Labia Majora Augmentation with Hyaluronic Acid Filler: Technique and Results

Efficacy and Tolerability of a Hyaluronic Acid-Based Extracellular Matrix for Labia Majora Rejuvenation and Augmentation: A Pilot Study

A new injectable solution containing low-molecular-weight hyaluronic acid (HA) and a specific amino acid mixture was formulated with proper aesthetic performance for the main signs of facial skin photoaging. The present study aimed to investigate its new application for rejuvenating and augmenting labia majora using clinical and biometric assessments. Three sessions of intradermal injections were performed using 3 ml of test extracellular matrix (ECM) for 10 eligible post-menopause female subjects (age 53.6 ± 7.93 years). The effectiveness of the intervention was assessed by an independent physician using before-and-after pictures based on the physician's global assessment score. Objective biophysical skin assessments, including skin hydration, skin erythema, and melanin index, as well as elasticity parameters including firmness (R0), gross elasticity (R2), and net elasticity (R5), were also performed before the first injection and then on the 2nd and 12th weeks after the last session. Patients' satisfaction and all reported or observed adverse events were documented. At week 12, all the subjects reported an aesthetic improvement of 25% or more in rejuvenation and sagging of the labia major area. A statistically significant improvement was also detected in R0 and R5 at week 12 (p-values 0.005 and 0.022, respectively). Patient satisfaction surveys revealed a median score of 8 at both follow-up visits. The results showed a new indication of the tested HA ECM for providing a beneficial, durable, rejuvenating effect on the labia majora with a good safety profile.

Treatment of Atrophy of the Labia Majora: Calcium Hydroxyapatite or Hyaluronic Acid?

PURPOSE

The study aimed to evaluate and compare the efficacy and safety of treating atrophied labia majora with hyaluronic acid (HA) and calcium hydroxyapatite (CaHA).

METHODS

Ten participants complaining of sagging or loss of volume in the labia majora were evaluated and randomly assigned to two groups-treated with CaHA or AH. Photographic documentation was taken and appreciated by the participants and by blind observers.

RESULTS

The study showed an improvement in labia majora regarding volumization and flaccidity that was more significant after 90 days of treatment in both treatments. Besides flaccidity, volume replacement resulted in better balance and proportion between the labia majora and labia minora. The evaluators, independent and blind, judged that in 80% of the cases of the HA group and in 50% of cases of the CaHA group, there was an excellent improvement.

CONCLUSION

CaHA and HA are both effective and safe for treating the intimate region, and this study cannot prove the superiority of one over the other. An appropriate assessment involving the analysis of sagging and/or volume loss and the creation of a sequential treatment protocol, involving CaHA and HA, seems to be the best solution.

LEVEL OF EVIDENCE I

Evidence obtained from at least one properly designed randomized controlled trial. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Efficacy of injecting hybrid cooperative complexes of hyaluronic acid for the treatment of vulvar lichen sclerosus: A preliminary study

BACKGROUND

Lichen sclerosus is a chronic relapsing inflammatory skin disease, which involves most commonly the anogenital region. The gold standard in treatment is ultra-potent topical steroids (clobetasol propionate): it aims at controlling the symptoms, stopping further scarring and distortion, and reducing the risk of cancer.

OBJECTIVES

The aim of this preliminary study is to evaluate the efficacy of injecting Hybrid Cooperative Complexes of Hyaluronic Acid (HCC) for the treatment of vulvar lichen sclerosus (VLS).

METHODS

Twenty female adult patients (range: 21-78 years), aged over 18, with histopathological diagnosis of lichen sclerosus and good general conditions were enrolled. Patients underwent HCC infiltration every month, for 3 times. Patients were evaluated at baseline (T0) and after one (T1) and six months (T2) after treatment. During every visit, each patient was studied clinically and with videothermography. Itching, burning sensation, pain, and dyspareunia were reported by patients at T0, T1, and T2. The effectiveness of the treatment on patients' quality of life and sexual function was evaluated using the Dermatology Life Quality Index (DLQI) and the Female Sexual Function Index (FSFI) at T0 and at T2.

