Tightening Inside the Vagina

Today women are not only more aware of their genitalia, but also participate actively in their sexual wellbeing. The concept that the main purpose of sex is for procreation is in the past. Along with the joy of childbirth and kids, woman experience changes in their vagina making it less tight, changes that impact sexual gratification, but woman were silent about it, talking about their sexuality was a tabu.

Why do these vaginal changes happen? With pregnancy, the baby is in the abdomen for approximately 9 months, during which time the weight of this baby is supported by the pelvic floor muscles. After the baby is born, these muscles are elongated after supporting the baby’s weight for all this time. As these muscles also support the vagina, after the baby is born, the vagina ends up being loose too.

Having a loose vagina has direct consequences on sexuality because for women, to experience sexual gratification with penetration, they need to feel friction on the anterior vaginal wall. However, if the vaginal walls are loose, they will not be able to contract them as hard as they did before having the baby. Vaginal walls will usually end up being loose during sexual intercourse once the pregnancy ends and the baby is born, but this does not mean that every woman needs a vaginal tightening procedure after childbirth, even though there is certainly some abdominal muscle diastasis.

This situation of feeling less sexual gratification during sexual intercourse is often discounted with the dedication the mother puts into raising her child, plus her busy career agenda, making her unconsciously leaving her sex life on standby, claiming that for her it is not a priority right now, as she has more important things to deal with. Although she initially thinks this is only a transitional period, it can end up staying like this forever, and when the kids are grown, there are fewer and fewer things in common between the couple and in the end, the relationship, as simple as this, can end up having an unhappy ending.

Today we have a more open-minded society where woman not only lead at home, but have leading positions in their careers, giving them the confidence to speak up about their sex life and empower them to have control over seeking ways to improve it.

According to world statistics in 2019 from the International Society of Aesthetic Plastic Surgery, the increase in vaginal rejuvenation procedures is increasing year after year to the point where this is the procedure that has increased the most compared with any other for the last 3 years in a row. For 3 years, two thirds of the total increase in surgical aesthetic procedures was as a result of vaginal rejuvenation procedures.

Now, as plastic surgeons, we are doing more and more labiaplasties. Actually, we are coming to the point that although vaginal rejuvenation is still the procedure that has increased the most compared with all other aesthetic plastic surgery procedures in this past year (2019; 24% increase), and we still have an increase in external vaginal rejuvenation procedures (1% increase of the total 24% increase), now the significant increase comes from vaginal tightening procedures (23% increase of the total 24% increase).

So, the question is, are you doing vaginal plastic surgery procedures in your practice? And if so, what are you doing?

I can now say I have accomplished my goal of making the plastic surgery community understand that vaginal rejuvenation is more than just doing a labiaplasty, but I still need to spread the message that vaginal tightening is not just tightening the vaginal entrance.

After years and years of teaching the concept of vaginal rejuvenation, I can say that in every main scientific meeting, we now have a panel dedicated to vaginal rejuvenation, and now we understand the concept that genital aesthetics is not just cutting the labia minora; it is a group of procedures that enhance the genital area. However, we still need more plastic surgeons doing vaginal tightening procedures, and doing them right.

What do we mean by “doing a vaginal tightening procedure right”? First, we need to remember how woman experience sexual gratification.

There are major differences between males and females regarding genital anatomy and also in how we feel sexual arousal and gratification. Women have several erogenous zones, many even unrelated to direct genital organs. Men have most of their arousal points around the genitalia and more specifically related to friction on the penis. When referring to sexual gratification secondary to sexual intercourse for men, it is much simpler; they need friction on the penis. But for women to have sexual gratification with penetration, they need friction on the anterior vagina wall.

Pregnancies, changes in body weight, or anything that makes the vagina wall less toned will affect sexual gratification for women. During sexual intercourse by penetration, women with loose vaginas are not be able to push the penis toward the anterior vagina wall as hard as before, and as a consequence, less friction in this area, where more sensitivity receptors are present, will happen. If the vagina walls are loose, women cannot contract their vagina walls as hard as before and thus experience less sexual gratification.

Understanding this is crucial for a successful surgery plan. If we think we only need to tighten the entrance of the vagina to increase sexual gratification, we are destined to fail in this procedure and have unhappy patients. The sad part of the story is that many patients will seek a vaginal tightening procedure and if only the entrance is tightened and they still do not have any improvement after the procedure, they can end up thinking that this is the way it has to be, that they will never enjoy their sex life again as when they were younger, and that this is their destiny as women. Do we want this for our patients? Remember once more our Hippocratic Oath: Always give the best to our patients and never harm them. Today, we have the knowledge, so why are we waiting to use the correct approach for vaginal tightening procedures?

