A moment on the lips

ELEANOR HARTLEY

Eleanor Hartley is an aesthetic nurse practitioner and NMC registered midwife with a core focus on women’s health and wellness. On completing postgraduate studies in Aesthetic Medicine, Clinical Dermatology, and a current MSc in Advanced Clinical Practice, she demonstrates her keen interest in the psychosocial context of health and a commitment to advancing clinical expertise. Hartley launched Hart Medical, Aesthetics and Integrative Wellness clinic in Mayfair, taking a holistic approach to balance and optimisation of face, body and internal wellbeing. hartmedical.co.uk • @hart.medical

The non-surgical lip-lift, Russian lips, baby doll lips, cherry lips - the pursuit of the ‘perfect pout’ prevails with patients and practitioners alike. But while many of our clients seek out facial symmetry, volume and hydration, a growing number of patients have shifted their focus to achieving these goals on their lesser-seen lips, opting for nonsurgical vaginal rejuvenation.

DESIGNER VAGINA VS INTIMATE WELLBEING

Rejuvenation of the intimate area is by no means a new concept, from the commonplace trends of bikini waxing, laser hair removal and skin lightening to the rise in surgical labiaplasties and pelvic floor reconstruction. Despite suggestions that the alteration of genital anatomy improves self-esteem, and sexual confidence (Karcher & Sadick, 2016) the concept of the ’designer vagina’ is laced with connotations of negative body ideals and shame, driven by popular culture and pornography (Fredrickson & Roberts, 1997; Allbright, 2008).

The advent of ‘intimate wellbeing’ marks a shift from ‘designer vaginas’ to a more holistic era of body confidence and empowerment, encompassing both psychosexual and physiological wellness. While breaking stigmas and admonishing the shame shrouding the female genitalia, intimate well-being allows a safe place for women to open the conversation about their vaginal and sexual health.

VAGINAL HEALTH

Intrinsic changes in the vulva, both functional and aesthetic, may be attributed to hormonal changes, childbirth, genetics, or lifestyle (Qureshi et al, 2017). Oestrogen has a significant impact on a wide range of tissues in our body, including bone, adipose tissue, vessels and skin. Fluctuations in oestrogen throughout a woman’s life, from puberty, menarche, childbirth and menopause, affect the integrity and senescence of our cells. Atrophy of the skin and mucosa, reduced collagen production and hydration and loss of subcutaneous fat consequently impact the anatomy and physiology of the female genital area. Where significant pathologies should be addressed by Ob/Gyn and surgical specialists, the aesthetic practitioner holds an arsenal of tools to significantly improve wellbeing with minimally invasive and clinically effective approaches.

TREATMENT OPTIONS

Exploring the range of appropriate modalities, considering combination approaches and early identification for referrals to a surgical specialist are all critical to achieving positive outcomes. Identification of the psychosexual impact on intimate well-being must also be considered to provide patient-centred care (Barnes, 2018).

From a dissatisfaction with the size and shape of both the inner and outer labia, vaginal dryness, laxity and urinary issues and genitourinary-related symptoms of menopause (GUSM), advancements in non-surgical treatment options allow patients to explore a plethora of minimally invasive procedures for these common presenting concerns. The modalities summarised here are not intended to be exhaustive, however can be considered as part of individual or combination approaches.

DERMAL FILLERS

Ageing in the intimate area mirrors that of the face. Soft tissue volume loss, fat atrophy, and decreased collagen production result in fine lines, wrinkles, and lack of structural integrity. Dermal fillers have therefore been adopted as an effective method of vaginal rejuvenation. Reshaping the labia majora, sometimes referred to as the ‘labial puff’, uses an injectable hyaluronic acid-based (HA) filler to replace lost volume, correct asymmetry, improve surface skin texture and reduce the signs of ageing skin. Replacing volume in the labia majora can successfully remedy hypotrophy of the outer labia and reduce the appearance of perceived hypertrophy in the labia minora (Berreni et al; in Lakhani, 2016). Not only does HA dermal filler address concerns with the appearance of the external genitalia but products have also been developed specifically for internal treatment, targeting dryness and collagen loss and have been suggested as an alternative to vaginal oestrogens (Berreni et al, 2021).

