Tuesday, 14 June 2011


Dr Aruku Naidu MD(UKM), FRCOG(London). Consultant Urogynaecologist
Dr Zalina Nusee MD(UKM), MOG(UKM), Fellow in Urogynaecology

Plastic surgery for the face and body is well accepted by our society and gradually    becoming a trend among our young and old women. Our society’s penchant for perfection has finally migrated “below the belt” as well. These latest procedures include tightening and reshaping of the vulva and vagina. What is unique about this area is the patented and secretive nature of some of the most marketed technologies and the large financial gain driving this industry. This leads to a serious concern with regards to its safety and efficacy.

This surgery has brought to public attention two years ago by extensive media coverage especially in developed countries. Articles have appeared in the Wall Street Journal, New York Times, Canadian National Post, and numerous online journals. This publicity has led to an outcry by providers in women’s sexual health especially on an international website. Driving many of the objections are the slick advertisements and supported assertions that patented their methods are superior to conventional techniques without mentioning of its adverse effect. The impact was tremendously increased request for genitoplasty in British NHS which has double in one year period from 2004-05 (Liao LM 2007).

 A similar article regarding cosmetic procedures has also been published In Malaysia, by Health at Large, Sunday 15 April 2007 revealed opinion from few private gynaecologists. A month later following this article, the  Ministry of Health, had came out with a technology review paper regarding their stand pertaining to the procedures titled ‘Laser Vaginal Rejuvenation and Design Laser Vaginoplasty’.

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. These are the most commonly performed DLV procedures:
  • 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.
  • 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.
  • 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).
  • 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.
  • Hymenoplasty (reconstruction of the hymen) can repair the hymen as if nothing ever occurred. 
  • 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.
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 frictional during intercourse and also provide an aesthetic enhancement of external vaginal structures, resulting in a more youthful look. The vaginal muscles and connective tissues are tightened as well as reduction of redundant vaginal mucosa. The procedure enhances vaginal muscle, tone, strength and control, and effectively decreases the internal and external introitus. It can also build up the perineal body. 


Designer perineal surgeries definitely will benefits these groups of patients: pelvic organ prolapsed,  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.

Current practice shows that gynecological surgery isn't just for medical reasons anymore; some women say it enhances sexual pleasure. Other subjective indications include feeling of discomfort when wearing clothing, performing exercises or during sex. Some women claimed that abnormal appearance of vulva shape decreases their self-esteem and confidence. Weak perineal muscles reduces vaginal support and vagina is no longer at it optimum state causing diminish sexual gratification.


The aim of cosmetic surgery is to reach to ideal vulva and vagina! Scientifically there is an exact medical terminology for the anatomy of female genitalia. Unfortunately majority of women do not really know what is normal and what is abnormal. Their knowledge is mainly base on the observation of children genitalia or from the ‘Playboy’ 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. 

Variation in genital appearance is to be expected , and as women aged there will be changes in labia minora. Some women are born with wide vagina. 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. The women spreading their legs, exposing their personal secrets to the antiseptic trimmings and surgical prunings of a trusty laser are 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 the perfect vagina? With the reasons for LVR and DLV as diverse as the vaginas themselves, the answers are not so cut-and-dried.
According to Matlock, Gynecology is a super surgical subspecialty, we dedicate our entire professional careers to the reproductive tract. But do we ever go back and look at the things that result from labor, delivery and childbirth? There can be relaxation of that structure and thus a diminishment or a decrease in sexual gratification. Do we concern ourselves with that?  We only concern ourselves with obstetrics. Research is needed in this area, because women do enjoy sex and want to enjoy sex. Women want to be able to enhance their sexuality if they can.
It's a personal preference. For women who are severely damaged, sex should still be intense and passionate." And herein lies 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, only 5 to 10 percent will be so damaged that they can easily fit a household appliance in their vaginas. This is why these 40-, 50-, 60-year-old men are running after 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. Those are facts. There is nothing remotely similar there for women.  There are over 200 prosthetic devices for men on the market but nothing similar for women. If men had babies, and certain body parts stretched out as a result, they would have been looked at, researched and solved a long time ago.
Virginity is restored by a technique called hymenoplasty. Essentially the reconstruction of the hymen, has brought the gynaecologist’s office a steady clientele of Middle Eastern women. Believe it or not how hysterical some of these women. They claimed that they're going to get killed unless they get this done. If the families get to know that they are no more virgin, they will kill them. The majority of these Middle Eastern women are coming in to have hymenoplasty because they're getting ready to get married in their home country.  The groom's side of the family can pick whatever doctor they want to determine whether or not she's a virgin, to determine whether she's worth it or not to be married to their son. So there are religious implications, there are social implications.