RESULTS

The results of this preliminary study are very promising, in fact, all patients had a significant reduction in most symptoms after 1 and 6 months of HCC treatment. The reduction of patients with itching (p value ≤ 0.001), pain (p value = 0.031), and burning sensation (p = 0.004) at 6 months is significant. The analysis of DLQI scores revealed a significant improvement in patients' quality of life. At baseline, the average score of DLQI (±SD) was 5.89 ± 3.68 while at follow-up it was 3.42 ± 2.36 (p = 0.002).

CONCLUSIONS

Our preliminary study has demonstrated the validity and tolerability of HCC infiltrations in patients with VLS, and the effectiveness of HCC in reducing symptoms and, thus, to improve sexuality and patient quality of life.

Hyaluronic Acid and Radiofrequency in Patients with Urogenital Atrophy and Vaginal Laxity

Vaginal laxity (VL) and genitourinary syndrome of menopause (GSM), as well as aesthetic changes in the vulvar skin, often occur together and cause physical, psychological, and functional problems for women and their partners. The current study evaluated the efficacy of a nonsurgical radiofrequency device (RF) procedure combined with hyaluronic acid (HA) injection into the skin of the labia majora on clinical, histological, and aesthetic levels. Twenty women with GSM and VL, aged between 36 and 72 (mean age 53.4), were treated with bipolar RF SECTUM, vaginal and vulvar application, as well as with a hyaluronic acid (HA) injection into the skin of the labia majora. The Vaginal Laxity Questionnaire (VLQ), Vaginal Health Index (VHI), and Female Sexual Function Index (FSFI) were used to examine the clinical effects of the operations. The Global Aesthetic Improvement Scale was utilized to measure patient satisfaction. On a histochemical level, the concentrations of elastin and collagen in the vaginal wall and vulvar skin were examined. Results: There was significantly higher patient satisfaction and a considerable clinical improvement across all areas of analysis. On the histochemical level, elastin and collagen fiber concentration increased after the treatment protocol both in the vulvar skin and in the vaginal wall: elastin in the vaginal wall, 11.4%, and in the vulvar skin, 61%; collagen in the vaginal wall, 26%, and in the vulvar skin, 27%. The current study demonstrated the efficacy and safety of this nonsurgical RF procedure combined with a hyaluronic acid (HA) injection into the skin of the labia majora on clinical, histochemical, and aesthetic levels.

Filler-induced non-thrombotic pulmonary embolism after genital aesthetic injection

Genital aesthetic procedures have increased in popularity among women and men. Many clinicians tried to expand the application of fill injection by using it for genital aesthetic injection. However, this procedure is not so safe as imagined and may lead to a fatal complication of pulmonary embolism. This article summarizes the clinical manifestations and proposed mechanism of the filler-induced non-thrombotic pulmonary embolism (FINTPE) cases. A literature review was performed with the search keywords including "genital aesthetic injection, vaginal injection, vaginoplasty, vaginal tightening, penile augmentation, penis injection, hyaluronic acid, fat grafting, pulmonary embolism, alveolar hemorrhage, hypoxemia, and dyspnea." Among the 14 cases from 11 articles enrolled, 12 patients were female, and two were male. Eight patients received silicone injection, followed by two received fat grafting and hyaluronic acid injection, respectively. All the female patients had one single injection site, including 11 cases for the vaginal wall and one for G-spot, while all the male patients received injections into the penis and scrotum. The main symptoms were dyspnea and chest pain. Almost 60% of FINTPE patients presented respiratory disorders within 12 hours post-operation. Treatment includes oxygen therapy, corticosteroids, and anticoagulation. Five patients improved with an average of 14.6-day treatment, and seven died due to organ failures. Genital aesthetic filler injections are experimental procedures without being strictly reviewed or approved. As a severe complication following these procedures, FINTPE requires cautious performance, careful prevention, timely identification, and treatment to decrease its incidence and mortality.

