Red Alinsod, MD

As the inventor of ThermiVa I have trained dozens of medical professionals who have done exceptionally well providing safe and effective treatments. Doctors, nurses, Physician Assistants can all perform ThermiVa excellently if they are well-trained and do the procedures on a daily basis. As with  any skill set, it depends on constant use and depth of experience. Ask about advanced training and volume. Ask about their comfort and skill doing vaginal exams. It is such a safe procedure with no known serious adverse events known. No blisters or burns ever in thousands of treatments. So safety wise it is okay for a licensed and trained medical practitioner to perform this very easy to do procedure once properly trained. Personally, in my practice, I do all ThermiVa treatments. My invention, my choice, My results to the best I can possibly give. 

Hope this helps.

Red Alinsod, MD

When you heal up it will probably look gorgeous and petite as the swelling goes down and scars recede. Removing "too much" is a problem that occasionally happens when underestimating the degree of tissue retraction that occurs.  There are two main ways to fix this. One is to bring down flaps from the clitoral hood region but it appears that you do not have much tissue in that area.  The other technique is to use advance radio frequency resurfacing technology to "create" the appearance of more prominent labia minora where there was none. I developed this technique over a decade ago and have found it to be useful in many but not all patients. 

Lastly, I have trained several doctors in Australia and New Zealand who may be able to help. 

Hope this helps. 

Red Alinsod, MD

Unfortunately, your particular problem is more common than we would all like to see.  Plastic surgeons typically build flaps from clitoral hood skin.  An alternative method I have developed and refined over the past decade, completely graft free and suture free, is to create labia minora from nothing using radio frequency surgical technique. It is quite remarkable.  

This is Red Alinsod, M.D. answering the question of "What is The Alinsod Technique?"  I just saw this question as I do not frequent these pages recently.  Have been very busy with the worldwide launch of ThermiVa (I have been in Cannes, Istanbul, Orlando, Vietnam, and Bangkok giving seminars recently and still here in Thailand for another teaching session tomorrow.  Have some free time now so I thought I would just set things straight.  There is no published "Alinsod Technique" in the literature. I have kept the technique quite and part of my decades old teaching program here in Laguna Beach, California, but do bring it out on my lecture circuit and meetings every year.  For those of you who do not know, perhaps plastic surgeons who have commented prior, I have been Chairing the oldest CME approved Congresses that deal strictly with Aesthetic Vulvovaginal Surgery.  In fact, it is called CAVS or the Annual Congress on Aesthetic Vulvovaginal Surgery.  We just completed our meeting a few weeks ago in Orlando.  My entire adult career has been quietly pushing for the acceptance of aesthetic gynecology along with the foresight and leadership of the Pelosis and Matlock who I consider dear friends.  Most plastic surgeons have never heard of me since I am never invited to speak at their meetings except perhaps local chapter dinners.  However, over the past decade my materials, techniques, and photos of both labia minoraplasty, labia majoraplasty, lateral and vertical clitoral hood reduction, RF resurfacing revision surgery, and now ThermiVa RF treatments (my invention) have been presented at national plastic surgery meetings by my dear friend and colleague and co-author of the upcoming textbook on the matter, Christine Hamori, M.D.  Anyway, my techniques are not published in literature and that is true, but they have been taught to my amazing colleagues over the past decades with great openess and care.  Those who valued my teaching have come from all over the world to learn extremely precise surgery that have become standards of surgical techniques worldwide without me pushing such methods.  An example is the modern medial labia majoraplasty that now the standard of how labia majoraplasty is done to hide scars and produce safe and attractive results.  I presented that technique at my meeting internationally in 2006.  If you did not attend my meetings you would not have heard of me or my techniques.  Somehow the patients found me and the plastic surgeons did not.

