Aesthetic and Functional Female Genital Surgery

Foreword
Foreword
Preface
Contents
About the Author
Part I: Introduction and General Instructions
1: Introduction to the Art of Aesthetic and Functional Female Genital Operations
1.1 Etymology and Terminology
1.2 Why Do Women Consult a Doctor?
1.3 Body Perception
1.4 Self-Esteem
1.5 Genital Area is the Mirror of the Patient
1.6 Aesthetic and Functional Genital Procedures Umbrella
1.7 Statistics
1.8 AGS Contraindications
1.9 Patient Selection and Surgery Planning
1.10 Female Circumcision
1.11 Types of Genital Mutilation in Women
1.12 History of Female Circumcision
Appendix
References
2: Should Aesthetic Genital Operations Be Done?
2.1 ACOG Declarations
2.2 FDA Warning
2.3 FDA Warning and a Review on Laser and Other Energy-Based Technologies
2.4 World Health Organization (WHO) Definition of “Health”
2.5 Patient Rights
2.6 Patient Perspective
2.6.1 Self-Esteem Issues
2.6.2 Being Ashamed, Avoiding Mutual Relations
2.6.3 Hygienic Problems
2.6.4 Protrusion while Wearing Trousers
2.6.5 Anatomical Defects and Dermatologic Pathologies
2.6.6 Vulvar Irritation
2.6.7 Functional Problems Due to Vaginal Relaxation
2.6.8 Dyspareunia
2.7 An Example of Legal Aspects: “Artwork Contract” in Turkey
2.8 Aesthetic Treatment Contracts and Legal Qualifications
2.9 Medical Ethical Aspect
2.9.1 Autonomy
2.9.2 First, Do No Harm (Non-maleficence)
2.9.3 Benefit (Beneficence)
2.9.4 Being Fair (Justice)
Appendix
References
3: Ideal Vulva Concept and Anatomic Structures
3.1 Reasons for Applying to a Physician for AGS
3.2 Anatomical Structures and their Place in Cosmetic Gynecology
3.2.1 Mons Pubis (Mons Veneris)
3.3 Labium Majus Pudendi
3.4 Labium Minus Pudendi
3.4.1 Labial Blood Circulation
3.4.2 Labial Morphology
3.4.3 Labial and Clitoral Dominance
3.4.4 Labial Asymmetry
3.4.5 Labial Protrusion
3.5 Vulvar Vestibulum
3.6 Clitoris
3.7 Hymen
3.7.1 Hymenoplasty
3.7.2 Excision of Hymen Protrusions
3.7.3 Painful Hymen (Eserdag)
3.8 G-Spot
3.9 Innervation and Vascularization of the Vulva
3.10 Normal Vulva Measurements
3.11 Vaginal Anatomy and Histology
3.12 Mucosal Layer (Superficial Layer)
3.13 Muscular Layer (Second Layer)
3.14 Adventitia Layer (Tunica Fibrosa, Deeper Layer)
3.15 Pelvic Floor Muscles
3.16 Perineal Body
3.17 Derivatives of Embryological Structures
Appendix
References
4: Skin Histology and Physiology
4.1 Layers of Skin
4.2 Epidermis
4.2.1 Stratum Basale (Stratum Germinosum)
4.2.2 Stratum Spinosum
4.2.3 Stratum Granulosum
4.2.4 Stratum Corneum (Keratin Layer)
4.3 Dermis (Cutis)
4.3.1 Superficial Dermis (Papillary Dermis)
4.3.2 Deep Dermis (Reticular Dermis)
4.4 Hypodermis (Subcutaneous Tissue, Subcutis)
4.5 Skin Pathologies
4.6 How Does Skin Color Occur?
4.6.1 Melanocyte Structure
Appendix
References
5: Vulvar Lichen Sclerosus
5.1 Epidemiology
5.2 Symptoms
5.3 Etiology
5.3.1 Autoimmunity, Molecular Mechanisms, and Genetic Factors
5.3.2 Infections
5.3.3 Hormonal Effects
5.3.4 Local Factors
5.4 Diagnosis
5.5 Histopathology
5.6 Pediatric Vulvar Lichen Sclerosus
5.7 Differential Diagnosis
5.8 Differences Between Lichen Sclerosis and Other Lichen Diseases
5.9 Management
5.9.1 Medical Treatments
5.9.2 Topical Treatments
5.10 Other Topical Treatments
5.11 Systemic Treatments
5.12 Surgical Treatments
5.13 New Approaches in the Treatment of Vulvar Lichen Sclerosus
5.14 Prognosis
Appendix
References
6: Physiology of Wound Healing
6.1 Phases of Wound Healing
6.1.1 Hemostasis/Inflammation Phase
6.1.2 Proliferation Phase
6.1.3 Maturation (Remodeling) Phase
