What is “Vaginal Reconstruction”?

​By Michael Goodman, MD
Copyright 2019. All rights reserved.
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​The lexicon 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, what is the difference in applicability and outcome comparing surgical with non-surgical approaches designed to “…reconstruct” one’s vagina…? What exactly is indicated in order to achieve each woman’s ultimate goal?

This does not have to be complicated, and I will not make it so. The vagina is composed of 1) a superficial skin layer, the “mucosa,” 2) a tough slightly stretchable fibrous layer, the “recto-vaginal fascia,” 3) loose, airy “areolar tissue” under the fascia and mucosa, and 4) 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 of childbirth, 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 estrogen that the vaginal mucosa is dependent upon, this “skin” can become thin, smooth, and less stretchable.

Far more important however are the underlying structures which support the vagina, giving it its structure and “tone.” Without a strong muscular layer supporting the mucosa, without an intact fibrous layer underlying the mucosa, without a strong, muscular, intact “perineal body” at the opening of the vagina, “rejuvenation” of the skin of the opening or the inside is little more than a Band-Aid.

There are mitigating factors. Women’s vaginas of course 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…) and the length of the “pushing phase” of labor all have their individual effects on the post-partum condition of an individual vagina. Partner’s penises (those with male partners) 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.

“Vaginal Rejuvenation” is a term first used in the early 2000’s by one of the Fathers of genital aesthetics, Dr. David Matlock, MD. Dr. Matlock utilized a laser fiber as is “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 of the vagina. Unfortunately, this originally surgical 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 re-surfacing.” 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,  utilize proper power settings, and 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 greater “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 ~ $25,000. At the end, the patient interested in vaginal tightening is really no better off than at the beginning, only $25,000 poorer… RF or fractional CO2 laser wands are not FDA-approved but have a significant amount of research and anecdotal proof 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 manner, 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 pf 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, bringing together, with strategically placed strong sutures, the stretched muscles (bulbospongiosis; bulbocavernosis. transverse perinealis) of the outermost portion of the vagina, of the vaginal opening, and of 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 (fingers; toy) is “pushed” more snugly upward, against the internal clitoris and “G-spot” for increased friction and sexual pleasure. 

The “before and after” photosets below, while of course not able to show you the inner tightening, nonetheless gives a good idea of what a surgical vaginal reconstruction can accomplish.

-MPG

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