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The Vaginoplasty Procedure—Techniques of Vaginoplasty and How
It’s Done . . .

First, it’s vitally important to understand that each surgeon who performs vaginal tightening may do so in a slightly different manner than another surgeon.  It’s not that there is a significant dissimilarity in general technique, but rather one of subtle differences in acquired skills from one surgeon to another—largely because they’ve performed many procedures.  Simply said, it’s a matter of experience.  Still, there are some basic surgical techniques describing how the procedure is done.

To begin the discussion, you must appreciate some basic anatomical “roadmaps” that describe the vagina and how it functions.  These will help you understand where most of the vaginal tightening work is done.  The majority of surgeons concentrate on the upper third of the vaginal canal, called the upper fornices.  The reason for their focus in this area is that this region naturally balloons, or expands during sexual intercourse with the male, thereby forming a very small cup for the sperm to be deposited into (so it doesn’t all fall out when the female stands), which enables the individual sperm cells to naturally migrate into the cervical orifice and make their way into the uterus to fertilize the egg.  In women who’ve had even one child, this upper fornice area has been stretched to varying degrees, because of the size of the fetus; hence it is not the size it once was . . . and therefore the need for vaginoplasty.

The vagina at this upper most extreme area, near the cervical opening (cervix of uterus), is divided into four small vaulted chambers/cavities . . . called the fornices.  There are two lateral fornices, (one on each side, left and right) one posterior fornice (to the rear or on the spine side) and one anterior cavity (on the front side).  In this upper extremity there is stratified squamous epithelial tissue, a kind of tissue naturally resistant to bacterial growth and because of the design of the fornices—it appears as folds of tissue (rugae).  Part of this design is because there is a unique ability for this region to easily stretch to accommodate the enlarged male penile glans (head of the penis).  As mentioned prior, it is stretched to accommodate the fetuses head during the delivery process.  Except for the opening of the vagina and one other area—now believed to also be at the anterior section where the urethra is external to the vagina, called the Grafenberg Spot (G-Spot)—vaginal mucosa/tissue sensory innervation (nerve endings) is minimal or non-existent.  This means there is minimal pain felt by the patient afterwards, from the surgeon working/excising tissue in this upper fornice region. More importantly, the upper fornices region don’t contain any muscular tissue, so there is no need to worry about resecting, excising and re-attaching muscular tissue.  It is here they remove the vaginal mucosa and underlying subcutaneous or superficial fascia (fibrous tissue/membranes than may connect skin or fatty tissue to supportive muscle underneath), which lies in planes at varying levels within/below the vaginal mucosa in the fornices regions.

The concept is to surgically reduce the volume of this pre-existing “cup” or “cave-like” fornice region, damaged by childbirth (stretched to a point that it won’t retract to its pre-birth size), making it more like it was before child delivery.  So, how does one do this?  Here’s how . . .

Depending on the volume of the fornice region in question—the surgeon may elect to work on the walls of this fornice “cup/cave” in the lateral areas, on each side, or perhaps the anterior or posterior areas.  It is usually done in two sections at a time, to achieve balance and a well-formed, uniform “cup/cave” once again, by making incisions that resemble an enlarged, fat-almond shape—similar to the shape of the human eye.  By doing this, they remove portions of vaginal tissue in the center of the “almond-shaped” cut, then bring the two sections remaining, back together and suture them . . . hence reducing the overall volumetric capacity of the fornice region, thereby making it a tighter, “cup” once again.  These fat-almond shaped incisions are often made with one of the tips of the incision facing upward, toward the cervix, much like spokes on a wheel. In some cases—depending on the surgeon and his individual preference, almost always based on experience at achieving the best result (that’s why it takes years and hundreds of these procedures to get it right)—he may elect to make the incision shapes sideways, or longitudinally, within the vaginal wall, or even at a transverse angle.  This, by the way, is just one of the variances involved from one surgeon’s technique, to another.  Simply stated, it requires years of experience to gain the aesthetic/anatomical eye, to do it right the first time.

As well, some additional issues may need to be addressed at the same time the vaginoplasty is being done.  Some women may have a mild cystocele, sometimes also called a vesicocele—basically a bladder hernia—whereby the bladder may bulge slightly into the vagina from the anterior (front/belly) side.  This condition is common and is a result of damage to the vesicovaginal fascia from delivering a baby.  It’s a weakening of the underlying fibrous fascia caused by delivery, and it can cause urinary incontinence, or urinary frequency and urgency, sometimes uncontrollable.  In cases like these, the surgeon may do what is commonly called an anterior repair.  By removing these almond-shaped sections from the side of the fornice where the bladder is located, the anterior fornice, the surgeon may, in mild cystocele disorders, remove the bulging vaginal tissue, careful not to incise too deeply to perforate the bladder, then re-suture the underlying fascia back together, allowing new fibrous tissue to stretch across this formerly bulging opening, then re-suture the almond-shaped incision opening to tighten the vaginal fornice, thus making it the proper dimension once again.  This solves the mild urinary incontinence problem the woman may have, AND tighten the vagina, all at the same time.  Keep in mind, however, that this mild cystocele procedure is not the recommended procedure when it comes to more dramatic instances of incontinence/cystocele.  These cases are usually solved by using a surgical sling.  Mesh is not considered to be the best method although some surgeons still use it despite medical studies that report in almost 20% of cases, there are sexual problems caused by tissue rejection, or dyspareunia (pain in the pelvic, vaginal or vulva areas during or after intercourse) by using surgical mesh. 