Migrated Bulking Material (Solesta) Presenting as a Vaginal "Cyst": Histopathologic and Chemical Analytical Features

Performing injections with a bulking agent consisting of nonanimal stabilized hyaluronic acid and dextranomer is a well-tolerated and efficacious treatment for mild to moderate fecal incontinence. Here, we discuss a case of a patient with a history of a bulking procedure for fecal incontinence who presented to the obstetrics/gynecology clinic for evaluation of a new vaginal "cyst," which was excised. Histopathologic examination revealed migrated bulking agent within the excised specimen.

Joint Report on Terminology for Cosmetic Gynecology

INTRODUCTION AND HYPOTHESIS

The current terminology used to describe cosmetic gynecologic procedures includes many nondescriptive, trademarked, or informal names, which contributes to substantial ambiguity about their aims and specific techniques. The development of clear, uniform descriptive terminology for cosmetic gynecology is needed for patients, researchers, and practitioners across multiple specialties.

METHODS

This document was developed from a collaboration of selected members from the International Urogynecological Association (IUGA) and the American Urogynecologic Society (AUGS). Wide-ranging literature reviews were performed to identify the breadth of currently used terms and tools for measuring efficacy and safety. After extensive internal review the adoption of each definition was ratified by group consensus.

RESULTS

A terminology report for elective cosmetic gynecology procedures, anatomical classification, outcome metrics, and reporting of complications has been developed. This document seeks to provide clear descriptive guidance for patients, researchers, and practitioners across multiple specialties. This document will be subject to internal review by IUGA and AUGS to incorporate and adopt evidence-based changes in the field.

CONCLUSIONS

A consensus-based document establishing clear terminology for cosmetic gynecology procedures has been created. Use of these terms should be encouraged to provide clarity to patients seeking these procedures and to facilitate future research to establish the safety and efficacy of these procedures.

Joint Report on Terminology for Cosmetic Gynecology

INTRODUCTION AND HYPOTHESIS

The current terminology used to describe cosmetic gynecologic procedures includes many nondescriptive, trademarked, or informal names, which contributes to substantial ambiguity about their aims and specific techniques. The development of clear, uniform descriptive terminology for cosmetic gynecology is needed for patients, researchers, and practitioners across multiple specialties.

METHODS

This document was developed from a collaboration of selected members from the International Urogynecological Association (IUGA) and the American Urogynecologic Society (AUGS). Wide-ranging literature reviews were performed to identify the breadth of currently used terms and tools for measuring efficacy and safety. After extensive internal review the adoption of each definition was ratified by group consensus.

RESULTS

A terminology report for elective cosmetic gynecology procedures, anatomical classification, outcome metrics, and reporting of complications has been developed. This document seeks to provide clear descriptive guidance for patients, researchers, and practitioners across multiple specialties. This document will be subject to internal review by IUGA and AUGS to incorporate and adopt evidence-based changes in the field.

CONCLUSIONS

A consensus-based document establishing clear terminology for cosmetic gynecology procedures has been created. Use of these terms should be encouraged to provide clarity to patients seeking these procedures and to facilitate future research to establish the safety and efficacy of these procedures.

360 Genital Fat Transfer

BACKGROUND

This study was designed to evaluate utility of transferring autologous adipose-derived mesenchymal stem cells with high regenerative capacity and adipose tissue derived-stromal vascular fraction, so-called 360 Vaginal Beautification technique, in labia majora augmentation and vaginal tightening operation.

METHODS

A total of 97 female patients who underwent labia majora augmentation and vaginal tightening operation with 360 Vaginal Beautification technique were included. Post-discharge early (3rd and 7th postoperative day) and late (1^st and 3rd postoperative month) surgical complications were assessed , while the Female Genital Self-Image Scale (FGSIS) was applied before surgery and also during postoperative 6-12 months.

RESULTS

All complications noted on postoperative 3rd day (ecchymosis of labia majus, ecchymosis of clitoral hood, tenderness in the pubic area and pain at the vaginal entrance points) regressed on postoperative 7th day with no infection, edema, lipoma or granuloma formation in any patient. Total mean FGSIS score was 17.7 ± 1.6 in the pre-operative period, and increased significantly to 20.9 ± 1.4 and 22.2 ± 1.8 in the postoperative 6th month (p < 0.001) and 12th month (p = 0.013), respectively.