So here is The Alinsod Technique in a brief but detailed description:  The Alinsod Technique is my method of in-office labiaplasty done without IVs, awake, with an average of 4-7cc of local anesthetic.  This is the safest way of surgery since there is no tubes down your throat nor needles in you spine.   The Alinsod Technique can mean either labial or vaginal surgery.  If The Alinsod Technique is meant to describe my method of vaginoplasty it is the same method described above in terms of anesthesia but with a deep dissection to the ischial spines, performing the Pudendo-Levator block I developed in 2005, narrowing the vaginal vault with sutures in a layered technique and plication of muscles and fascia, excising excess vaginal mucosal tissue after careful measurements, then closing in a detailed and beautiful fashion with more layers of fine sutures.  This detail and depth of dissection is very rarely done by plastic or cosmetic surgeons and is typically done by highly skilled urogynecologist and gynecologist.  This is the "Full Length" vaginal tightening I described over ten years ago in both my meetings, teaching, and marketing.  The Alinsod Technique was not the superficial perineoplasty that  most plastic surgeons had started to perform and labelled their vaginoplasty.  I was fortunate to teach amazing plastic surgeons "my" technique of going all the way up the vaginal to the very top and doing that full length repair.  Otto Placik, Johan Brahme, Christine Hamori, Paco Canales are a few of the friends who came to Laguna to learn.  Now in terms of The Alinsod Technique of labial surgery, Dr. Goodman has it pretty correct. He knows since I trained him on my technique and we worked on a textbook together last year.  But let me add details to his description in the next paragraph.

My "Alinsod Technique" is really a curvilinear resection of labia minora that is typically done along with a lateral clitoral hood reduction (a method I developed as well as the medial clitoral hood reduction).  Surgery is performed after Dermoelectroporation is done to numb the tissues and micro tumescent anesthesia has been completed.  I also may give some anti anxiety pills and mild narcotics and nausea reducers.  I put carefully placed marks with my blue marker on the agreed upon locations.  I can remove just the edge of dark tissue and I call that a RIM Look.  I can remove all or almost all of the labia minora to be below the level of the majora and I call that a Barbie or Smooth Look.  Then I can split the difference and remove most of the labia minora but leave a "peek-a-boo" slice of labial tissue that many want and I call that a Hybrid Look.  I always use a pinpoint radio frequency excision tip that is extremely precise and that is why it has probably evolved to become called the "Alinsod Technique."  It is because I use precision radiofrequency and not a laser, not a knife, not standard electrocautery.  Ultimate precision with the leas lateral thermal damage known.  About 20 microns with my radio frequency versus the 1 mm with standard cautery or laser based system.  With this level of precision I angle the hair tip just the precise degree and debulk the unattractive or uncomfortable labia minora, which results in the edges just falling in towards each other in the midline and pretty much disappearing due to the precise location of excisions.  In regular English, The Alinsod Technique is able to hide the scars to be invisible because of its ability to vary the length of the left over medial and later labial edges.  It is so cool and so beautiful on how that all lines up and vanishes into a gorgeous natural look.  Then The Alinsod Technique ends with clitoral hood reduction and management of the dog ears so that there is absolutely a petite and natural flow of tissues from the clitoral hood to the frenulum to the labia minora tissue.  Experienced labiaplasty experts will understand what I just wrote but lay patients and/or new labial surgeons may find it difficult to picture what I just wrote.  

It is funny that I have never once in my memory called what I do "The Alinsod Technique" except in my PowerPoint slide for the doctors who take my course.  Wonder if my slides have gotten out into the public for this discussion to even occur.  In all my lectures and academic writings for the public I have referred to my method as a generic curvilinear resection sometimes degradingly called "amputation technique" by plastic surgeons.  Perhaps I am biased but this method is the safest and most precise way of doing thins in my opinion since there is minimal risk of wound breakdown like wedge labiaplasties.  Those fall apart about 20% of the time and leave gaps and holes and that is a problem that I would rather completely avoid.  The common comment that wedge labiaplasties are done to "keep the natural edge" carries weight if the patient truly wants to keep the dark and corrugated labial edges.  However, in my practice, just about all the women who see me select me because they know I will remove those dark, irregular, corrugated labial edges to leave smooth and scar free labias.  It is good to have choices.  