Likewise, the surgeon may remove an almond-shaped section of tissue at the posterior fornice, although this is a much more delicate procedure, because of the proximity of the rectum, just underlying the vagina in this area.  In these cases, often referred to as rectocele repair, (bulging of the rectum into the rear—posterior fornice), the surgeon needs to be exceptionally careful and know what they are doing.  Needless to say, any perforation of the rectal area, for any reason, would have dramatic, possibly life-threatening circumstances, because the infection risks could cause sepsis (complete bodily infection and possible death).  

Lastly, and in about half of all vaginoplasty cases, a perineoplasty repair (posterior repair) is performed to tighten the underlying muscles of the lower vagina.  In about half of all vaginoplasties, this procedure is added to enhance muscular support for the lower vaginal area, thereby increasing friction and enabling more sensation against the anterior (front) of the vaginal canal, specifically at the G-Spot, by increasing the friction and penile pressure from the man’s penis.  This is usually done by making kite-shaped incision, where the apex of the top of the incision is inside the vagina slightly, then incised in the shape of a kite, with the outer-most incision points at both eight and four o’clock, and the bottom incision ending just above the anal verge, this section can be easily removed, thus removing existing scar tissue from multiple births.  This then exposes the muscle bundles, which are stitched closer together, slightly increasing the tension of their elevation capability.  One must not plicate (stitching folds or tucks in tissue to reduce size) the levators (in this case, the levator ani, l. ani—and transverse perineal muscles that raise or elevate the pelvic floor) by using large sutures or one may end up with a patient with spasm, or dyspareunia (Other FCGS Procedures-Definitions).  Again, it’s the surgeon’s skill at knowing how tightly to plicate these levator muscles without creating pain afterwards in the patient.

So, how does the surgeon perform these seemingly “hidden” incisions, deep inside the vagina?  To begin, vaginal cosmetic surgeons are trained to operate in closed surgical settings.  Many years ago, hysterectomies and surgeries such as vaginal repair were done largely by General Surgeons.  But, today, vaginal cosmetic surgeons perform virtually all surgeries of these types because of the extensive training they’ve received at working in such tight spaces.  Today’s top-notch surgeons use retractors to open the vaginal area, while the woman is under anesthesia, so they can see inside the vagina up to the fornice areas, visually evaluate the region, and apply just the right amount of vaginal tightening.

The instruments often used to make the almond-shaped incisions can be laser scalpels, radio-frequency needles, cautery needles, scalpels, Mayo scissors, Iris-type scissors, Kay’s scissors and other instruments that each surgeon may have a preference for.  But, the choice of the instrument for vaginoplasty is entirely up the surgeon and one type of instrument is not necessarily better than another.  The real issue is the surgeon’s skills at USING their surgical tool of choice.

Vaginoplasty Using Autologous Fat Transfer with Stem Cells—How It’s Done . . .

A relatively new procedure, very much in limited application is vaginoplasty using Free Fat Transfer (FFT).  Basically, this is injection of autologous (originating within one’s body) fat that has been harvested from the patient, separated using centrifugal methodology to increase concentrations of adult stem cells, then reintroduced into the patient to build up volume. 

Unlike surgical tissue excision of sections of the vaginal fornices as mentioned earlier, to reduce volume in the vagina, FFT supplemented with stem cells to enhance vascularization (development of new blood vessels) seeks to augment sub-vaginal volume by building a layer of sedentary fat within the fibrous subcutaneous vaginal fascia.  The concept is one of building up the volume from behind the vaginal wall, using a fat cannula/syringe, and pushing outward the fornices, thereby reducing the inner volume of the upper fornice cavities.  At present, almost no surgeons are performing this procedure, but in theory autologous fat injection could occur as it is being used today, for naso-labial facial folds, Phalloplasty and other dermal filler applications.  It would be fairly accurate to assume that the same problems with FFT for vaginoplasty would occur in varying degrees as they exist in other applications.  Those are, uneven reabsorption of autologous fat by the patient over time, leaving uneven and nodular bumps in the upper fornices that could result in dyspareunia, vaginal spasms, pain to one’s partner or other unknown inhibiting factors.  The advent of stem cell applications has reduced many of these reabsorption issues but, in select patient cases, they still remain.  There is not any surgeon to date that can claim successful vaginoplasty augmentation using FFT to our knowledge.

Vaginoplasty Recovery—So, When Can You Get Back To Normal?

You’re out of surgery, so now what?  When do you begin to feel normal, again?