CONCLUSIONS

The use of autologous fat, called 360 vaginal beautification, in the labia majora augmentation and vaginal tightening appears to be a safe technique due to use of autologous tissue transfer and to be associated with high satisfaction rate and an advantage of being more minimally invasive than surgical labia majora augmentation and vaginal tightening.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Female Genitourinary Treatments in Aesthetics

Female genitourinary treatments in aesthetics utilize energy-based treatments and other non-invasive modalities. These include CO2 and Er:YAG lasers, radiofrequency (RF), high-intensity focused electromagnetic energy (HIFEM), hyaluronic acid (HA) injection, platelet-rich plasma (PRP), and silicone thread treatments with an objective to treat sexual dysfunction and symptoms of genitourinary syndrome associated with menopause (GSM), which include atrophic vaginitis, urinary incontinence, and vulvovaginal laxity that is characterized by vaginal dryness, thinning of the epithelium, laxity, prolapse, incontinence, dyspareunia, and increased bacterial infections. The body of evidence is growing for the use of these modalities to improve signs and symptoms of GSM and sexual function, as well as rejuvenate the appearance of external female genitalia. We reviewed the currently available modalities in this rapidly advancing area of expertise.

The Safe Practice of Female Genital Plastic Surgery

The purpose of this article is to guide surgeons in the safe practice of female genital plastic surgery when the number of such cases is steadily increasing. A careful review of salient things to look for in the patient’s motivation, medical history, and physical examination can help the surgeon wisely choose best candidates. The anatomy is described, with particular attention given to the variations not generally described in textbooks or articles. Descriptions are included for labiaplasty, including clitoral hood reduction, majoraplasty, monsplasty, and perineoplasty with vaginoplasty. Reduction of anesthetic risks, deep venous thromboses, and pulmonary emboli are discussed, with special consideration for avoidance of nerve injury and compartment syndrome. Postoperative care of a variety of vulvovaginal procedures is discussed. Videos showing anatomic variations and surgical techniques of common female genital procedures with recommendations to reduce the complication rate are included in the article.

Genital Beautification and Rejuvenation with Combined Use of Surgical and Non-surgical Methods

AIM

In female genital rejuvenation and beautification, interest and demand for combined surgical and non-surgical methods are increasing. This study presents the results of our labia minora reduction technique and a vulvovaginal rejuvenation and beautification concept, where a combination of fat injection into the mons pubis and labia majora, if necessary, combined with fractional carbon dioxide (CO₂) laser is used.

PATIENTS AND METHODS

Genital rejuvenation and beautification were performed on 37 patients between January 2014 and January 2019. Postoperative follow-up for 1 year to obtain data on the satisfaction of surgical and non-surgical procedures was performed.

RESULTS

Of the 37 female patients included in the study, 33 (94.5%) were satisfied or very satisfied with their postoperative appearance. Thirty (80%) patients were satisfied or very satisfied with functional results.

CONCLUSION

The described genital beautification and rejuvenation technique combines different aesthetic female genital surgery techniques and non-surgical noninvasive procedures. These procedures, like other plastic surgeries and procedures, are designed for the subjective improvement of the patients' appearance and feelings.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Labial Fat Grafting After Penile Inversion Vaginoplasty

BACKGROUND

Penile inversion vaginoplasty (PIV) has become the most commonly performed genital surgery for transfeminine patients. However, patients undergoing this procedure may still require revisions to achieve a satisfactory result.

OBJECTIVES

The authors report on the utilization of autologous fat grafting to the labia majora to improve results after PIV and complications that may predict the need for grafting.

METHODS

A retrospective chart review was conducted of a single surgeon's patients who underwent PIV between July 2014 and December 2019. Demographic information, operative information, and postoperative outcomes were abstracted from the health records. Wilcoxon rank sum tests and chi-squared test were employed for continuous variables and categorical, respectively.