6.2 Factors That Negatively Affect Wound Healing
6.2.1 Lack of Oxygenation
6.2.2 Development of Hematoma and Seroma
6.2.3 Development of Infection
6.2.4 Surgical Technique Defects
6.2.5 Advanced Age
6.2.6 Poor Diet
6.2.7 Smoking and Alcohol Intake
6.2.8 Poor Postoperative Care
6.2.9 Medication Use
6.2.10 Chronic Diseases
6.2.11 Pain
6.3 Wound Complications
6.3.1 Bleeding
6.3.2 Infection
6.3.3 Wound Dehiscence
6.3.4 Excessive Wound Healing
Appendix
References
7: Preoperative Evaluation and Patient Selection
7.1 Preoperative Evaluation Stages
7.1.1 Detailed Anamnesis
7.1.2 Gynecological Examination
7.1.3 Planning the Surgery and the Following Process
7.2 Photographs and Archiving
7.2.1 Important Issues to Consider When Taking Photos
7.3 Body Dysmorphic Disorder (BDD)
Appendix
References
8: Instrumentation, Set-Up, and Anesthesia
8.1 Tools and Devices Used
8.2 Suture Materials and Needles
8.2.1 Polyfilament (Braided) Sutures
8.2.2 Barbed Sutures
8.2.3 Monofilament (Non-braided) Sutures
8.2.4 Needles
8.3 Marking
8.4 AGS Anesthesia
8.4.1 Surgery at Office Conditions
8.4.1.1 Local Anesthesia Applications
Duration of Numbness
Drug Reactions
Local Anesthetic Toxicity
Local Anesthetic Allergy
8.4.1.2 Tumescent Anesthesia
8.4.1.3 Pudendal Block
How Is a Pudendal Block Performed? RCOG Recommendations
Office Premedication
8.4.2 Surgery at the Hospital
8.4.2.1 Sedation
8.4.2.2 General and Regional Anesthesia Methods
Appendix
References
Part II: Surgical Operations in the Art of Aesthetic Genital Surgery
9: Labiaplasty
9.1 Labiaplasty Indications
9.2 Labial Hypertrophy
9.3 Labial Asymmetry
9.3.1 Labial Asymmetry Classification (Eserdag)
9.4 Other Psychological Causes
9.5 Operation Principles
9.6 Historical Background
9.7 Labiaplasty Techniques
9.7.1 Curvilinear Excision
9.7.2 Wedge Resection (V-Plasty)
9.7.3 Extended Central Wedge Resection
9.7.4 Bilateral De-epithelialization
9.7.5 Zigzag Technique
9.7.6 Modified Double Wedge Resection (Star Labiaplasty)
9.7.7 Laser Labiaplasty
9.8 Labiaplasty According to Patient Expectations: “Queens, Princesses, and Venuses” (Eserdag)
9.8.1 Queens
9.8.2 Princesses
9.8.3 Venuses
9.9 Eserdag ‘Venus Vagina’ Aesthetics Concept
9.10 Office Labiaplasty
9.11 Combined Procedures
9.12 Botched Labiaplasty and Revision Surgeries
9.13 Neolabiaplasty (Eserdag)
9.14 Common Complaints After the Operation
9.14.1 Vasovagal Reflex
9.14.2 Bleeding
9.14.3 Pain
9.14.4 Itching
9.14.5 Edema
9.15 Complications
9.15.1 Acute Term
9.15.2 Subacute Term
9.15.3 Chronic Term
9.16 Vulvar Hematoma and Management
9.16.1 Approaches in Hematoma
9.16.1.1 Passive Management
9.16.1.2 Active Management
9.17 The Postoperative Term
9.18 Long-Term Results
9.19 Postoperation Psychological Effects
Appendix
References
10: Clitoral Hoodoplasty and Frenulaplasty
10.1 Why Is Hoodoplasty Required?
10.2 Isolated Hoodoplasty
10.3 Classification and Management of Clitoral Hood Abnormalities
10.4 Hoodoplasty Techniques
10.4.1 Bilateral Longitudinal Skin Excisions (Classical Method)
10.4.2 Inverted V-Plasty and Extended Central Wedge Resection
10.4.3 Hydrodissection with Inverted V-Plasty
10.4.4 Inverted-Y Plasty (Eserdag Technique)
10.4.5 Inverted-U Extended Hoodoplasty (Eserdag)
10.4.6 Hat Trimming (Eserdag)
10.4.7 Subepithelial Hoodoplasty
10.4.8 Edge-Wedge Labiaplasty (Edge-Wedge Technique)
10.5 Complications
10.6 The Postoperative Term
10.7 Clitoromegaly
10.8 Clitoral Protrusion
10.9 Frenulaplasty
Appendix
References
11: Vaginoplasty
11.1 Ideal Vagina Concept
11.2 Juicy Vagina Syndrome (Eserdag)
