Female genital cosmetic surgery: the good, the bad, and the ugly
In 1946, the World Health Organization (WHO) defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Esthetic surgeons similarly recognize that self-perception of body image, beauty, and physique may strongly influence a woman’s mental and social well-being. Cosmetic surgery, therefore, is generally considered ethical and beneficial when the intervention is able to improve the quality of life (QoL) and well-being of the patient. In recent decade, however, a new esthetic concept has been introduced into urogynecological practice: correction and/or modifying the genital anatomy in the absence of a specific organic problem or disease with the objective of improving a woman’s self-perception. This scenario has resulted in a growing demand for cosmetic genital procedures and is based on the same premises as that of plastic surgery performed on other bodily structures, such as breast, face, and abdomen, without evidence of organic disease. This growing demand for cosmetic genital procedures is also due to the misleading information push by mediatic advertisements about the “unproven benefits” of gynecological esthetic surgeries.
In gynecological settings, it is estimated that >90% of performed cosmetic genital procedures involved the labia minora. The National Health Service in the UK has reported a fivefold increase in labiaplasty operations over a 10-year period, although this procedure is being more restricted when performed primarily for cosmetic indications. Most labiaplasty studies reported that different techniques appear to offer excellent and equally similar esthetic results with high patient satisfaction and very low complication rates . In addition, using validated symptom questionnaires in some studies, significant improvements in sexual satisfaction, pain during intercourse, and psychological state were found in patients after genital cosmetic surgery . However, most such data lacks strong scientific evidence and are reported by esthetic surgeons without any urogynecological assessment. Moreover, if we exclude labiaplasty, the efficacy and advantages of all the other cosmetic genital procedures are not at all demonstrated and clear.
The WHO defines female genital mutilation as resection of any part of the external genitalia for nonmedical reasons. At present, performing female genital mutilations is an unacceptable medical practice and a serious offense in European countries, as the law protects children and women from such procedures. Female genital mutilation is classified into four types, and labiaplasty can be considered female genital mutilation type 2a: partial or total removal of the labia minora according to the WHO classification. If we acknowledge this anatomical assumption, the philosophical argument that follows is: Do we perform a surgical procedure that is prohibited by law based purely on patient request?
Notwithstanding the legal issues, the reported results of genital cosmetic surgery are not always consistent. It is alarming, therefore, that the number of such procedures has progressively increased recently despite the paucity and discrepancy of outcome data. Only two prospective studies have thus far been published evaluating psychosexual outcomes of genital cosmetic surgery. In both studies, there was an initial increase in women’s sexual satisfaction 1 month after surgery, but this effect was not maintained at medium- and long-term follow-up. More recently, another study demonstrated that labiaplasty seems to have a mild beneficial effect on women’s genital satisfaction but without improvement in their general psychological well-being or intimate relationship quality .
The scientific rationale underlying cosmetic genital surgery lacks sufficient theoretical support mainly because of the methodological limitations in the available literature. Most authors have described cure and complication rates of different genital cosmetic techniques without controlling for patient factors or surgical indications, and it is therefore not possible to conclude the reliability or reproducibility of postoperative outcomes. In fact, women who had labiaplasty for hypertrophy of the labia minora causing pain at penetration or injuries during intercourse are not expected to be comparable with women wo had the procedure to treat complications of female genital mutilations or to reduce labial size primarily for cosmetic reasons. Moreover, most studies included small patient populations with short follow-up periods .
The justification that serious complications are very rare after any surgery—cosmetic genital procedures included—does not apply in the absence of obvious medical indications or strong scientific evidence of efficacy and safety on both physical and psychological health domains. We, therefore, believe that professional urogynecological societies should take the lead in developing a patient registry to document techniques, indications, and complications of labiaplasty and genital procedures and that they should monitor these procedures only if they are performed and justified by a clinical indication. Moreover, it is desirable that, in case of clear clinical indication, these surgical procedures should be ideally performed by subspecialist urogynecologists to reduce complication rate and patient dissatisfaction. We also recommend more research in this field on larger patient cohorts evaluated over longer postoperative periods to better identify the subgroup of women who will benefit from this surgery. Future studies should control for surgical indications, particularly whether performed for symptomatic or cosmetic purposes, and include detailed description of the surgical technique used and the outcomes measured. This knowledge is expected to further our understanding of the appropriate therapeutic role of cosmetic genital surgery in urogynecology.
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