How I Do It: Er:YAG laser Vaginal Rejuvenation

By Jorge Gaviria, MD
Head Chief, Laser Platform at the Fotomedicine Institute
Teknon Medical Center, Barcelona, Spain; Medical Director, Korpo Laser, Caracas, Venezuela.

​Copyright 2019. All rights reserved.

I first started using my Fotona laser in 2008 on the exterior of the vagina and for vulva skin
tightening. In 2010 I began doing research on vaginal laser tissue induction to achieve
vaginal tightening and sexual enhancement. After a few successful treatments, I noticed an
improvement of continence in patients who were leaking. I then started doing
reinforcements of the anterior wall, and after having successfully treated a few thousands
patients, I am very excited about the results and I can say now that more than 60% of my
patients have come for a solution to the symptoms of stress urinary incontinence.

Fotona was the first manufacturer to introduce the Er:YAG wavelength in gynecology to
improve upon the existing laser gynecology treatments. Fotona SMOOTH® procedures are
non-invasive, non-ablative laser procedures that use a patented Er:YAG laser technology to
send mild heat pulses to the vaginal walls, resulting in functional strengthening of
connective tissue inside the vaginal wall, and an overall increase in vaginal wall thickness
and functional improvement in the mucosal tissue. Since the introduction of the unique
Fotona SMOOTH® laser technology, more than 40 independent gynecological studies
examining its safety and effectiveness have been published in the most highly respected,
peer-reviewed international journals.

I really like the safety aspect of Fotona SMOOTH®. The patented Fotona SMOOTH®
technology holds a very unique position among medical lasers. It is a completely nonablative solution and involves not only the additional superficial heat-shocking mechanism
of tissue regeneration, but also includes a unique self-regulating safety feature. These
characteristics are responsible for the extraordinary safety and efficacy of Fotona
SMOOTH®.

With Fotona SMOOTH® you can treat several genitourinary conditions such as SUI, atrophy,
vaginal laxity and prolapse. Thanks to the laser’s high pulse versatility, you can also
perfectly perform ablative procedures, such as vaginal bleaching, condyloma treatments,
scars, striae and other vaginal aesthetic treatments such as labiaplasty. This high
versatility and minimal-invasiveness is what I really love about Fotona.
My patients are very pleasantly surprised to discover that we can offer non-invasive
treatments.

Most patients decline or postpone a treatment decision when they are offered a surgical
option due to its inherent risks, potential pain and the inability to return immediately to
their normal lives. Many also find it very important that as ambulatory procedures these
treatments are much more affordable than the alternative of going to a surgical
environment.

Apart from the minimally-invasive treatments for SUI and vaginal tightening, I also perform
many vulvar aesthetic treatments. Being a gynecologist and also an aesthetic doctor allows
me to be non-conventional, due to the reality that the vulvar area has the same skin
qualities as the rest of the patient’s body, just that it is more sensitive, with more
moisture and more friction during walking. So I treat my patients’ vulvar area as any other
area of the body, but with less energy, for vulvar tightening or bleaching. I also treat scar
tissue, episiotomies, C-section hypertrophic scars and stretch marks, plus genital hair
removal and treatment of folliculitis.

Procedure
One of my main procedures is vulval rejuvenation combined with whitening. The melanic regions like the linea alba and genital region are naturally darker, and with genital hair removal this is noticeable. I use a unique combination of different Er:YAG and Nd:YAG pulse durations. The first step of my protocol is labial and vaginal superficial tightening using Er:YAG in Fotona SMOOTH® mode (PS03: 7mm, 3.25-3.50J/cm2, 1.4Hz) for non-ablative thermal stimulation and collagen contraction. I use a brushing technique with six passes throughout the contour of the labia.

The second step is a whitening procedure. For cold ablation I use Er:YAG in medium-short pulse (MSP) mode (R11, 7mm spot size, 1.1J/cm2, 2-3Hz). Before using higher parameters, I apply anaesthetic cream. When doing more passes for deeper ablation, I always make sure to wipe the ablated tissue between each pass. Instead of one single pulse that will burn the skin, I perform multiple passes and precisely control the depth. I instruct the patients to apply 2% hydroquinone cream twice a week for two months and then once a week.

In the third step, the Frac3 short pulse Nd:YAG modality is used to remove pigmented imperfections (R33 handpiece 9mm, 20J/cm2, 3.6Hz). In the last step, the Nd:YAG super-long PIANO pulse for bulk heating and skin tightening is used (with R33, 9mm, 90J/cm2, six seconds with a brushing technique doing several passes over the labia).

The results I have seen are excellent, and down-time is minimal; usually just a few days of redness because of the ablative MSP.
​
Being able to provide non-ablative, no-downtime procedures to achieve great results in
these and similar applications places the laser as one of the top choices among my
patients. 

Jorge Gaviria, MD, is an expert in laser therapy and a consultant for Fotona laser systems and a Fellow of the ISCG.
​A version of this article appeared in the PMFA Journal on October 1, 2019.