Prof Aboubakr Elnashar

1. CONTROVERSIES IN
AESTHETIC GYNECOLOGY
Prof. Aboubakr Elnashar
Benha university Hospital, Egypt
ABOUBAKR ELNASHAR

2. ABOUBAKR ELNASHAR
CONTENTS
 INTRODUCTION
1. DEFINITION
2. STATISTICS
3. CAUSES OF INCREASED DEMAND FOR FGCS
4. INDICATIONS
5. PROCEDURES
6. OUTCOMES
 CONTROVERSY
1. OPPONENTS
2. PROPONENTS
3. ETHICAL GUIDELINES

3.  Aesthetic Gynecology: Aes G
Alteration of anatomy
vaginal or labial: for
Aesthetic reasons (artistic& visual) or
Treatment of normal changes that occur throughout
the life span.
Cosmetic procedures
Non medically indicated:
Change the structure& appearance of
healthy vulva or vagina.
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4. FGM FGCS
1. Practice Condemned Requested
2. Conducted on Girls Adult women
3. Consent Against Mandatory
4. Objective False belief to
control female
sexuality
Improve their
appearance&
sexuality.
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5. 2013:
 In US:
 Labiaplasty was reported to be the 4th most
common cosmetic surgical procedure, rising by
44%.
 Following liposuction, breast augmentation, and rhinoplasty,
 Australia:
 3-fold increase in labiaplasties performed between
2003 and 2013
 UK:
 5-fold increase in these surgeries during the same period.
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6. CAUSES OF INCREASED DEMAND FOR AES G
1 Perception of ‘normal’ Vs ‘desirable’
‫والمرغوب‬ ‫طبيعي‬ ‫هو‬ ‫لما‬ ‫اﻻدراك‬
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7. 4. Lack of anatomy education throughout life
5. In some countries:
 Decreased cost & shame
 Increased ease of access to Aes G
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8.  Comparing 2017 to 2016 data.
 11% decrease in surgical procedures
 Increase in laser/nonsurgical interventions
(American Society for Aesthetic Plastic Surgery, 2018)
 This raised the question
 Whether surgical procedures is a passing
trend? (Placik et al, 2019)

9. INDICATIONS: Why do women seek Aes G?
1. Aesthetic reasons
 To reduce dissatisfaction associated with actual or
perceived abnormality of genital anatomy
2. Functional reasons:
 To reduce
 pain or interference with SI
 discomfort when exercising or wearing tight clothing
 To improve s. function or s. enhancement.
3. Psychological reasons: To address
 embarrassment, poor self-esteem, anxiety
 inhibition in relationships, or to be more 'normal'
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10. PERFORMED BY
 It is most commonly performed by:
1. Gynaecologists: 50%
2. Plastic surgeons: 30% (Placik et al, 2019)
3. GPs or non-specialist surgeons
(including dermatologists), with additional training in
cosmetic procedures
4. Urologists
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11. PROCEDURES
I. Vulvoplasty: Augmentation or more frequently,
reduction of the external female genitalia
 Labiaplasty: Augmentation or reduction of the labia
minora, or less commonly the labia majora
 Hymenoplasty or ‘revirgination: Restoration of the
intact hymen
 Clitoral hoodoplasty: Reduction of the clitoral hood
to expose the underlying clitoris
 Vulvar lipoplasty: Removal of fat from mons pubis.
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12. II. Vaginoplasty: Alteration of the internal female genitalia
 Surgical vaginal tightening
 Perineoplasty: Restoration of perineal length
 Laser Vaginal Rejuvenation: vaginal tightening
using laser therapy
 G-spot augmentation or amplifcation ('G-shot'®)
Autologous fat, collagen, or various filler injections
into a predetermined G-spot'
 Orgasm Shot ('O-Shot’®): Patient’s own blood
products are injected into the clitoris & upper vaginal wall
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13.  Surgical:
 Non-surgical
1. Energy-Based Procedures: use of
 Lasers or
 Radiofrequency (RF) energy
 US
2. Injection
 Botox
 PRP
 Filler
 Autologs fat
 Collagen ABOUBAKR ELNASHAR

14.  Wilkie et al, 2018
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15. ABOUBAKR ELNASHAR
Aesthetic
Genital
Surgery
OPPONENTS

16. Opponents Of Aes G
1. There is a wide range of normal genitalia:
surgery& rejuvenation procedures unnecessary
(Lloyd et al, 2005)
2. There are numerous marketing claims stating that
these procedures
 enhance sexual satisfaction
 treat both aesthetic& functional issues:
patients request surgery for the wrong
reasons (Braun, 2010)
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17. 3. These procedures are lucrative
patients pay out of cost for these procedures,
raising concerns about direct patient cost& provider
conflict (Lglesia, 2012)
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18. 4. A number of patients seeking Aes G are
 at risk of body dysmorphic disorder
(Recurrent obsessive ideas that a particular aspect of
their appearance is severely faulty)
should be treated, rather than proceeding with
Aes G (Higgins, Wysong, 2018)
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19. 5. The performance of some procedures can be
accepted in some instances
Others:
 No medical justification or biological
acceptability.
 Unethical (Pedro et al, 2018)
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20. 6. Protrusion of the labia minora’
 not a medical problem, but a cultural one.
 Therefore, the solution should be
 Cultural change
 Female -centred strategies that support body-
positivity for women, rather than surgery (Nurka,
2019)
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21. ABOUBAKR ELNASHAR
Aesthetic
Genital
Surgery
PROPONENTS