RESULTS

A total of 182 transfeminine and gender-diverse patients underwent PIV, with 6 patients (3.3%) eventually undergoing labial fat grafting. The most common indication for labial fat grafting was flattened labia majora (83%). All fat grafting procedures were performed concurrently with other revisions of the vaginoplasty. There were no demographic or medical history differences detected between the fat grafting and non-fat grafting groups. Patients who underwent labial fat grafting were more likely to suffer from introital stenosis (33% vs 6%, P = 0.007) and prolonged granulation tissue greater than 6 weeks after initial vaginoplasty (83% vs 32%; P = 0.01).

CONCLUSIONS

Labial fat grafting is a safe and effective method to address defects in the labia majora after PIV. Prolonged granulation tissue and introital stenosis may predict the need for labial fat grafting, possibly due to increased scarring and contracture at the surgical site.

LEVEL OF EVIDENCE: 4

Safety in Female Genital Plastic Surgery

LEARNING OBJECTIVES

After studying this article, participants should be able to: (1) Identify the most appropriate type of anesthesia for the female genital plastic surgical patient and minimize risks of nerve injury and thromboembolic event through proper preoperative evaluation and knowledge of positioning. (2) Define the vulvovaginal anatomy, including common variants, and assess vulvovaginal tissues after childbirth and menopause. (3) Apply surgical techniques to minimize complications in female genital plastic surgery. (4) Classify the types of female genital mutilation/cutting and design methods of reconstruction after female genital mutilation/cutting.

SUMMARY

Female genital plastic surgery is growing in popularity and in numbers performed. This CME article covers several aspects of safety in the performance of these procedures. In choosing the best candidates, the impact of patient motivation, body mass index, parity, menopause and estrogen therapy is discussed. Under anesthesia, consideration for the risks associated with the dorsal lithotomy position and avoidance of compartment syndrome, nerve injury, deep venous thromboses, and pulmonary embolus are covered. Anatomical variations are discussed, as is the impact of childbirth on tissues and muscles. Surgical safety, avoidance of complications, and postoperative care of a variety of vulvovaginal procedures are discussed. Videos showing anatomical variations and surgical techniques of the most common female genital procedures with recommendations to reduce the complication rate are included in the article. Finally, female genital mutilation/cutting is defined, and treatment, avoidance of complications, and postoperative care are discussed.

Measuring Quality of Life in Female Genital Cosmetic Procedure Patients: A Systematic Review of Patient-Reported Outcome Measures

BACKGROUND

In the subspecialty of female genital cosmetic procedures, patient satisfaction and quality of life are key outcome measures. As such, valid and reliable patient-reported outcome measures (PROMs) examining these outcomes are essential.

OBJECTIVES

The authors sought to identify and scrutinize all PROMs developed for female patients undergoing genital cosmetic procedures.

METHODS

The authors performed a systematic literature review utilizing MEDLINE, PreMEDLINE, Ebase, Embase, OVID, CINAHL, Cochrane Library, PsycINFO, PubMed, and Google Scholar to identify PROMs developed and validated for utilization in female genital cosmetic procedure patients. Instruments identified were assessed according to international guidelines for health outcome measures development and validation.

RESULTS

The authors identified 50 outcome questionnaires employed in the female genital cosmetic procedure literature. Of these, 26 were ad hoc instruments (ie, had not been formally developed and tested) and 22 were generic instruments (ie, intended for use in broad groups of people, not only specific patient groups). Only 2 instruments have been validated in a female genital cosmetic procedure patient population. These were the Genital Appearance Satisfaction scale and the Cosmetic Procedure Screening Scale-Labiaplasty. Although both these scales had undergone fairly rigorous psychometric development and validation, both had content limitations.

CONCLUSIONS

There is a lack of specific, valid, and reliable satisfaction and quality-of-life PROMs in the field of female genital cosmetic procedures. Future research should involve the development of such measures to more accurately assess the outcomes and benefits of these procedures.

[Secondary labiaplasty: Retrospective study about 44 cases. Annual report SOFCPRE 2019]

INTRODUCTION

Labiaplasty is a surgery currently booming. The number of publications on this subject is also increasing significantly. With the increase of the operated cases, we see more and more consultations for revisions after a labiaplasty, called secondary labiaplasty. The author reports here his experience with secondary labiaplasties in 44 cases.