PRP

The efficacy of platelet-rich plasma (PRP) has been studied about a variety of clinical presentations, from wound healing to hair regeneration, and scar treatments (Scalfani et al, 2011). PRP activates pluripotent stem cells around injection, resulting in rejuvenation and even enhancement of damaged or undamaged tissue (Reddy, 2018). Studies evaluating the impact of autologous PRP for vaginal atrophy, stress incontinence, dyspareunia, and sexual dysfunction purport clinical efficacy in the treatment of vulvovaginal concerns (Suckgen, 2019, Neto, 2017, Runels et al, 2014). The autologous nature of PRP lends to its safety, with minimal to no risk of granuloma formation, inflammatory response, or infection when FDA-approved preparation kits are utilised (ibid.), rendering PRP a minimally invasive option to be adopted, particularly around sexual arousal and lubrication (Runels, 2014).

FAT TRANSFER

Autologous lipofilling is an effective modality to restore soft tissue volume and has become a popular ‘non-surgical’ option for body contouring and tissue rejuvenation. Grafting locally harvested fat to the external genitalia not only improves wrinkling and skin laxity but can also lighten pigmentation (Bapar, 2022). Adipocytes have been found to contain mesenchymal stem cells (MSC) and adipose-derived stem cells (ADSC) with the potential to support tissue regeneration (Kim et al, 2017). Therefore infiltration of stem cells as Stromal Vascular Fraction (nano graft) can be adopted to rejuvenate vaginal dystrophy and vulvovaginal atrophy (Aguillar et al, 2016, Bapar; 2022).

ENERGY-BASED TREATMENT

Energy-based approaches to non-surgical vaginal rejuvenation can be divided broadly into radiofrequency devices (RF) and laser. Energy-based modalities harness thermal or light energy to elicit a tissue response. When absorbed in sufficient amounts, this can induce changes in the skin and muscle matrix (Targeting a dermal and epidermal tissue response, and an increase in fibroblastic activity results in both neocollagenesis and neovascularisation, and promotion of growth factors.)

Histopathological evidence suggests heat-based devices offer effective rejuvenation of vulvovaginal tissues (Leibaschoff et al, 2016; Desai, et al, 2019), resulting in improved muscle tone, improved moisture in mucosal tissue and increased sensation (Millheiser et al, 2010).

NICE (2020) published a systematic review of transvaginal laser therapy (CO2 & Er:Yag) for urogenital atrophy, drawing statistically significant results for improvement in dyspareunia, dryness, itching, urinary incontinence and improved sexual function.

HIFU/HIFEM 

High-intensity focussed ultrasound (HIFU) technology has more recently been advocated for the purpose of vaginal rejuvenation, utilising the high-intensity focused power of ultrasound to stimulate fibroblastic activity and new collagen synthesis in the deep dermis and subcutaneous tissues (Joshi & Jindal, 2022). High-intensity electromagnetic field procedure (HIFEM) technology harnesses powerful electromagnetic fields to target neuromuscular tissue and stimulate supramaximal muscular contractions and has been advocated for the strengthening of the pelvic floor through muscle fibre hypertrophy (Brunk, 2021).

IN SUMMARY

Non-surgical vaginal rejuvenation and the management of vulvovaginal atrophy is an increasingly critical area of aesthetic and regenerative medicine. Both the wide-ranging aetiologies and the psychological context of sexual health lend to a wide scope of practice for clinicians seeking to integrate intimate well-being into their practice. Through individualised counselling and personalised treatment plans considering the range of modalities and treatment strategies, the aesthetic clinician maintains the capacity to deliver patient satisfaction and improve the quality of life for their clients. This area requires research, expertise, and a patient-centred approach to deliver safe and effective results.

REFERENCES

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