22. Proponents Of Aes G
1. We should maintain
 Patient autonomy for a woman requesting
surgery
 For reasons that she believes important to her,
even if severe anatomic pathology cannot be
exhibited (Cartwright, Cardozo, 2014)
‫الذاتي‬ ‫الحكم‬
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23. 2. One of the most basic human rights is
 right to self-choice & self-governance,
 Free from
 interference by others
 limitations (including inadequate education or
inability to speak for themselves) to making an
autonomous choice (Cain et al, 2013)
‫الذاتي‬ ‫الحكم‬
ABOUBAKR ELNASHAR

24. 3. A patient's desire for
 Symmetry
 Lack of functional restriction
 Improved sexual function& relationships
positive self-image
are reasonable concerns
it is difficult to argue with
what a patient believes as real or perceived
anatomical distortion.
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25. 4. As long as there is
proper preoperative counseling&
patients have realistic expectations about
outcomes,
they should be free to decide for Aes G.
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26. 5. The initial controversies over Aes G have almost
settled down
Evidence suggesting that a number of procedures are
 Safe
 Effective
 Capable of treating to a considerable extent the
conditions associated with life vulvo-vaginal
changes.
 Delivering What Women Want (Magon, Alinsod;
2018)
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27. ABOUBAKR ELNASHAR
6. Overall patient satisfaction rates: high(Goodman, 2008)
 Complications: 4% to 18% of women (Alter, 2008,
Goodman, 2010)

28. ETHICAL GUDELINES
 Evidence based
1. RCOG, 2013
2. SOGC, 2013
3. RANZCOG: Royal Australian& New Zealand College of
Obstetricians and Gynaecologists, 2011, 2015
4. FIGO: 2015
5. ACOG: 2007, 2013, 2017
6. ISSVD: International Society for the Study of Vulvovaginal
Disease, 2018
7. ISSVD & ICS, 2019
8. ACOG, 2020
 ALL state that
they cannot clearly support such surgery ethically.
(Goldstein, Jutrzonka, 2016)
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29.  All (Goldstein, Jutrzonka, 2016)
1.There is a need to exercise caution in providing
Aes G. The message is clear: there is inadequate
evidence to support the beneficial claims of Aes G.
2.The need for informed consent & lack of clear
evidence on which to base such consent.
3.The procedures are not medically indicated& are
not part of the training of gynecologists or plastic
surgeons during residency.
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30. 4. Conflict of interest and the veracity of web-based advertising.
5. Terms commonly used to advertise these procedures
are
 poorly understood
 marketing terms only
 Non-medical terms:
 Vaginal rejuvenation
 Clitoral resurfacing
 G-spot enhancement
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31.  RCOG Ethics Committee, 2013
1. Counseling
1. Normal variations of vulva
2. Body image distress
3. Risks
4. Lack of reliable evidence of postive effects
2. Written records of physical & mental health reasons for the procedure
3. Advertising should not mislead people on
 what is deemed to be normal or
 what is possible with surgey
4.FGCS should not be undertaken within the NHS
unless it is medically indicated
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32.  ACOG, 2017
 Minimal adequate long-term studies addressing
satisfaction, safety, and complication rates
 Use of fractional laser is not FDA approved for
gynecologic uses including vulvovaginal
atrophy or rejuvenation.
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33. ABOUBAKR ELNASHAR
II. FDA 2018:
 Not approved any energy-based device for vag cosmetic
improvement or TT of symptoms associated with the GMS.
 Neither the safety nor effectiveness of these devices for
treatment
 Warns against use of laser-type devices as their use
may result in serious adverse events
 Vaginal burns
 Scarring
 Dyspareunia
 Recurring/chronic pain

34. III. The International Society for the Study of Vulvovaginal
Disease, 2018
• We strongly recommend against
 G-spot augmentation
 Hymenoplasty
 Vulvar& perianal bleaching/whitening
 Any FGCS with the intention of enhancing sexual
function
{lack of evidence to demonstrate benefit in the literature}.
• Robust evidence to support the use of laser or
radiofrequency to treat vaginal atrophy or “vaginal laxity” is
lacking ABOUBAKR ELNASHAR

35. ABOUBAKR ELNASHAR
 The International Society for the Study of
Vulvovaginal Disease (ISSVD) and
International Continence Society (ICS) , 2019
 Based on the available scientific evidence, with no
supporting long term follow-up data:
 use of LASER should, at present, not be
recommended for TT of
 Vaginal atrophy
 Vulvodynia, or
 Lichen sclerosus.

36.  The data for the role of LASER for
 Stress urinary incontinence&
 Vaginal laxity are inadequate to draw any
conclusions or safe practice
recommendations.

37. ABOUBAKR ELNASHAR
 ACOG 2020
 Lack of
 Published studies
 Standardized nomenclature
 Outcomes: risks & benefits.
 Counseling:
 Effectiveness: lack of high-quality data that support
 Potential complications: pain, bleeding, infection,
scarring, adhesions, altered sensation, dyspareunia, and
need for reoperation.

38. ABOUBAKR ELNASHAR
 Gynecologists should have sufficient training to recognize
women with
 Sexual dysfunction
 Psychiatric conditions:
 depression, anxiety
 body dysmorphic disorder.
 referral for evaluation before surgery.
 Gynecologist: inform patients about outcomes
 Substantial risk
 Safety & effectiveness have not been established.

39. ABOUBAKR ELNASHAR
 NICE 2021.
 The evidence on TV laser therapy for SUI or
urogenital atrophy does not show any short-
term safety concerns.
 Evidence on long-term safety & efficacy is
inadequate in quality and quantity.
 Therefore, this procedure should only be used
in the context of research.

40. You can get this lecture and 480 lectures from:
1.My scientific page on Face book: Aboubakr
Elnashar Lectures.
https://www.facebook.com/groups/2277448840913
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2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthwara St. Mansura