11.3 Vaginal Wind (Flatus Vaginalis, Queef)
11.4 Vaginal Gaping
11.5 Lost Penis Syndrome
11.6 Vaginal Relaxation Syndrome (VRS)
11.7 Surgical Vaginoplasty Techniques
11.7.1 Posterior Colporrhaphy Technique (Posterior Vaginoplasty)
11.8 Surgical Results
11.9 Combined Procedures
11.10 Common Complaints After the Operation
11.10.1 Vasovagal Reflex
11.10.2 Bleeding
11.10.3 Pain
11.10.4 Itching
11.10.5 Edema
11.11 Complications
11.11.1 Acute Term
11.11.2 Subacute Term
11.11.3 Chronic Term
11.12 The Postoperative Term
11.13 Vaginoplasty Revision Surgery
11.14 Neovaginoplasty Due to Vaginal Aplasia
11.14.1 Management
11.14.1.1 Non-surgical Methods
11.14.1.2 Surgical Methods
Appendix
References
12: Perineoplasty
12.1 Perineoplasty Indications
12.1.1 Perineal Traumas
12.2 Perineoplasty Techniques
12.2.1 Diamond-Shaped Excision
12.2.2 Elliptical Excision (Episiotomy Scar Revision)
12.2.3 Triangle-Shaped Excision
12.2.4 Z-Plasty
12.3 Atrophic Scar Treatments
12.4 Perineal Hernias
12.5 Perineal Granuloma Fissuratum
12.6 Complications
12.7 The Postoperative Term
12.8 Perianal Aesthetics
Appendix
References
13: Labia Majoraplasty
13.1 Vulvar Laxity
13.2 Primary Hypertrophy
13.3 Secondary Hypertrophy
13.4 Labia Majoraplasty Surgical Techniques
13.4.1 Elliptical Excision
13.4.2 Horseshoe Excision
13.4.3 Teardrop Incision (Eserdag)
13.5 Majoraplasty with Adipose Tissue Excision (Fat Pad Debulking)
13.6 Combined Procedures
13.7 Complications
13.7.1 Acute Term
13.7.2 Subacute Term
13.7.3 Chronic Term
13.8 The Postoperative Term
Appendix
References
14: Labia Majora Augmentation Via Fat Transfer and Monsplasty
14.1 Historical Background
14.2 Labia Majora Fat Graft Indications
14.3 Methods
14.3.1 Fat Harvesting (Lipoaspiration)
14.3.2 Fat Processing
14.3.3 Lipofilling
14.4 Combined Procedures
14.5 Fat Transfer to Different Regions
14.6 Operation Success
14.7 Complications
14.8 The Postoperative Term
14.9 Monsplasty
14.10 Mons Reduction Methods
14.11 Surgical Methods
14.12 The Postoperative Term
Appendix
References
15: Hymenoplasty
15.1 Hymenoplasty Techniques
15.1.1 Long-term Operations
15.1.1.1 Vestibulo-Introital Tightening Technique (VITT, Eserdag)
15.1.1.2 Luminal Reduction Hymenoplasty
15.1.1.3 Flap Operation
15.1.1.4 Septum Repair
15.1.2 Short-term Operations
15.2 Psychological Influences
15.3 Combined Procedures
15.4 Complications
15.5 The Postoperative Term
Appendix
References
Part III: Non-surgical Operations in the Art of Aesthetic Genital Surgery
16: Vaginal Laser Applications
16.1 Laser Physics
16.2 Laser Parameters
16.2.1 Wavelength
16.2.2 Distance
16.2.3 Overlap (Stack)
16.2.4 Moving Time
16.2.5 Energy
16.2.6 Power
16.2.7 Energy Current (Fluence)
16.2.8 Energy Density (Irradiance)
16.2.9 Spot Size (Beam diameter)
16.2.10 Pulse Duration
16.2.11 Thermal Relaxation Time
16.3 Properties of Laser Light
16.3.1 Collimation (Alignment in One Direction)
16.3.2 Coherence
16.3.3 Reflection, Transmission, and Absorption Properties
16.4 Which Laser Should Be Used in Which Indication?
16.5 Lasers in Gynecology
16.5.1 Carbon Dioxide Lasers
16.5.2 Er:YAG (Erbium:YAG) Lasers
16.6 Laser Indications: Use in Gynecology and Dermatology
16.7 Vaginal Laser Contraindications
16.8 Preparation
16.9 Laser Applications for Vaginal Rejuvenation
16.10 Steps of Laser Vaginal Rejuvenation (LVR) Procedure
16.11 Application Protocol
16.12 Some Laser Devices on the Market
16.13 Laser Applications for Stress Urinary Incontinence (SUI) Treatment
16.14 Laser Applications in Menopausal Genitourinary Syndrome (GSM)