Hope this helps those who were curious as how I did my labial surgeries.  Started labiaplasty surgery in 1988 when I was part of the exenteration teams for genital cancers then continued on in my military career and private practice from 1990 till today.  Thousands of cases and lots of practice.  

Lastly, I would not go to a surgeon just because they are plastic surgeons.  There are lots of poorly trained plastic surgeons and lots of poorly trained gynecologists who attempt to do labial and a vaginal surgeries.  I would personally go to the most experienced vulvovaginal surgeon that does only labial and vaginal surgery.  It is just my preference to to go to the surgeon who does the one thing over and over and has built the eye and the reputation for gorgeous results.  If I wanted a nose job I would not go to a plastic surgeon who spends the majority of their surgical time doing tummies, breasts, boobs.  I would go to the guy who concentrates on the nose whether they are in plastics or whether they are ENTs who are facial plastic surgeons.  Board certification says you can pass a test but tells you nothing about artistic eye, gentle hands, sound decision making, ability to communicate, and volume load of cases that pertain to what you want done.  Being a chairman in this, a leader in that, a moderator/organizer/planner tells you nothing about surgical skills and results.  Look at the surgeons depth of photos on the specific procedures, their testimonials, talk to their patients, go interview them.  Where did they train and who were their mentors?  Do they disparage colleagues?  Do they answer their own emails or call you back personally when you have questions or are they unavailable to you?  Must do your homework and ultimately go with your guy.

Warm regards,

Red Alinsod, MD

What are the Differences Between ThermiVa Radiofrequency and FemiLift/MonaLisa/IntimaLase Lasers for Use in Aesthetic Vulvovaginal Therapies?

From the Perspective of a Full-Time Aesthetic VulvoVaginal Surgeon
November 5, 2015

Red Alinsod, MD, FACOG, FACS
South Coast Urogynecology
Alinsod Institute for Aesthetic Vulvovaginal Surgery

I am writing this piece to an audience of both lay person (or potential patient) as well as clinician (MD, RN, PA) to give my personal views on the new ThermiVa technology and how it stacks up to the numerous laser devices for the purpose of feminine rejuvenation. These are my views and do not necessarily reflect the views and opinions of Thermi, the company. This was written as response to an article Dr. Steven Gitt wrote on September 28, 2015 and published on LinkedIn Pulse.  I believe it best to review Dr. Gitt’s written opinion and compare and contrast it with mine to get a balanced take on this important emerging topic.

There has been an amazing and rapid growth in the field of non-surgical feminine rejuvenation. In 2005 we were perhaps the first center to provide non-surgical tightening of the vulvar structures using CO2 lasers and later on Erbium 2940 lasers. We used ablative settings and progressed to fractional ablative and non-ablative methods. We were able to get tightening of the labial and internal vaginal skin but at quite a cost in terms of pain and recovery and skin discoloration. The tightening obtained with the most effective CO2 lasers on external vulva were impressive for a short period of time until gravity and aging effects wore out the effects in a few months. Using the highest powered CO2 lasers intravaginal, tightening effects were obtained but the downtimes were many many weeks to months. Depending on where you focused the lasers and what tissue you shrunk down you would get some improvement in continence in some patients. But these ablative lasers were not known to improve vaginal moisture or help atrophic vulvovaginitis. Todays lasers, both CO2 and Erbium, are used with less power and with less to no ablative effects but are better in improving vaginal moisture with very little downtime. They give enough tissue tightening effects to help reduce incontinence also when the pubocervical fascia are treated. This is the case with FemiLift or MonaLisa, both fractional CO2 lasers. This is also the case for IntimaLase using 2940 Yag lasers. These three systems, released in the US within the past year or so, are the state-of-the-art for the laser arm of feminine rejuvenation. They will battle for laser supremacy in the market filled with over a dozen laser copycats. However, when looking objectively at choices, ThermiVa radiofrequency technology is rapidly becoming the standard by which all feminine rejuvenation devices are being compared to and judged by. Why such a little company is making huge headways in the industry dominated by laser titans? There are many reasons why Thermi is the fastest growing small company in the industry. As the director of the team that put ThermiVa together I would like to share my views that will be based on my personal clinical use of ThermiVa since its inception as an idea in 2009.