MATERIAL AND METHOD

The study carried out by the author reports 44 cases divided into two categories of secondary labiaplasties. The first category is characterized by a wound dehiscence, including those following the author's lambda laser procedures, which are easily repaired under local anesthesia after border cutting and suture. The second category is characterized by over-resections or real amputations or even remains of atypical flaps.

DISCUSSION

The over-resection is a technical fault. In this case, the technique used to improve the aesthetic, functional and psychological aspect is the use of the remains of labia minora in the form of a flap to avoid a dog-ear appearance at the anterior and posterior part. The use of lipofilling of the labia majora is to mask the area and improve the function. The future of this surgery is probably the reconstruction of the labia minora by local flaps.

CONCLUSION

The conclusion of the study is that it is imperative that surgeons performing labiaplasties be trained in both anatomy and labiaplasty techniques and avoid as much as possible over-resections and amputations, mending being often difficult.

Dynamic Quadripolar Radiofrequency: Pilot Study of a New High-Tech Strategy for Prevention and Treatment of Vulvar Atrophy

BACKGROUND

The well-being of the vulva and a woman's quality of life are strongly correlated. Dynamic quadripolar radiofrequency (DQRF), one of the newest nonsurgical light- and energy-based vulvar rejuvenation technologies, has been demonstrated to be an effective option in aesthetic gynecology.

OBJECTIVES

The aim of this study was to perform qualitative and semiquantitative evaluations of short-term changes in vulvar aesthetics to illustrate the efficacy of an accelerated DQRF vulvar rejuvenation program in women with mild to moderate vulvar atrophy.

METHODS

Twenty women with mild to moderate vulvar atrophy were prospectively screened and evaluated. Serial photographs documented the aesthetic impact of DQRF on the vulvar area over the 2-month study period. The overall aesthetic improvement was rated on a Global Aesthetic Improvement Scale modified to create a 10-point semiquantitative rating tool. Complications and side effects were recorded.

RESULTS

All women successfully underwent 3 planned DQRF procedures spaced 7-10 days apart. Signs and symptoms of vulvar atrophy and the range of aesthetic judgments of the vulvar area were improved in most women after the first DQRF session, and improvements in vulvar aesthetics were persistently highly significant 1 month after the end of the DQRF rejuvenation program. No complications or side effects occurred.

CONCLUSIONS

Improvements in the signs and symptoms of vulvar atrophy by DQRF rejuvenation of the labia majora confirm the efficacy and safety of this technically simple outpatient procedure. In women with mild to moderate atrophy, a rapid rejuvenation program of closely spaced sessions achieved significant improvements.

LEVEL OF EVIDENCE: 4

Labia Majora Augmentation: A Systematic Review of the Literature

BACKGROUND

Currently, there is no standardized approach for labia majora augmentation and controversies still exist regarding this subject.

OBJECTIVES

This systematic review aimed to assess the evidence in the literature regarding labia majora augmentation.

METHODS

On November 20, 2016, we conducted an online search of published articles in the Medline, Embase, and Cochrane databases. All articles describing labia majora augmentation were included in this review.

RESULTS

Nine studies were selected for inclusion in the systematic review. Only 2 studies were prospective trials. The most commonly used technique was fat grafting with a total of 4 articles and 183 patients. The mean total injected fat volume ranged from 18 mL to 120 mL per session. Two articles described hyaluronic acid injection techniques. The total injected volume of hyaluronic acid ranged from 2 to 6 mL per session. Three articles used surgical techniques for labia majora augmentation. All included articles did not report any major or life-threatening complications. All techniques demonstrated high satisfaction rates.

CONCLUSIONS

Labia majora augmentation appears to be a safe, efficient technique with a high satisfaction rate and no reported major complications. However, further randomized controlled trials are warranted.

LEVEL OF EVIDENCE

4.

How and why to take a Martius labial interposition flap in female urology

The Martius modified labial fat pad flap at nearly 90 years old is still very much part of the modern vaginal surgeon’s armamentarium. Here we describe this straightforward and adaptable technique, the avoidance of pitfalls, its advantages and uses in vaginal surgery, and outcomes both short and long term. Specifically patient reported outcomes related to scar perception and sexual function are explored.