"All you wish to know" about Perineoplasty and Vaginoplasty
AKA “Vaginal Rejuvenation” a “Vaginoplasty,”/ Perineoplasty is an aesthetic vaginal tightening operation designed to improve a woman’s (and man’s) sexual pleasure and ability to orgasm by tightening the vagina, bringing the pelvic floor muscles into closer approximation and, by building up the perineum and perineal body, tightening and changing the vaginal angle to provide for better friction and greater pressure with stimulation of both the G-Spot and the clitoris. Ideally, a woman will embark on a series of pelvic floor strengthening exercises after surgery to further improve her sexual pleasure results. The “goal” in vaginal tightening is to produce a situation similar to experiencing intercourse with a man with a larger penis: more friction, more contact, more stretching of the G-spot/internal clitoral area…
Who are candidates? Women who, secondary to childbirth(s), genetics, and age, notice relaxation and “sensation of a wide vagina” with difficulty feeling much friction and achieving orgasm are candidates for perineoplasty. Very frequently, the appearance of the vaginal opening, which may gape and show part of the inner vagina, is a part of the issue. Many women have already tried pelvic floor strengthening exercises, but have been unsuccessful because of thinning, disattachment, or separation of the pelvic floor (“levator”) musculature.
How to find a surgeon who knows what (s)he is doing: A perineoplasty performed for vaginal tightening and enhancement of sexual function is a whole different operation than a “simple posterior repair/posterior colporrhaphy.” Your surgeon should:
1. Be a Board-Certified Ob-Gyn. These are the only physicians who receive the training necessary to be able to safely negotiate vaginal floor anatomy.
2. Have special specific training in pelvic floor operations specifically geared towards tightening and enhancement of sexual pleasure. This is the primary goal of a genital plastic perineoplasty. Secondarily, incontinence issues may be very well corrected at the same time, but the primary goal is sexual enhancement.
3. Have performed at least ten perineoplasties specific for sexual enhancement.
How is the surgery performed? A diamond/kite-shaped incision is made, beginning at the top of the “bulge” in the vaginal floor, going laterally on either side to ~ 4 and 8 o’clock at the old hymenal ring and vaginal opening, and then meeting again in the midline just above the anal verge. All of the surface skin within this “diamond”, both inside the vagina, in the vulvar vestibule, and on the perineum is removed. Then the skin of the vagina and vaginal opening is peeled back over the pelvic floor fascia, and all the old scar tissue from episiotomies or tears is removed, down to the muscles. The muscles are then carefully re-approximated (put back together) all along the pelvic/vaginal floor. The fascia is then, like a blanket, pulled to the center to cover the muscles. Any excess skin is then dissected away, and the incision is closed in a careful, purposeful, aesthetic manner so as to bring the appearance of the vaginal opening a bit closer to how it looked “pre-babies…”
Preparing for surgery. After you have chosen your surgeon, the next important thing to do involves preparing yourself for surgery. If you are post-menopausal, or even “perimenopausal,” your vaginal walls very likely are under-estrogenized unless you already use intra-vaginal estrogen therapy. If you do not, you would be well advised to make sure your surgeon prescribes for you, as you will upgrade the strength and healing capacity of your vagina by using intra-vaginal estrogens for a minimum of a month, and usually 2-3 months prior to surgery. A good vaginal plastic surgeon will be aware of this and will suggest it.
Your surgeon should carefully explain to you which activities you should and should not engage in, in the weeks after your surgery. Before surgery is the time to make any necessary arrangements for your recovery. Of course, eating a balanced complex carb/protein diet, drinking plenty of water, and engaging in an aerobic exercise program prepares you well.
Most doctors will either give you either an antibiotic injection just prior to surgery, or place you on oral antibiotics for a short time just prior to, and for 1-2 days after surgery.
The surgery is only half the job; after surgery you will need to build up your newly re-approximated muscles through pelvic floor physical therapy exercises (see below). If you are able to start these at least a month or more before surgery, you will be “ahead of the game…”
What about afterwards; what to expect. In general, you will pretty much be resting for the first week; up and around but no exercising, running, lifting, heavy activities for the next 2 weeks. By 3 full weeks, you most likely will be able to begin to resume most activities, but it will be a month before full exercising, lifting heavy objects, and swimming, and 6-8 weeks before penetrative sexual activities. My patients tell me that the pain was less than expected, but you can expect to be taking hydrocodone or other pain medication for several days after surgery. Because of post-surgical inactivity and pain pills, which slow down the motility of the bowels, it is important to drink lots of liquids and prunes and maybe use a stool-softener for the first week after surgery to minimize constipation.
Occasionally the vagina is a bit “over-tight” after surgery, and several weeks or longer working with special “dilators” is necessary before you can comfortably resume intercourse.
Although not all surgeons utilize post-operative pelvic floor physical therapy, most savvy and experienced pelvic floor surgeons do. Beginning around the same time that you resume penetrative sexual activities, you should begin a diligent program of pelvic floor exercises, much like super Kegel’s exercises. Utilizing either an “Apex™” or “In-Tone™ or similar device, and/or working with a pelvic floor physical therapist and doing the exercises at least once (twice is better!) daily, you will significantly improve both the outcome, and the longevity of the repair. I recommend at least 6 months of twice-a-day, thereafter going to at least 3-4 times a week doing the exercises. The more and longer you exercise these repaired muscles, the better the long-term results!
What can go wrong? Remember, this is elective surgery. Carefully weigh the risks and benefits to make an informed decision for yourself. That said, there are potential complications. The vagina might not be as tight as hoped, or it may be too tight, necessitating dilations, and rarely even re-operation to remove a stitch or two. Healing might take significantly longer than envisioned, and/or the incision line may open with lovemaking, necessitating an even longer recovery. An infection may set in or an abscess form, necessitating antibiotics and/or drainage. Rarely, the rectum, underneath the vaginal incision, is inadvertently entered, necessitating a repair and longer recovery. Very rarely, a “fistula” (permanent opening) develops between the vagina and rectum, necessitating a specialized surgical repair.
“Vaginoplasty”/Perineoplasty Before and After: The Results: While most women re-telling their experiences and outcomes online are positive, horror stories exist and are usually predictable: unprepared patient and/or poorly experienced surgeon, although even excellent, experienced surgeons occasionally have complications.
In my experience, roughly 90% of women I operate on for vaginal tightening are happy with their results; probably 75% very happy, the other 15% moderately satisfied. Outcome is directly dependent on how faithful the patient has been with the frequency and longevity of her pelvic floor exercises. These statistics are similar to other well-trained genital plastic/aesthetic surgeons I have polled, and parallel findings in peer-reviewed literature ,
 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.
 Pardo J, Sola V, Ricci P, Guiloff E, Freundlich D. Colpoperineoplasty in women with a sensation of a wide vagina. Acta Obstet Gynecol Scand 2006;85:1125–8.