DOI: 10.1111/tog.

12905 2024;26:6–15
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Cosmetic gynaecology
MD FRCOG*
a
Roberta Bugeja MRCOG, James McConnell,b Swati Jha c,d

a
Subspecialty Trainee in Urogynaecology, Department of Urogynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Jessop Wing, Tree
Root Walk, Sheffield S10 2SF, UK
b
Speciality Trainee, Department of Urogynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Jessop Wing, Tree Root Walk, Sheffield
S10 2SF, UK
c
Consultant Gynaecologist and Subspecialist in Urogynaecology, Department of Urogynaecology, Sheffield Teaching Hospitals NHS Foundation
Trust, Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK
d
University of Sheffield, Sheffield S10, UK
*Correspondence: Swati Jha. Email: [email protected]

Accepted on 3 October 2023. Published online 11 December 2023.

Key content  To understand the procedures that are currently available, the
 Female genital cosmetic surgery (FGCS) includes several evidence-base behind these procedures, and their risks and benefits.
procedures involving the labia minora, labia majora, clitoris,  To understand the implications of genital cosmetic surgery on
vagina, mons pubis and genital area; procedures may involve, for patients, including their psychosexual wellbeing, and the legality of
example, reduction or augmentation and be surgical or these procedures with reference to female genital
energy based. mutilation (FGM).
 Indications for FGCS can be broadly divided into cosmetic and
Ethical issues
functional reasons.  The ‘postcode lottery’ in commissioning cosmetic gynaecological
 Counselling on the risks and cosmetic outcomes, as well as sexual
procedures in the UK leads to the question: should they be
and functional results, should be provided, and the woman’s
available on the NHS?
expectations discussed.  Who should be performing cosmetic gynaecological procedures: the
plastic surgeons who do little vaginal surgery, or the gynaecologists?
Learning objectives
 There is currently no formal training in this area for gynaecologists.
 To develop a holistic view when discussing cosmetic gynaecology
concerns, including psychosexual assessment. Keywords: clitoral hood reduction / hymenoplasty / labiaplasty

Please cite this paper as: Bugeja R, McConnell J, Jha S. Cosmetic gynaecology. The Obstetrician & Gynaecologist 2024;26:6–15. https://doi.org/10.1111/tog.12905

precisely quantify the demand for FGCS, as most procedures

Introduction
are performed in the private sector. However, increased
Cosmetic gynaecology is a growing subspecialty of medicine provision is acknowledged and has prompted ethical debates
and surgery linked to increased demand for aesthetic female and standard setting for these procedures.3
genital cosmetic surgery (FGCS) procedures.1 FGCS refers to ‘Vaginal rejuvenation’, on the other hand, is an ambiguous
“non-medically indicated cosmetic surgical procedures which colloquial term used to describe both FGCS and the use of
change the structure and appearance of the healthy external energy devices, but it can be misleading. The commonest
genitalia of women (Figure 1),2 or internally in the case of type of FGCS is labiaplasty; clitoral hood reduction,
vaginal tightening.”3 This increased demand is attributed to hymenoplasty and vaginoplasty are also common.
the influence of social media and greater access to female Indications for FGCS can be broadly divided into cosmetic
body images, in turn leading to a desire to achieve the and functional reasons. Healthcare professionals should
‘perfect genitalia’ – at times skewing the perception of a ensure that women considering FGCS are adequately
‘normal’ appearance. A random Google search for “cosmetic counselled about variations of normality and have realistic
gynaecological surgery” retrieves over 4 000 000 results. expectations about the outcomes, and undertake appropriate
FGCS involves specialties including gynaecology, informed consent before performing such procedures.
urogynaecology, urology, plastic surgery and dermatology. Here, we discuss patient selection and appropriate
These surgeries do not purely address aesthetics, but also counselling for women seeking FGCS. We do not address
women’s functional and sexual concerns. It is difficult to gender reassignment procedures, nor surgery for creating a

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Bugeja et al.

in demand for genital cosmetic surgery services, there

remains inadequate guidance from professional bodies
regarding service accreditation. Ethical issues, training and
service provision are also discussed.

