the upper vagina will become significantly stretched, leading to “looseness” and little friction between penis or toy in the upper vagina. There are no muscles in your uppermost vaginal wall, so if you are considerably stretched, with “looseness” between penis and vaginal wall, only a surgical procedure will minimize this enlargement. By surgically repairing the fibrous fascia of this area (to strengthen), and by removing wedges of vaginal skin, the size of this area may be minimized for a tighter grip.
3) Re: labiaplasty, anything that minimizes discomfort and labial “rearranging,” anything that, in the opinion if its “wearer” beautifies this area, anything that improves self-esteem will, by its nature, improve sexuality and sexual function.Our research (1) and that of others (2-5) confirm these improvements in sexual satisfaction. Our study (1) is the largest outcome study of genital plastics published in the world thus far.

1) Goodman MP, Placik OJ, Benson RH III, Miklos JR, Moore RD, Jason RA, Matlock DL, Simopoulos AF, Stern BH, Stanton RA, Kolb SE, Gonzalez F. A large multicenter outcome study of female genital plastic surgery. J Sex Med 2010;7:165-77 2) Rouzier R, Louis-Sylvestre C, Paniel BJ and Hadded B. Hypertrophy of the labia minora; experience with 163 reductions. Am J Obstet Gynecol 2000;182:35-40. 3) Pardo J. Sola P, Guiloff E Laser labiaplasty of the labia minora. Int J Gynec Obst 2005;93:38-43. 4) Alter GJ. Aesthetic labia minora and clitoral hood reduction using extended central wedge resection. Plast Reconstr Surg. 2008;122:1780-89. 5) Pardo J, Sola V, Ricci P, Guiloff E, Freundlich D. Colpoperineoplasty in women with a sensation of a wide vagina. Acta Obstet et Gynec 2006; 85:1125-28.
8. How do I pick a surgeon to do my work?

Carefully! Do your homework! Read as much as you can online about techniques and procedures from “legitimate” (translation: NON-advertising ) sites. Visit at least 2 potential surgeons, using the “rating sheet” that you can easily download from the educational site, (go to “Choosing a Surgeon”).
Who to choose: A surgeon who has performed at least 25 procedures of the type you request; a surgeon who is adept at more than one technique for the work you wish done. (Make sure you see at least 10-15 “before and after” photos of his/her work; look for anatomy similar to yours, and see what (s)he has done with it.) Choose a surgeon who is clearly aware of the sexual aspects of your situation, and asks specific questions relating to this area. Choose a surgeon who gives you the option (for labial and superficial vaginal work) of having the surgery in an office setting under “local” anesthesia; this will make it much less costly, without the “Surgicenter” fee…
Who NOT to choose: A “novice genital plastic surgeon; one who has “taken a 2-day course & is rarin’ to go…” One who tells you that (s)he can get the procedure covered by insurance, when it is really a cosmetic/plastic/elective surgery (usually only novices do this; also, the insurance company can later make you pay them back the whole fee…) If you do not live in the surgeon’s area, do not choose a surgeon who has no specific arrangements for your aftercare.


9. Does Insurance cover this type of surgery?

Generally, no- genital plastic/cosmetic surgery is considered to be just that: not “medically necessary…”
However, if a portion of the surgery is considered “medically necessary” (for example, in situations involving urinary incontinence or certain types of prolapse/symptomatic pelvic support conditions), your surgery may cover a portion of the costs, including a good part of the facility and anesthesia fee. If this is combined with some purely plastic work (e.g. vaginal or perineal tightening/reconstruction), your surgeon may accept insurance payment for the medically indicated part, and bill additionally for that portion, not covered by your insurance, that is purely “aesthetic.” DISCLAIMER: Be aware of any Gyn who says (s)he'll do your surgery in a hospital under "Insurance."  They are not doing the aesthetic procedure you want, and are rarely well trained; these often are the docs who end up with "botched" outcomes...


10. How long does it take to recover from LP or VP?

For external work (labiaplasty; reduction clitoral hood, superficial reconstruction of the vaginal opening…), you should really take it easy, mostly around the house, for 4-5 days, and, although you may return to relatively sedentary activities at work/home, you shouldn’t “push it” for another ~ 5 days. At 10-14 days after surgery (after your first post=op visit, and you are “cleared,” you may begin modest exercise, and return to normal basic activities. You may exercise fully at ~ 3-4 weeks, and climb back on your bike or lover in ~ 4-6 weeks after your surgery.
For internal work (vaginoplasty; “vaginal rejuvenation”), the recovery is similar, but add ~ 5-7 days to everything. Do not go back to internal sexual intimacy until cleared to do so by your surgeon (usually 5-6 weeks after surgery.) Also, you may need a period of gently vaginal stretching prior to comfortable intercourse. And, don’t forget: this is the time to work on vaginal muscular strengthening exercises!
Article by
Davis OB/GYN