Typically, recovery after vaginal rejuvenation is LESS stressful than a second child delivery.  Vaginoplasty is generally a SLIGHTLY more complex surgery than labiaplasty, but the basic post-operative instructions are similar.  You’ll usually need 2-3 days of rest—icing the surgical area for the first 48-72 hours—then heat afterwards if there is minor swelling.  Showering and dabbing the surgical area dry and applying antibiotic ointment to the external stitches is recommended.  Most patients return to work in 2-3 days unless they do combination vaginoplasty/labiaplasty, which requires 6-7 days off work.  There should be no strenuous exercise for twenty-three (23) days.  After that, bathing or Sitz bathes will help the stitches dissolve—return to normal exercise and activity is permitted at this point.  At four (4) weeks post-op the use of a small toy, vaginally, is recommended to dilate the vaginal canal—acclimating oneself to the newly rejuvenated vagina. If the use of a vaginal dilator is comfortable, then a return to gentle sexual activity at 5 ½-6 weeks is the norm.  Complete healing is thirteen (13) weeks as with any surgery.  Rarely, (less than 8%) is there a 2nd stage need for additional tightening or loosening. Prophylactic antibiotics are also prescribed but infection is generally very, very low, usually less than 5% of all cases.

How Much of This Surgery Do You Really Need? Need versus Want.

So, You Want To Get Vaginoplasty To Improve Sexual Function, But How Much Surgery Do You Really Need?

You’ve evaluated, researched, checked credentials and you’ve finally decided that you want to get this vaginal tightening procedure done.  Your next step is the consult.  Sometimes you pay for this service, sometimes it’s not charged for by the surgeon—they all differ.  You meet with your doctor and they say, for example, “well, Ms. Jones, I’ve evaluated your situation, and I think you need a perinoplasty, a mild rectocele and mild cystocele repair, and a vaginoplasty.” But, he continues . . . “All told, Ms. Jones, I can BUNDLE the entire surgery to save you a considerable amount of money, so with the vaginoplasty, perinoplasty, cystocele and rectocele repair, you’re looking at about $12,000.  The good news is that if I bundle it as I described, it may be covered by your insurance carrier, but I can’t say for certain.”  Your head begins to spin.  You feel moisture forming on your upper lip as your heart begins to race.  Did he just say, “You’re looking at about $12,000?”  After that HUGE number, you didn’t hear anything else . . . you’re numb.  It’s understandable.  The only thing you’re thinking is, “what happened to the $5,000 number that was quoted on his website and what was discussed on the telephone consult (if you have one)?”  At this point, you’re almost in shock . . .

What just happened?

The issue here is Gynecologic surgery, versus Vaginal Cosmetic Surgery!

What happened, more likely than not, is that you went to see a urogynecologist, instead of a vaginal cosmetic surgeon.  A urogynecologist is someone that is trained in gynecology with an additional focus on urology.  A urogynecologist can fix that bulge or hernia-like protrusion into the vagina from the front side (bladder or anterior side, called a cystocele), or the back side (rectum or posterior side, called a rectocele), because they specialize in those types of medical organ repairs.  These are surgical procedures that you may NEED.  Just remember, a vaginoplasty, in its truest form is not NEEDED—it’s WANTED, by you, to improve your sexual feeling, function and enhance your sexual life.  It is really a cosmetic or aesthetic procedure.

Yes, urogynecologists can do a vaginoplasty and even a labiaplasty, but those two procedures are not what they generally do most often, hence they don’t do them with the same aesthetic considerations and experience as a cosmetic gynecologist. 

Even further, vaginoplasty and labiaplasty are considered elective procedures by insurance companies, because they are NOT always necessary, as explained earlier.  They aren’t necessarily NEEDED, but are WANTED by the patient to improve sexual function.  Don’t forget this vital point.  Yes, if you DO need a urogynecology repair, you should certainly see one of these specialists, and it will usually be paid for by your insurance company.  But, if you then want a labiaplasty or a vaginoplasty, you should see a cosmetic gynecologist because you’ll generally get a better result as they specialize only in these types of elective procedures because they do them more often.  Some of these urology/gynecology surgeons may even try to bundle the surgical procedure to include vaginoplasty and labiaplasty in one bill to the insurance company simply to increase the cost of the surgical procedure as a whole, but it will sometimes not be covered, and you’ll end up paying a major portion of the remaining bill yourself. 

The answer to the question, “how much of this surgery do you really need?” is one that can only be obtained by going to a cosmetic gynecologist (cosmogynecologist) first.  These types of surgeons will tell you honestly what YOU NEED and answer the critical questions about what YOU WANT to improve sexual function.  A vaginal cosmetic surgeon can tell you honestly, because he doesn’t perform rectocele, cystocele, or perineum repairs . . . he specializes in labiaplasty and vaginoplasty only, because he is a cosmetic/aesthetic surgeon with a focus on genital surgery.  He won’t confuse you with excessive marketing or hard-to-understand medical jargon.  Equally important, he WILL refer you to a urogynecologist if, after examination, he discovers that you do need these other medical repairs.













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