Normal genital anatomy and patient

perception
The appearance of external female genitalia varies widely.
Public knowledge about the extent of normal variation is
relatively poor (Figures 2-5).4 Women choose to undergo
these procedures for various reasons, including functional
and aesthetic reasons,5 as well as negative perceptions of the
vulva on their sexuality.6 As a major source of comparative
information, use of the internet may be attributed to the rise
in requests for genital cosmetic surgery because the social
definition of ‘normal’ conforms to those images seen online.
Comments from partners or from people in public areas,
such as swimming pools or school changing rooms, can
trigger increasingly negative views of one’s own anatomy,
Figure 1. Normal female genitalia. Reproduced from The Obstetrician which can develop into a cycle of sexual dysfunction.
& Gynaecologist,3 with permission from John Wiley and Sons. However, for most women, minimal outside influences
affect their decision.5 Widely publicised campaigns
neovagina. We include an outline of the commonest surgical including “The Great Wall of Vulva” have been developed
procedures performed and the associated risks and benefits to try and improve public knowledge of the variety
that should be discussed during consultation. Despite the rise of normality.7

Figure 2. Variation in appearance of normal labia minora. (a) Symmetrical labia minora with pigmentation. (b) Lichen sclerosis. Labia minora
protruding outside the labia majora. Reproduced from Ridley’s The Vulva,4 with permission from John Wiley and Sons.

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Cosmetic gynaecology

Figure 3. Variation in appearance on normal labia minora. (a) Fimbriation and pigmentation of labia minora. (b) Asymmetry of labia minora with
bifid insertion on right side.

Figure 5. Presence of urethral caruncle in a patient with lichen

sclerosis. Reproduced form Ridley’s The Vulva,4 with permission from
John Wiley and Sons.

Figure 4. Hymenal remnants and skin tags. Reproduced from Ridley’s anatomy in context. A joint report issued8 by the
The Vulva,4 with permission from John Wiley & Sons. International Urogynecological Association (IUGA) and
the American Urogynecological Society (AUGS) shows an
There is little information in the literature regarding adaptation of the systems used to classify labial anatomy
clitoral or labial size. This paucity of information can hinder (Table 1). Documenting the staging prior to surgical
both the clinician and the patient when discussing their intervention can help the clinician to illustrate the change

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Bugeja et al.

improvement in sexual function among women with FGCS,

Table 1. Labia minora and clitoral prepuce (hood) classification. Labia
minora measurements are from the hymen to the distal edge8 hence caution is advised for preoperative counselling about
expected outcomes from vaginoplasty and perineoplasty.9
Stage Definition For women with considerable sexual dysfunction, referral to
psychosexual services is advised before surgical intervention.
0 Labia minora absent (e.g. female genital mutilation)
The increased prevalence of an underlying psychological
disorder among women seeking FGCS is recognised. In a
1 <2 cm study by Veale et al.,6 women seeking labiaplasty were more
likely to suffer from body dysmorphic disorder (BDD) than
2 2.1–4.0 cm
the control participants (18.2% versus 0.0%) and had a
3 4.1–6.0 cm higher frequency of avoidance behaviour. Screening for
psychopathology and referral to the appropriate services
4 >6 cm
before surgery is important to address any psychological
Suffixes Used in addition to above stage issues. The use of validated questionnaires11 such as the
Genital Appearance Satisfaction (GAS) scale12 and Cosmetic
A Asymmetric – note which side is larger Procedure Screening Scale (COPS)13 is recommended for
women seeking labiaplasty.10
B Cosmetic bother
In preoperative counselling, clinicians should emphasise
C Clitoral hood involvement to women that all anatomic variants are normal. Any
possibility of coercion or exploitation should be
D Dyspareunia associated with the labia, or discomfort during
exercise
eliminated.9 Guidance developed by the General Medical
Council (GMC) on decision-making and consent specifies
that clinicians should allow the patient sufficient time to
reflect on the information provided before a decision is
made.14 This is especially relevant in FGCS, where
in anatomy before and after surgery and to document procedures are irreversible and there is paucity of
indication for intervention. evidence of efficacy for improving sexual and functional
Comments from clinicians can have the unintended results. Consent to surgery should preferably not be taken at
consequence of reinforcing negative perceptions or causing the first appointment; instead, the patient should be given
shame. They may subconsciously reflect previous negative adequate information leaflets and time to reflect on these
comments or experiences that contribute to women’s body before agreeing to proceed with surgery.
image. When considering cosmetic surgery, it is important to FGCS should be avoided in patients presenting with a
ascertain a patient’s reasons for the request and to identify history of vulvodynia, dyspareunia and chronic pelvic pain.15
and address any underlying psychosexual dysfunction or
psychological distress. It is also important to discuss the
Types of genital cosmetic surgery
uncertainty about long-term outcomes, both in terms of
sexual and obstetric function, and the potential for causing FGCS includes several procedures (Table 2). The following
both long-term pain and/or loss of sensation. Unfortunately, format is recommended for describing FGCS: anatomic
very few studies have assessed the long-term impact of region + therapeutic descriptor + therapeutic approach. The
these procedures.9 therapeutic descriptor describes the intended effect, which
could be reduction or augmentation, and the therapeutic
approach describes the technique used, which could be
Preoperative consultation
surgical or energy based.8
The initial consultation should be utilised to educate women
about the variety of normal genital appearance. The aim of Labia minora
this consultation is to establish goals, understand motivations The labia minora are flaps of skin originating from the
and set realistic expectations before surgery. clitoral prepuce and frenula, extending to the posterior
It is important to understand why a woman is seeking fourchette. They vary widely in size and may be hidden by the
cosmetic surgery to offer the appropriate counselling labia majora or extend beyond them – both of which are
regarding the expected outcome from the intervention. normal. Table 1 summarises the IUGA labia minora
Counselling on the risks and cosmetic outcomes, as well as classification system, which was developed to improve
sexual and functional results, should be discussed, alongside consistency in documentation and allow objective
the woman’s expectations.10 There is limited evidence for description of the change to the anatomy after surgery.8

