Information on FGCS

Exactly what constitutes ‘normal’ female genitalia is an area of medicine in which very few studies have been published. The handful of articles that do outline the measurements of female genitalia vary in their definition of hypertrophy and normal.^4,6–10 There are currently no criteria that measure and describe normal female genital anatomy and medical textbooks also lack detail regarding range of diversity and measurements.

FGCS has been described as aiming to ‘improve the appearance of the external female genitalia’ and cure labial hypertrophy,⁹ yet it relies on little evidence of what exactly constitutes labial hypertrophy and, by extension, a normal labia which can include size, colour and shape.¹¹

FGCS is also referred to in the public domain as ‘designer vagina’, ‘vulvovaginal aesthetic surgery’,² ‘barbiplasty’ and ‘vaginal rejuvenation’. Documentation describes the labiaplasty procedure as being performed as early as 1976.⁹

FGCS can be performed by anyone with a medical degree, including cosmetic surgeons (usually a GP or dermatologist who performs cosmetic procedures), gynaecologists, plastic surgeons and urologists.^3,5,9,12

No formal training is required and there are currently no evidence-based guidelines that support the cosmetic procedures. For all specialties, guidelines need to be established from reputable long-term studies in order to support surgical procedures, but these have not yet been developed.⁴

Labiaplasty – the most commonly performed FGCS procedure, this involves removal of tissue from labia minora that extends beyond the labia majora and/or removal or increase tissue from the labia majora in order to achieve symmetry. The procedure falls into two broad categories:

• Amputation technique, or labial trim, where the edge of the labium is cut out and the edges sewn over.¹⁰
• Removal of a section of the labia to preserve the natural contour, such as wedge resection^4,5 and de-epithelialisation techniques.^12,13

Clitoral hood reduction – exposes clitoris and aims to increase sensitivity. This is sometimes combined with a labiaplasty procedure.

Perineoplasty – undertaken to strengthen the pelvic floor and, in the FGCS setting, aimed at establishing penile pressure with coital thrust.¹⁴ This procedure is technically similar to perineal reconstruction, in which the perineal length is restored following childbirth trauma or previous surgery. It is commonly performed as part of vaginal prolapse surgery. However, even in this setting there is no evidence that this procedure improves sexual function and, in fact, it may cause dyspareunia.

Vaginoplasty – the purpose of this procedure is vaginal creation in gender reassignment but, in the FGCS setting, it refers to tightening the vagina, which can be surgical or non-surgical – as in ‘laser vaginal rejuvenation’ or ‘designer laser vaginoplasty’.

Hymenoplasty – also called ‘revirgination’ and is designed to restore the hymen. It is often advertised as a ‘gift’ to one’s partner.¹⁴ This procedure is occasionally requested by women of certain cultural backgrounds in which premarital sex is forbidden and an intact hymen is considered evidence of virginity.¹²

Vulval lipoplasty – removal of fat from mons pubis or augmentation of the vulva.

G-spot augmentation – involves autologous fat or collagen transfer via injection into the pre-determined G-spot location. There is no existing scientific literature describing this procedure. Similar procedures include G-spot amplification and G-shot collagen injection into the region.¹⁵

Orgasm shot (O-shot) – often described as a sexual and cosmetic rejuvenation procedure for the vagina using the preparation and injection of blood-derived growth factors into the G-spot, clitoris and labia.^12,14

Terms such as ‘vaginal rejuvenation’, ‘designer laser vaginoplasty’, ‘revirgination’ and ‘G-shot’ are commercial in nature. The consumers at whom they are targeted can then mistakenly believe such official-sounding terms refer to medically-recognised procedures.^17,18

Cosmetic surgery redefines the patient as a ‘consumer’, and uses advertising to promote the ‘product’. Advertising for female genital cosmetic surgery tends to reflect and reinforce sociocultural messages about the vulva and vagina, potentially creating dissatisfaction among women who do not meet the narrow ideal of normality. Advertising suggests that FGCS procedures are simple, and offer high levels of satisfaction. It normalises surgical procedures and is likely to create demand among those women who experience genital dissatisfaction.^14,15

The potential risks associated with FGCS include:

• bleeding⁴
• wound dehiscence⁴
• infection⁴
• scarring, resulting in lumpy irregular margins of tissue or eversion of inner lining of labia, resulting in an unnatural appearance^4,12
• sensorineural complications secondary to poor healing or scarring
• dyspareunia^4,19
• removal of too much tissue, resulting in pain with and without intercourse – for example, clitoral hood reductions where too much clitoral tissue remains exposed and rubs onto undergarments and causes pain and discomfort³
• tearing of scar tissue during childbirth following previous FGCS procedures⁴
• psychological distress⁴
• reduced lubrication.⁴

The long-term outcomes of FGCS have not yet been researched.¹⁰ Trends change and the aesthetic ideal that is promoted now might alter with time.⁸

No controlled evaluation of short- and long-term clinical effectiveness of cosmetic procedures can be identified in published literature.^4,16,20 According to Professor Helen O’Connell, urological surgeon at the Royal Melbourne Hospital, tissue that is excised in labiaplasty may appear to be ‘just skin’, but the labia minora are derived from the primordial phallus and its excision is likely to interfere with sexual pleasure.¹⁹

In the past, cosmetic genitoplasty has been criticised and debated because it can result in impaired sexual function.^21–23 The nerve density, epithelial qualities and vascular compartments of the labia minora that contribute to sexual arousal and orgasm are poorly defined. Surgical procedure development and counselling about surgical risks related to labiaplasty may be based on inadequate information.²⁴