The language relating to the upgrades available involving female vaginal appearance and function can be confusing. So many descriptive terms exist. Vaginoplasty. Perineoplasty. Vaginal tightening. Vaginal Rejuvenation. Vaginal Reconstruction. What’s what, and how do these terms compare and differ? Equally important to know, what is the difference in applicability and outcome comparing surgical with non-surgical approaches designed to “reconstruct” the vagina? What exactly is indicated in order to achieve each woman’s ultimate goal?
The answers to these questions don’t have to be complicated, and I will not make it so. The vagina is composed of:
- a superficial skin layer called the mucosa
- a tough slightly stretchable fibrous layer called the recto-vaginal fascia
- loose, airy areolar tissue under the fascia and mucosa ,and
- an underlying bastion of muscular bundles called the levator muscles (or levators), all backed by the bony pelvis
The superficial layer of vaginal skin (the mucosa) may be stretched or scarred by the ravages and tears caused by childbirth. It is always healing itself, but undergoing traumatic scarring and thinning. Initially comprised of healthy accordion-like folding (called rugae), with childbirth damage, age, and especially the waning of the estrogen that the vaginal mucosa is dependent upon, this skin can become thin, smooth, and less stretchable.
Far more important are the underlying structures which support the vagina, giving it its structure and tone. Without a strong muscular layer supporting the mucosa, an intact fibrous layer underlying the mucosa, a strong, muscular, and an intact perineal body at the opening of the vagina, rejuvenation of the skin of the opening or the inside is little more than applying a Band-Aid.
There are mitigating factors. Women’s vaginas come in an array of sizes and contours; there may be more space in one woman’s pre-baby vagina than another’s. Babies come in different sizes and assume different angles as they descend the birth canal. The forces of labor and the necessity for operative vaginal delivery (suction cup, forceps, etc.) and the length of the pushing phase of labor all have their individual effects on the post-partum condition of an individual vagina. For those with male partners, penises come in a wide array of lengths, thicknesses, and degree and longevity of turgor (stiffness). These factors need inclusion when designing the best procedure for an individual woman.
The term vaginal rejuvenation was first used in the early 2000s by one of the fathers of genital aesthetics, Dr. David Matlock, M.D. Dr. Matlock utilized a laser fiber as his cutting tool when he was surgically reconstructing a patient’s vagina and was the first to coin the term vaginal rejuvenation, referring to a surgical reconstruction of the vaginal/pelvic floor for the purposes of tightening, re-building, and better functional and aesthetic appearance. Unfortunately, this original term has been co-opted to include the placement of various radiofrequency or laser wands into the vagina to recondition the mucosal skin layer, with no surgical component.
Non-invasive (non-surgical) Vaginal Rejuvenation (VRJ) is not vaginal reconstruction. It is, literally, vaginal skin resurfacing. These procedures may be performed by practitioners not trained or experienced in true vaginal floor surgical reconstruction so long as they understand how to place the wand in the vagina, how to utilize proper power settings, and how to step on a foot switch. Both radiofrequency (RF) and laser treatments require a total of three visits, a month apart, for full effect. These modalities act to stimulate the generative layer of vaginal skin (the dermis) to regenerate more collagen and elastin connective tissue for modestly improve springiness of vaginal skin for a limited (~ 6-12 months) length of time. No reconstruction is involved with the wand-type VRJ options. For pre-menopausal patients interested in increased vaginal tone/vaginal tightening, these treatments must be repeated (~ 3 visits annually) for ongoing modest effect. The cost for the 3-visit series may range between $2,000-$3000 annually. The 10-year cost for so-called non-invasive VRJ is about $25,000. In the end, the patient interested in vaginal tightening is really no better off than she was at the beginning but is $25,000 poorer. RF or fractional CO2 laser wands are FDA-approved for resurfacing vaginal skin in post-menopausal women as an adjunct to (or substitute for) intra-vaginal estrogen or DHEA to rejuvenate or loosen the vagina of post-menopausal women with tight, atrophic vaginas. In this case, the term rejuvenation is accurate. This rejuvenation in no way refers to ongoing help for women with vaginal laxity secondary to either nature (a big vagina) or childbirth injury.
A true vaginal reconstruction includes the surgical procedures of vaginoplasty, perineoplasty, and something called a posterior repair or posterior colporrhaphy, a procedure usually performed as part of a surgical vaginoplasty, whereby the hernia bulge of a woman’s rectum upwards into the vagina (caused by weakness and separation of the levator muscles) is corrected. A vaginoplasty is a combination of surgically bringing the widely separated levator (Kegel’s) muscles back together (aka levatorplasty), reconstructing the rectocele hernia, and reconstructing the stretched-out fascial layer. A true perineoplasty (PP) involves much more than simply revising the appearance of the vaginal opening (the type of perineoplasty often performed by plastic surgeons). In the hands of a properly trained cosmetic gynecological or urogynecological surgeon, a PP involves a meticulous removal of all of the scar tissue from an episiotomy or lacerations from childbirth. The procedure uses strategically placed strong sutures to bring together the stretched muscles of the outermost portion of the vagina, the vaginal opening, and the perineal body (the area of the opening and vulvar vestibule), along with a meticulous aesthetic reconstruction of the appearance of the vaginal opening including the base of the labia, hymenal ring, and vulvar vestibule. Laser or RF wands do none of this.
The purpose of vaginal reconstruction is improvement in sexual function and pleasure, as well as improved self-confidence from an improved, less wide-open appearance of the vaginal opening. By reconstructing the vaginal/pelvic floor in such a fashion, the penis (or fingers, toys, or other item) is pushed more snugly upward against the internal clitoris and G-spot for increased friction and sexual pleasure.