Here I also want to add another important concept. Many times, our attention as surgeons is focused on tightening the vagina as much as we can, and this is also the wrong approach. Tightening only the entrance will give sexual satisfaction after the procedure to the partner but not to the patient, and when too much tightening is done, instead of giving any benefit for her, it can even be worse, because having a very tight vagina can be painful for the woman, facilitating tearing of the vaginal wall and ruining her sex life, ending with totally the opposite result of what was intended for the procedure.

Expert Approach: Tightening Inside the Vagina

• Lina Triana

• Plastic Surgeon

• Cali, Colombia

Why did you decide to do this technique? when did you learn it or if it is your own, how did you end up doing it?

Once I finished my plastic surgery training, I joined a very busy aesthetic plastic surgery practice of three mature male plastic surgeons and my task in the practice was mainly to listen to the patients. I had to do the follow-ups, and in particular, with those who were not happy. I learned that the best thing I could ever do for these patients was to listen to them.

Many times, they had chosen to have the procedure done for the wrong reason, and of course this was the main reason why they were still not happy after having it done. Letting them speak and really listening to them without any judgment was crucial for allowing them to open their hearts to me and show me they were just not happy with their life as a couple. Many wanted to regain their sex lives and were just seeking this with the wrong approach. This is how I became interested in the procedure and started gathering information, first obtaining the knowledge on how to do it, then seeking training, which I did with gynecologists who showed me that tightening the entrance or a little bit of the posterior wall was enough, and lastly, gaining experience on what was best for the patient. After doing the procedure and listening to my patients, I started to discover that just tightening the entrance was not enough to really improve their sexual gratification.

Can this technique be compared to others and why?

Certainly, this technique is similar to when a small prolapse of the posterior or anterior vaginal wall is repaired. It is just the concept of when to do it that makes the difference.

Also, it is important to know that when working on the anterior vaginal wall, depending on how much we go up on the plication, we can even improve stress urinary incontinence, although here we are getting out of our competency zone, so this procedure must never be intended to be done for correction of stress urinary incontinence symptoms. The purpose of the procedure must always be to increase sexual gratification, but often, if the patient also has these symptoms, they will be resolved after the surgery.

What do you consider to be important landmarks and anatomy to be able to better perform this technique?

It is important to know that when working on the vaginal cavity, we are working in a corridor-like structure that has distinctive layers such as the mucosa, fascia, and vaginalis muscularis, which are only millimeters wide, and that we are also working very near, only millimeters away, from important pelvic organs, such as the bladder and urethra anteriorly and the rectum posteriorly.

A question that I am constantly asked when training is whether if I do an anterior vaginal wall plication and end up resecting some mucosa, can I damage the G spot/zone. The answer is no, because the G area is up and behind the symphysis bone, very near the vaginal entrance, and the plication does not go that far. However, if we plicate too much in this area, we can end up changing the urovesicular angle, making the patient experience problems during urination.

Can you explain to us how you do the assessment on a patient asking for this procedure? can you give us some guidelines for constructing an assessment chart?

It is important always to first ask why they are there. You really need to understand the reason why they are seeking the procedure. It is also important to ask about stress urinary symptoms and questions about vaginal lubrication.

We have already mentioned that a vaginal tightening procedure is not intended to solve any urinary stress incontinence symptoms, but many times it will resolve them. However, if prolapses are found, the patient should be redirected to another specialist.

Then you need to do an internal vaginal exam. You start the exam by asking the patient to push and actively look for any prolapses. Then you need to touch and feel the vaginal entrance and the inner vaginal walls to properly plan the procedure. How much you are going to do depends on how and where you feel the need to improve the vaginal tone. If you feel the vaginal anterior wall is loose, you will do an anterior vaginoplasty; if the posterior wall is loose, you will do a posterior vaginoplasty; and if the entrance is loose, you will do a perineoplasty. You do not need to do all three procedures in all patients; it will depend on how and where you feel the loss in vaginal tone as to where you will focus your repair. However, it is very common that the patient needs all three repairs.

It is also important to tell the patient that if she suffers from vaginal dryness, this will not be fixed with the procedure, and that if she lubricates too much during sexual intercourse, that cannot be solved either.

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