16.15 Laser for Symptomatic Treatment of Lichen Sclerosus
16.16 Post-Laser Histological Changes
16.16.1 Inflammation Phase
16.16.2 Proliferation Phase
16.16.3 Maturation Phase
16.17 Collagen Structure and Types
16.17.1 Collagen Types
16.18 Comparison of Laser and Surgical Tightening Operations
16.19 Survey Studies and Scientific Data
16.20 Scientific Data
16.21 Combined Procedures
16.22 Complications
16.23 The Post-Procedure Term
Appendix
References
17: Genital Bleaching Treatments
17.1 Skin Color Types
17.2 Causes of Hyperpigmentation
17.3 Hyperpigmentation Treatments
17.3.1 Treatment Protocol
17.4 Lasers with Q-switched Technique
17.5 Post-procedure Term
17.6 Contraindications
17.7 Complications
17.8 Postinflammatory Hyperpigmentation (PIH)
17.9 Other Methods Applied in Bleaching Treatment
17.9.1 Trichloroacetic Acid (TCA)
17.9.2 Different Chemical Agents
17.9.3 Ready-to-Use Solutions
17.9.4 Injectable Mesotherapy Preparations
17.9.5 Dermabrasion: Microdermabrasion
17.9.6 PRP
Appendix
References
18: Genital Radiofrequency Applications
18.1 Increasing Trend in Vaginal Rejuvenation
18.2 Radiofrequency (RF) Technology
18.3 Mechanism of Action
18.4 Indications for Use in Gynecology and Dermatology
18.5 Some RF Devices on the Market
18.6 Genital RF Contraindications
18.7 Preparation
18.8 Performing Genital RF Treatments
18.9 Effects on Orgasmic Function
18.10 Histological Studies
18.11 Combined Procedures
18.12 Complications
18.13 Post-procedure Term
Appendix
References
19: G-Spot Augmentation by Hyaluronic Acid
19.1 Historical Background
19.2 Scientific Data
19.3 Conflicting Thoughts
19.4 G-Spot Dermal Filler Injections
19.5 G-Spot Augmentation Indications
19.6 Contraindications
19.7 How is G-spot Augmentation Performed?
19.8 Complications
19.9 Post-Procedure Term
Appendix
References
Part IV: Regenerative Treatments
20: Hyaluronic Acid Applications to Genital Area
20.1 Where Is Hyaluronic Acid (HA) Found?
20.2 Historical Background
20.3 Obtaining of HA
20.4 Indications of HA in Cosmetic Dermatology
20.5 FDA Declaration on Dermal Fillers (2020)
20.6 Applications in Genital Area
20.7 Use of HA in Gynecology
20.7.1 Functional Purposes
20.7.1.1 Vaginal Dryness Treatment
20.7.1.2 Vulvar Vestibulitis Treatment
20.7.1.3 G-spot Injection
20.7.1.4 Perineal Lifting
20.7.1.5 Perineal Scar Treatments
20.7.2 Aesthetic Purposes
20.7.2.1 Correcting Labium Majus Hypotonicity and Hypotrophy
20.8 HA Application Techniques
20.8.1 Linear Threading Technique
20.8.2 Point-by-Point Application (Serial Puncture) Technique
20.8.3 Fanning Technique
20.8.4 Cross-Hatching (Cross Radial) Technique
20.9 Some Fillers in the Market
20.10 HA Filler Applications for Labia Majora Augmentation
20.11 Vaginal and Vestibular HA
20.11.1 Fillers
20.11.2 Features in HA Selection: HA Rheology
20.11.3 Contraindications
20.11.4 Comparison with Autologous Fat Transfer
20.11.5 Combined Therapies
20.11.6 Complications and Undesirable Effects
20.11.7 Hyaluronidase Enzyme
20.11.8 Post-procedure Term
20.12 Different Tissue Fillers
20.12.1 Absorbable (Temporary) Materials
20.12.1.1 Collagen
20.12.1.2 Calcium Hydroxyapatite
20.12.1.3 Poly-L-Lactic Acid (PLLA)
20.12.2 Non-absorbable (Permanent) Materials
20.12.2.1 Polymethylmethacrylate (PMMA Microspheres)
Appendix
References
21: Genital PRP, PRF, and ACRS
21.1 What is the Platelet-Rich Plasma (PRP) Procedure?
21.2 Platelet-Rich Fibrin (PRF)
21.2.1 What is Platelet-Rich Fibrin (PRF)?
21.2.2 Comparison with PRP
21.2.3 How to Prepare PRF?
21.3 Autologous Cytokine-Rich Serum (ACRS)