Laser companies have known for some time now that the tightening effects of lasers on skin were not satisfactory and not impressive. They have focused their energies on skin smoothing, skin texture, wrinkling, treating sun damage, and blood vessels. Since the advent of Thermage RF treatments and less so infrared devices, the swing for skin tightening has convincingly swung away from lasers. Clinical research and experience has proven radiofrequency to be the winner at this point in time when it comes to consistent and non-surgical/non-ablative treatments for skin tightening not just in the face and body but in the feminine regions. There is a reason large laser companies like Cynosure have purchased RF companies like Ellman. To obtain RF technology for tissue shrinkage.

Enter ThermiVa, a unipolar radiofrequency device with FDA clearance for dermatologic use. It has a broad FDA clearance purposely obtained because of the wide spectrum of clinical effects it is able to bring to treated skin. This is not the radiofrequency system that “many feel that their effectiveness remains unsatisfactory.” Early RF systems were known to cause lots of pain with little consistent clinical effects. Those systems blasted RF heat and used cooling measures to reduce the pain. There was not sustained heat given to tissues. They were “blast and cool” devices. In contrast, ThermiVa applies heat (40-45 Celsius) that is sustained and comfortable because it is “Temperature Controlled.” ThermiVa uses very smart software and technology that is able to slowly heat tissues to targeted temperatures and then maintain the temperatures there to obtain the tissue contraction “blast and cool” methods could not achieve consistently. RF science and use on vulvovaginal tissues started around 2009 in our office, years before any vulvovaginal laser technology was used in the U.S. to treat vulvovaginal issues. It is not accurate to say that there is little research regarding long term results of RF devices. I have reported on the results of RF use on vulvovaginal tissue and its safety and excellent efficacy almost every year since 2009 at my yearly CAVS meetings (Congress on Aesthetic Vulvovaginal Surgery). Every year I showed dozens of photos and clinical studies. More recently my Pilot Study has been published and the ThermiVa multi-site IRB has been completed. Safety has been established clearly as no blisters or burns or adverse events have occurred since 2009. Blister and burn temperatures at 55 Celsius are not reached by ThermiVa.

So what can ThermiVa do? It can do two things well. First, it can tighten vulvovaginal tissues uncontestably better than any laser system on the market. Hands down. No contest. It can tighten the labia majora sagging dramatically to levels not seen by laser systems both CO2 and Erbium, both ablative and non-ablative, both fractional and non-fractional. There are dozens of photos on the thermiva.org website and other websites showing the amazing tightening effects externally with the use of ThermiVa. Go try to find a single set of photos showing the Before and After tightening effects of any laser system and compare them to ThermiVa. They will be hard to find because the laser systems, like FemiLift or MonaLisa or IntimaLase, are not routinely used to shrink the labia majora. In fact, you need a separate hand piece and anesthesia if you choose to use it for the labia majora. There is significant downtime with that ablative treatment. Common sense dictates that laser companies with good results of their tightening would be proud of their outcomes and show them off on their websites and brochures. Common sense would also find owners of laser systems proudly displaying the results of FemiLift or MonaLisa or IntimaLase. Good luck finding those photos of their results. Here is the kicker, RF is known to shrink moist mucosal tissues even better than external dry skin and that is exactly what we find. ThermiVa’s internal treatments of the vagina are superior in tightness than any currently available laser system geared for vaginal rejuvenation. This is from my personal examination of hundreds and hundreds of women who have received ThermiVa treatments and comparing them to my years of laser use. This has been clinically confirmed by dozens of ThermiVa users. One more thing, with the tightening of vaginal tissues, you can target the tightening effects to the area of the urethra called “pubocervical fascia.” This results in the amazing reduction in leaky bladder. Both stress incontinence (leaking from increased pressure such as a cough, sneeze, jump) and overactive bladder are relieved consistently. The tightening is immediate and many are dry after just one treatment. Dribbling goes away, urge symptoms subside. In fact, the effects of radiofrequency on the bladder are just about as good as any of the anticholinergics drugs available without the dry mouth and constipation. Urogynecologist who have ThermiVa have reported dramatic reduction in number of slings needing to be placed and number of prescriptions written for overactive bladder. No mesh, no drugs. I have not seen this type of dramatic effects with laser based systems though some do claim to be able to help.