Serious perhaps, but not always a question of life or death, make hymenoplasty at one point became a regular thing. These cited the occasional flurry Japanese women who come to the States, do a little school, go on vacation, then come here, have hymenalplasty and go home.  As for Americans, women is seeking the "virgin experience" to share with their husbands and some do it just before celebrating their wedding anniversary.
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.
"Now we want little doll-like genitals and vaginal orgasms and Viagra for women!" she laments, reemphasizing the need for women to assert their "clit power" as the only true road to enhanced sexual gratification. "If men can get close enough to lick and diddle, they don't give a rat's ass about the size of your genitals or the shape of your labias," she says. Dismissing the link between vaginal tightness and sexual gratification as a way for men to cash in on women's insecurities and for women to appease the male ego.
"I think this is a way of preying on vulnerable women," says Dr. Linda Brubaker, fellowship director of Female Pelvic Medicine & Reconstructive Surgery at Loyola University Medical Center. "I reconstruct vaginas all the time. I agree that the field of women's sexual functioning is a poorly studied area. But I don't buy any of what Matlock is saying. There are standard pre- and post-operative intervention tests and tools that could be applied here to substantiate his claims. Curious that Matlock has not applied any of them to his own work, nor published any scientific material relating to his work, nor subjected anything to peer review. The longer this is untested, the better for him."
The effectiveness of the procedures is still unclear. Matlock (2006) claimed that he is currently 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).
Those procedures are not permanent, aging process and delivery will destroy the integrity of the vagina. Augmentation labioplasty using outologous fat will only last for few weeks. Like face lift, vaginal cosmetic surgery need to re do. There was no retrieval evidence regarding the effectiveness of the procedures and the safety aspect of this technology, only anecdotal claims from customers were found from the web site. To those considering LVR or DLV two procedures that 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 was no literature found mentioning about legal aspect of the procedure. It could level DLV as a form of female genital mutilation. Following 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. On the contrary. 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”.
  There were women who claimed no changes in her sexual life after the procedure (R Bramwell 2007). Some of them still not satisfied with the look of her vagina following the procedure because of the lack of understanding of how is the normal vagina look like. By obscuring the lines between the severely damaged and the naturally relaxed vagina, Matlock has leveled the playing fields among all women and widened the market potential for his genital landscaping. His tight-vagina hype also flagrantly misses the point. With sexual ground zero located in the clitoris, one can only wonder for whom the tight vagina truly tolls -- men or women?
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 a women the procedure their sexual life need to be explored, preferably by psychosexual counselor. Unfortunately women who see the problem as physical may resist referral to psychosexual or other psychological services. Furthermore such services are currently rare and have long waiting lists (R Bramwell 2007). 
Till now there is no retrievable evidence on safety, efficacy or cost effectiveness and legality of DLV and VLV. Patient who wish to undergo the procedure need a 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 practice by gynaecologist as this procedure may be used for wrong purposes.   

Figure 1: Training on use of laser for vaginal Rejuvenation


1. Liao LM, Creighton SM. Requests for cosmetic genitoplasty: how should health providers respond? BMJ 2007;334:1090-2.

2. Braun V, Kitzinger C. Telling it straight? Dictionary definitions of women’s genitals. J Socioling 2001;5:214-32.

3.  Braun V, Wilkinson S. Socio-cultural representations of the vagina. J Reprod  Infant Psycol 2001;19:17-32.
4. Braun V, Kitzinger C. The perfectible vagina: size matters. Cult health sex 2001;3:263-77.

5. Debra Ollivier.Designer vaginas, Nov.14,2000

6. Conroy R.M. (2006). Female genital mutilation: whose problem, whose solution? BMJ,333(7559):106-107.

7. Matlock D(2006). The Laser Vaginal Rejuvenation Institute of Los angeles. Cited 14” May 2007 and 21st May 2007. Available from http://www.drmatlock.com

8. Laube D.W. Clinical Obstetrics&Gynaecology,.49(2):335-336

9. Bramwell R, Morland C, Garden AS. Expectations and experience of labial reduction: a qualitative study. BJOG 2007;114: 1493-1499

10. Kong Howe Leng. Reviving the passage of birth. After birth april 2007.

11. Junainah S, Norzakiah M.T, Rugayah B. Laser Vaginal Rejuvenation, Designer Laser Vaginoplasty. Health Technology assessment Unit, Medical Development Division Ministry of Health Malaysia. Mei 2007

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