Now that I have decided, on the 50th anniversary of opening my practice of Obstetrics, Gynecology and Infertility in June of 1972, and on the 25th anniversary of my foray into the world of Intimate Plastic Surgery with a labiaplasty in 1997, to “…hang up my scalpel,” I thought I would regale you with reflections on the field of vulvo-vaginal aesthetics that I have closely observed over the past 25 years.
I’ve never stayed with one thing (medicine) for so long. I was an avid white water kayaker & sometimes a river guide. Then I wasn’t. I was a small plane pilot, putting down on short runways throughout the West. Then I wasn’t. I dabbled in music. And then I didn’t. I was a gardener/farmer. Well… I still am. I’m still a parent, and still deal with the occasional crisis, even though all my kids are up & gone. And I have been an obstetrician, an infertility doc, a gynecological surgeon, and then a gynecologic plastic surgeon over the past 50 years. My hands are still steady. I’m not yet drooling (that I know of…) but it’s time to step away, at the top of my game, rather than awaiting the inevitable decline. When did Linda Ronstadt know? Drew Brees know? Brett Farve? Jerry Rice? When will Tom Brady make the decision?
For me, it was these anniversaries plus the fact that I have trained a more-than-competent replacement who has absorbed my techniques, and is on the path to improving them.
And it was my bass guitars. Sitting in the corner, with the amps, and with the rub-boards and Cajun percussion I used to play in the days I fancied myself a bit of an R&B guitarist, and Cajun & Zydeco percussionist. While it is time to travel more, it is with these instrumental friends that I wish again to spend more time.
But, we were going to talk about what I have seen after 25 years in the field of Genital Aesthetics, and 50 years as an Obstetrician, Gynecologist, and Gynecologic Plastic Surgeon.
In regards to the field of female genital plastic/cosmetic surgery (“FGCS”) and vulvovaginal aestetics, I have seen both great progress, and unproven marketing hype. Back in 1997 and 1998, several surgeons, each on their own, began “re-designing” women’s genitalia. Gary Alter, in Beverly Hills, generously wrote his seminal article describing a modified V-Wedge technique for labiaplasty (LP) in 1998 in the journal Plastic and Reproductive Surgery. I performed my first LP in 1997 on a patient who suffered a complete transection of her right labum during childbirth, and asked if I could “…put it back together.” …And, while I was at it, could I reduce the size of her other (hypertrophic) labum? This was prior to Dr. Alter’s article. I decided to “refresh” the edges of her right labum prior to a wedge-type closure, and repeated the V-like excision for her left labum, and luckily it worked, and looked good. Shortly after, in early 1998, a close friend of my patient who did not like the large size of her labia minora asked if I could do the same thing from her. I did, and the result was good. My third case was in 1998 or 1999 did not fare as well, and both sides came apart, as at that time my technique was not as it is now, and I only closed the skin without using “scaffolding sutures” in the subcutaneous tissue to take the pressure off the skin closure and make the repair stronger. Techniques have improved, suturing options have evolved, hundreds of surgeons have been trained, and countless more have attended lectures or read either mine or Christine Hamori’s textbooks on FGCS.
Unfortunately, I cannot be as optimistic regarding the field of medicine and surgery in general. Medicine and surgery used to be noble callings, a place where intelligent persons with scientific interests and the ethos of truly wishing to help people, to “…Be Of Use…” blended their skills and entrepreneurial bent. An Internist… a Surgeon… truly cared for his or her patients, treated them as individuals, and when they needed to be hospitalized followed them into the hospital and provided care. When a surgeon performed an operation (s)he followed that patient through her or his post-operative course. There was continuity of care and each patient was treated as an individual.
No More!! Hospitalized patients are now cared for by in-hospital physicians known as “Hospitalists” who do not know the patient, his or her history, social connections, etc. Yes, they have the “records” on what is known as EMR (“Electronic Medical Records”), which are usually very inaccurate as they relate to medications, history, and diagnoses. Surgeons do the surgery, perhaps see their patient the next morning, and then turn over care to a stranger Hospitalist who then provides the remainder of hospital care. These Hospitalist specialists cannot provide individualistic care, and provide what is called algorithmic care. Same with nursing care: algorithmic care. In algorithmic medicine, everyone is treated the same; there are what is called “algorithms:” If this, do that. If that, do this. Algorithmic care treats everyone the same, and this, along with the overarching fear of lawsuits (“care by the hospital attorney…”) leaves no room for treating the individual as an individual, and has led to a serious decline in hospital care. It is considered “old-fashioned” for a physician or surgeon to follow their patient through their hospitalization, and hospitals themselves, far more concerned about getting sued. Additionally problematic is the quality of nurses on the medical, surgical, and postpartum wards. While the “sharp” nurses gravitate to the ER, the OR, Labor & Delivery, the ICU or Cath Lab, care on the wards has been relegated to mostly foreign-trained nursing staff who, while they are good at “smiling” and basic algorithms, are abysmal at thinking and responding to an individual problem than providing good care for the individual. Hospital administrators, backed by “yes-men” among the hospital’s medical bureaucracy, strongly discourage physicians & surgeons from caring for their patients in-hospital. Also, the hospital can make much more money by employing their own physicians and then billing insurance plans or patients for this care. “Modern medicine” is about money and avoiding lawsuits; patient care occurs as an afterthought. I say this as a physician and surgeon with 50 years of experience, and as a medical consumer who has experienced firsthand hospital care for several operative procedures.