Secondly, Thermiva increases blood flow. This is perhaps the “Biggest Deal.” It is true that vaginal and vulvar biopsies have not been published to show the microscopic effects and those studies are not quite complete yet. But on visual exam, a macro exam, you can see vessels forming on labial and vaginal tissues. The increased blood flow is real as evidence by the increased transudate from arterioles going into the vaginal canal and resolution of the dry vagina. This effect is one of the few things in my practice that I can say is 100% since not a single patient has failed treatment for atrophic vulvovaginitis (dry vulva and vagina). Along with the increased blood flow also comes the improvement in the sensitivity of the vulvar structures, the clitoral region, and internal vagina. Akin to “Female Viagra” due to the increase in blood flow to the genital structures treated. Treatment of the G-Spot areas have increased sensitivity there and have improved orgasmic response consistently. Because of this increased blood flow there is increased production of collagen. Tighter new collagen that is more pliable and soft. This is both from patient report and physical exam. For example, even the most atrophic vagina with a pinpoint hole for entry (not at all amenable to the large FemiLift or MonaLisa laser hand pieces) will get softer, more pliable, and moist that will even allow for comfortable sex after 3 treatments! ThermiVa’s thin and gently curved hand piece allows for such delicate treatments. Because of blood flow ThermiVa does result in collagen regeneration that is needed for thickening of the vaginal lining and resolution of painful intercourse. Again, for clinical proof, look at the photos on the thermiva.org website.  Lots of photos on the improved blood flow resulting in increased moisture.

What about the comment that ThermiVa is not able to get hot enough and “heats tissue to 50 Celsius, which may be too hot for a Jacuzzi but quite insufficient to cause collagen generation.” This lacks clinical truth. There are many studies that show that tissue tightening occurs at around 42 Celsius and that it is both temperature plus time of exposure to heat that matters. ThermiVa can comfortably bring vulvovaginal tissues to 40-45 Celsius for 3-5 minutes and cause immediate tissue contraction you can see during the treatment then tighten even more over the next 3 months. Again, look at the pictures. There is significant collagen regeneration.

Is FemiLift and other lasers like MonaLisa and IntimaLase really less expensive over the long haul over ThermiVa? Let’s do some math. First, you can but 2-3 ThermiVa systems for the price of one laser system. ThermiVa costs the doctor $65,000. MonaLisa is $175,000. FemiLift and IntimaLase are somewhere in between. Those prices are going down because of pricing pressure ThermiVa has exerted on the market. A good thing for doctors and patients both. So who has the larger lease payments and may need to charge more per treatment? For the patient, the average cost of 3 ThermiVa treatments is $3500 in Southern California. Laser treatments are more expensive at some places and less in others. ThermiVa does need maintenance about once a year as do laser treatments. There is zero price advantage for laser systems over Thermiva for both the doctor and the patient. It is inaccurate to say that ThermiVa treatments will be more expensive in the long run. I have had many calls and emails from doctors across the country asking me if there is a way to part with their expensive lasers and trade up to cost effective ThermiVa systems. They see the tsunami wave of ThermiVa damaging their laser vaginal rejuvenation business. I have not heard of a single ThermiVa user trading for a laser system. Just does not happen with happy doctors with a device that is game changing. The acceptance of ThermiVa has been widespread from OBGYNs, Plastic Surgeons, Dermatologists, Cosmetic Surgeons, and even bread and butter Primary Care doctors. You do not have to own a laser center or be a plastic surgeon to use ThermiVa successfully. When treatments are completed properly you cannot tell if it was done by a gynecologist or plastic surgeon.