21.3.1 How to Prepare Autologous Cytokine-Rich Serum?
21.3.2 Action of Mechanism
21.3.3 Difference from the PRP
21.3.4 Possible Indications
21.4 Platelet Structure
21.5 Platelets in the Wound Healing Process
21.6 Growth Factors (GF)
21.7 How to Prepare PRP?
21.8 Post-Centrifuge Values
21.9 Different Medical Applications of PRP
21.10 Use of PRP in Cosmetic Dermatology
21.11 Indications of PRP in Cosmetic Gynecology
21.11.1 Treatments for Functional Purpose
21.11.1.1 Sexual Pleasure Treatments
21.11.1.2 Menopausal Genitourinary Syndrome (GSM)
21.11.1.3 Lichen Sclerosus Treatment
21.11.1.4 Other Indications
21.11.2 Treatments for Aesthetic Purpose
21.11.2.1 Labium Majus Rejuvenation
21.11.2.2 Episiotomy Scar Treatment
21.12 Different Indications of PRP in Gynecology
21.13 PRP Contraindications
21.14 Combined Therapies
21.15 Complications
21.16 Post-procedure Term
Appendix
References
22: Carboxytherapy
22.1 Mechanism
22.2 Cosmetic and Dermatologic Indications
22.2.1 Stretch Marks
22.2.2 Cellulite and Local Adiposity Treatment
22.2.3 Face Rejuvenation
22.2.4 Psoriasis
22.2.5 Alopecia
22.3 Genital Indications
22.3.1 Genitourinary Syndrome of Menopause (GSM)
22.3.2 Mons Pubis Reduction
22.3.3 Vulvar Rejuvenation and Lichen Sclerosus Treatment
22.4 Other Indications
22.4.1 Adverse Events
22.4.2 Combined Treatments
22.4.3 Post-procedure Term
Appendix
References
23: Regenerative Medicine
23.1 Regenerative Medicine Fields
23.2 Autologous Fat Treatments
23.2.1 Macrofat Transfer
23.2.2 Microfat Transfer
23.2.3 SEFFI (Superficial Enhanced Fluid Fat Injection) Transfer
23.2.4 M-SEFFI (Micro-SEFFI) Transfer
23.2.5 Nanofat Transfer
23.2.6 SVF Transfer
23.2.7 Alternative Techniques
23.3 Exosomes
Appendix
References
Patient Consent Forms
Patient Consent Form for Female External Genital Organ Cosmetic Plastic Surgery (Vulvoplasty, Labiaplasty Operations)
Information About Genital Lip Aesthetics (Labiaplasty Operation)
Alternative Treatments
Drugs You Use and Its Important Features
Risks and Complications
Information About the Probability of Success of the Process
Critical Lifestyle Suggestions for Your Health and Your Home Care
Informed Consent
Patient Consent Form for Vaginal Tightening and Reconstruction Operations (Colporrhaphy Surgery)
Information About Vagina Tightening Operations
Alternative Treatments
Drugs to Be Used and Its Important Properties
Risks And Complications
Information About the Probability of Success of the Process
Critical Lifestyle Suggestions for Your Health and Your Home Care
Informed Consent
Patient Consent Form for Fat Injections to the Genital Region
Information About Fat Injection to the Genital Area
Alternative Treatments
Drugs to Be Used and Their Important Properties
Risks and Complications
Information About the Probability of Success of the Process
Critical Lifestyle Suggestions for Your Health and Your Home Care
Informed Consent
Patient Consent Form for Laser Vaginal Rejuvenation, Non-surgical Vaginal Tigtening, and Stress Urinary Incontinence Treatments
Detailed Information
Informed Consent
Patient Consent Form for Genital Filler Applications
General Information
Informed Consent
Important Issues to Be Considered Before Application
Side Effects That May Occur After Filler Application
Important Issues to Consider After Application
Consent Form for Laser Genital Bleaching Treatments
General Information
Consent
Important Issues to Be Considered Before Application
Side Effects That May Develop After the Bleaching Process
Important Issues to Be Considered After Application