The same algorithmic approach, plus the crushing burden of EMR, follows into the doctor’s office. Medical groups are no longer personal, all phones have massive phone trees, patients are more of “…a number…” and, unless you have concierge care, docs are “9 to 5” rather than individual providers for their patients.
While general medical, and especially hospital care is on the decline, Female Genital Plastic/Cosmetic (FCGS) surgery (aka “vulvovaginal aesthetics”) has ascended from its humble beginnings, as both women become aware of treatments available and surgeons become better trained, but there are caveats.
As women become aware of alternatives to modify hypertrophic and bothersome labia, and remodel and tighten vaginas and vaginal openings destroyed by childbirth, trusting and medically unsophisticated women are approaching their “general Ob/Gyn” for surgery that their general Ob/Gyn has not been trained to do, resulting frequently in poor or even horrific results. There remains a “stigma” attached to female genital alteration. More medically sophisticated women will go online, do their “due diligence” and carefully research well-trained, experienced, quality providers. While an Ob/Gyn Residency training program will train Gyns to do vaginal “site-specific repairs” (aka “Posterior Repair”) for defecatory difficulties, this operation does nothing to tighten the vagina and tighten and re-design the opening for better and more fulfilling sex (“Vaginal Reconstruction,” or “Vaginoplasty”). Ob/Gyns learn how to amputate labia, or just barely trim the edges for benign tumors, unless they have taken a dedicated post-grad genital plastics training program in LP and vaginal reconstruction. So, while more and more surgeons are becoming trained in aesthetics, because of the press and popularity more and more women are asking their general Gyn if (s)he can operate and bill insurance, and since insurance will cover non-aesthetic LP “for cause” but will not cover a cosmetic or sexually enhancing procedure, I and many aesthetic LP revision surgeons are seeing more and more patients with poor outcomes from general Gyns, seeking an aesthetic revision of their suboptimal or “botched” surgical results.
At the beginning, in the early 2000’s, there were only a handful of surgeons interested in genital plastics, and most held their technique cards very close to their chests, and none of the early genital plastics meetings, organized by either ISCG (International Society of Cosmetogynecology), or CAVS (Congress of Aesthetic Vaginal Surgery) featured any “how-to” or technique-specific lectures. I was the first surgeon, at a CAVS meeting around 2008, to specifically describe both LP and vaginal reconstruction techniques.
In 2007, disturbed by the marketing of genital plastic procedures by one of the “fathers” of these techniques, Dr. David Matlock, the organization that purports to represent Ob/Gyns, the American College of Obstetricians and Gynecologists (ACOG) issued a “Committee Opinion” in which they damned vulvovaginal aesthetic surgery performed by Gynecologists, indirectly accusing Dr. Matlock of marketing successful results that were not officially “…evidence-based.” At that time those of us involved in this emerging subspecialty, including myself, Red Alinsod, Marco Pelosi, Rob Moore, John Miklos, Rob Jason, Otto Placik, Jack Pardo S, Adam Ostrzenski, and a few others KNEW that we were making a difference in the sexual and overall satisfaction of life for our patients. We observed this. We realized that we were successful the great majority of the time, and that our complications were low. But none of this was “evidence-based.” There were no published evidence-based studies. While there were “technique” articles in the literature, there were no good scientific papers regarding outcomes and risks. I had already authored a journal article in the Journal of Sexual Medicine presenting a Forum on FGCS (2007), and an Opinion piece in the official Ob/Gyn journal, Obstetrics and Gynecology (2008), and had written several other scientific articles in the fields of Menopausal Medicine, Minimally-Invasive Surgery, Obstetrics, and other fields, and was pretty much the only FGCS surgeon familiar with writing protocols and organizing scientific studies. I recruited 11 other surgeons from 10 groups and 8 states to contribute data, and in 2009 in the Journal of Sexual Medicine published what is still the largest outcome series involving FGCS (LP and Vaginoplasty, or “VP”), with 254 patients and a total of 341 procedures, which remains the largest retrospective study on the subject. I have subsequently published several other studies, including what is still the largest prospective study on body image and sexuality outcomes in women choosing vulvovaginal aesthetic surgery, and several other authors have contributed to a burgeoning prospective and retrospective literature. Yet ACOG continues to virtually ignore us and this literature, quoting only its members who have never performed any aesthetic work!