So let’s go point for point on a few things now:

• 1.Costs: ThermiVa is significantly cheaper for the doctor to use and probably about the same for the patient. The single use hand piece is cheap and disposable. The system warrantee costs are a fraction of what laser companies charge.
• 2.Availability: ThermiVa is rapidly growing in availability worldwide because it is more affordable and fits the practice of gynecologists better than laser systems. Even plastic surgeons are opting out for ThermiVa over lasers since they own so many already.
• 3.Safety: No known adverse reactions or complications with ThermiVa. No blisters or burns. No need for a special laser room with signage, no need to use laser glasses or smoke evacuators or masks for the venereal wart viruses that may get in the air with laser systems when they smoke tissues.
• 4.Simplicity: ThermiVa is a simple lightweight box that can be carried or pushed from room to room or office to office quite easily. About the size of a small gym bag. No reticulating arms or smoke evacuator or mirrors to align and worry about. You press button to start it, raise or lower the temperature, use a simple disposable wand. Super simple controls without having to worry about watts, spot size, depth of penetration, patterns.
• 5.Convenience: ThermiVa has a single use wand. No cleaning of wand. No cross contamination. No sharing of vaginal hand pieces. You know it is a brand new and clean wand when you open the package yourself. Plus, with not having to switch hand pieces, there is no downtime when you go from external to internal treatments and no need to disconnect and reconnect anything. It is a totally seamless procedure.
• 6.Anesthesia: ThermiVa does not need any type of anesthesia. Laser systems typically do not need anesthesia for internal vaginal treatments but will most likely need anesthetic cream for treatment of the vaginal opening and labia majora. ThermiVa treatments feel like a warm stone massage while laser treatments are known to give prickly and pokey sensations during treatment.
• 7.Downtime: Zero downtime for ThermiVa. You can have sex, go to the gym, do anything you want to immediately after treatments. There is no abnormal discharge after treatment. Laser systems claim no downtime also but there is a discharge from the ablative or resurfacing effects for 5-7 days. It is not appropriate to claim that there is no downtime or discharge with the use of FemiLift or MonaLisa or IntimaLase.
• 8.Versatility: Excellent for
• a.Labia Majora Laxity: Non-surgical treatment
• b.Vaginal Laxity: Non-surgical treatment
• c.Atrophic Vulvovaginitis: Non-hormonal treatment
• d.Stress Incontinence: Non-mesh treatment for mild to moderate incontinence
• e.Overactive Bladder: Non-drug treatment
• f.Pelvic Prolapse: Can reduce a fallen bladder or fallen rectum about one stage so that surgery may be avoided
• g.Orgasmic Dysfunction: Average reduction in time to achieve orgasm is 50% in those with a problem achieving orgasms
• h.Repetitive Vaginitis: Normalizes vaginal pH
• i.Repetitive UTI: Normalizes vaginal tissues and vaginal pH
• j.Lichen Sclerosis and Hyperplastic Dystrophy: Adjunct to steroid and PRP
• 9.Results: Patient satisfaction is very high with ThermiVa and the stories told are simply amazing. It is more than just tightening of the feminine structures! ThermiVa addresses the complete spectrum of feminine rejuvenation. Pelvic pain and discomfort from atrophy or dryness improves. Everyone who is dry and atrophic gets moister (even irradiated pelvis). Results for incontinence are similar to surgery and drugs. Improvement in orgasmic response is consistent for those who suffer with orgasmic dysfunction.
• 10.Doctor Training: No laser training needed with ThermiVa. Simple procedure. If you can do a Dilation and Curettage you can do ThermiVa.
• 11.Doctor Support: ThermiVa support is rapid and immediate and the reps are always available. They provide on-site training by their nurse instructors and also offer free webinars and live training at established centers such as mine.