While, with the advent of better training from the Labiaplasty and Vaginoplasty Training Institute of America, Inc., The Alinsod Institute, and the International Society of Cosmetogynecology among others, more and more surgeons are being trained in proper technique and procedure design, at the same time “Industry” has stepped in, marketing expensive and unproven so-called “minimally-invasive” procedures. These “treatments” are marketed as a panacea for women unwilling to undergo surgery. They include Radiofrequency procedures such as Thermi-Va and Viveve; laser procedures such as DiVa, FemiLift, MonaLisa, etc., and “fillers” including fat transfer. None of these procedures are permanent, with the huge majority needing to be repeated every 3-10 months. The laser and RF procedures require 3 separate administrations a month apart, so patients must visit their provider 3-5 times a year, pay ~ $3000-$5000 annually, for suboptimal results. But they avoid surgery, even though these techniques are much more expensive in the long run. For clinicians, it is the “…gift that keeps on giving…” While time off for surgical recovery is avoided, a huge amount of time is spent in the many office visits necessary annually for noticeable improvement. As a practitioner who is invited to be a “peer-reviewer” for articles attempting to be published in the literature, I have reviewed several potential articles, and can accurately say that there is no evidence that any of these techniques reliably last more than 3-6 months, despite the less-than-true marketing seen from the companies that manufacture these “machines,” and the providers who have spent $100,000+ for a “machine” and now need “cases” to make their lease payment!
Attendant with a rush of publicity surrounding labiaplasty and vaginoplasty in the early and mid-2010’s, FGCS became the fastest growing area of plastic surgery, according to the American Association of Aesthetic Plastic /Surgeons. The figures, reaching a peak around 2017 have since leveled out and even declined a bit. According to an insightful article about to be published in the Aesthetic Surgery Journal, there remains a stigma surrounding FGCS and LP in particular, with public (and certainly academic) attitudes trending significantly lower when it comes to reducing labial size than for women choosing to reduce the size of their breasts. Puritanical “…we don’t talk about sex…” attitudes die hard, and are still alive and well in the U.S.
I have performed > 1100 genital plastic/cosmetic procedures, and have worked with women from age 14 to 81. With women from different social, educational, racial, religious and geographic backgrounds. Matter-of-fact, relaxed, tense, anxious (and super anxious) women. Women who know exactly what they want, and women who know only that “…what they have they don’t like!” I’ve worked with women who haven’t told anyone, and fly in alone from someplace distant from Davis, and women who arrive supported by family members or significant other. With rare exception, my patients, and the vast majority of other women operated on by a surgeon with training and experience commensurate with the task at hand, finish their 6-month recovery process somewhere between “sort of” and “hugely” happy with the results, and with rare serious complications. This is borne out by the several evidence-based studies in the literature, and by my personal observations. There of course are occasional disappointments; you can’t make everyone happy, all of the time!
But one must understand that all of the evidence-based studies emanate from experienced surgeons. The “botched” procedures, which I like to term “Unintentional Avoidable Female Genital Mutilations” come as a rule at the hands of a “general Ob/Gyn who does his or her best to help her patient, but is not informed sufficiently to understand that LP, that Vaginal Reconstruction is an entirely different (and cosmetic) procedure than the one they learned in their 4 years of Ob/Gyn Residency, which includes neither instruction in plastic surgery technique, nor specific training in aesthetic LP and the type of vaginal reconstruction that improves “grip” and sexual satisfaction. Unsophisticated and medically-trusting women who do not do their “due diligence” to research experienced and specialized surgeons and simply go to their general Ob/Gyn are the fodder that specialized revision surgeons such as myself see for “clean-up” of poor outcomes. Sometimes this is possible, but involves recovery from two surgeries and sometimes all that can be done is work with the aesthetic dissatisfaction, psychosexual, and neurological/pain issues surrounding their far less-than-ideal outcome.
Both Cosmetic Gynecologists and Plastic Surgeons operate in the niche of women’s intimate surgery. I am humbled and honored to have participated in the ongoing history and practice of this subspecialty. Having seen it from the dawn, it is satisfying to now participate in National and International subspecialty meetings that draw hundreds, not the dozens we were happy to see in the early 2000’s. I teach at these meetings, but I always come away learning more than have taught, with a fire in my belly to try this new technique, to communicate with that patient I have just consulted with regarding perhaps a better way to meet her outcome ideal.
Fifty years as a Gynecologist. 25 years as an intimate female surgeon. It’s been a fine medical ride!