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Cosmetic gynaecology

Table 2. Female genital cosmetic surgery procedures8

Anatomic region Therapeutic descriptor Therapeutic approach Examples

Labia minora Reduction Surgical Labiaplasty

Labia majora Augmentation Filler* Labia majora augmentation

Reduction Surgical Majoraplasty

Tightening Energy based Majoraplasty

Clitoral Reduction (frenulum or prepuce) Surgical Frenulectomy/clitoral hood resection

Augmentation Filler* O-shots, G-shots, G spot amplification

Vaginal Reduction Surgical Colpoperineorrhaphy

Tightening Energy Vaginoplasty

Mons pubis Reduction Surgical/lipectomy Monsplasty

Tightening Energy based Monsplasty

Genital Depigmentation Energy based Genital brightening

Depigmentation Topical Genital bleaching

*Fillers include platelet rich plasma (PRP), lipofilling, hyaluronic acid injections, collagen, amniotic fluid.

Labia minora elongation is defined as “any dimension or combination. More research is required into efficacy, long-
morphology at which a woman experiences physical term effects and acceptability to patients.
discomfort that causes distress and impairs quality of life.”
Symptomatic labia minora elongation should be treated as a Labia majora
medical condition rather than as a purely cosmetic issue. The labia majora are the skin folds extending from the mons
Where the elongation is entirely asymptomatic, labiaplasty pubis to the perineum. They vary in fat content and have hair
would be considered a cosmetic indication. However, given on the outer but not inner aspect. A groove called the
the considerable variation in normal external genitalia and interlabial sulcus usually separates the labia majora from
the overlap between women seeking FGCS and not, it is the minora.
difficult to use a purely anatomical cut-off for decisions
regarding surgery, hence the emphasis on symptoms. For Labia majora augmentation
example, if a patient presented with superficial dyspareunia Fat harvested from other sites in the body can be used for
caused by labia minora measuring 7 cm (stage 4D), but had labia majora augmentation. The fat is harvested using a
no cosmetic concerns, labia minora surgery would be syringe for liposuction, which is then injected into
considered for physical symptoms.7 If the same patient the labia majora. Fat reabsorption can occur; hence,
presented without physical symptoms, but her concerns were outcome may vary and be unpredictable.17 Hyaluronic
purely cosmetic (stage 4B), then this would be a cosmetic acid and platelet-rich plasma (PRP) can also be used
procedure. In a study of 131 patients seeking labiaplasty of for augmentation.
the labia minora, Miklos et al.5 reported that most women
sought surgery for functional reasons rather than for purely Labia majora reduction
aesthetic reasons. This was independent of their anatomy in Depending on the anatomical reason for labial hypertrophy,
terms of size of their labia. various procedures can reduce the size of the labia majora. If
fat is the source, liposuction can be performed. This is usually
Labia minora reduction combined with a mons pubis procedure, but when performed
Table 316 summarises the different procedures performed for in isolation can leave excess loose skin. If excess skin is the
labia minora reduction. These can be used in isolation or in cause, an elliptical or bow-shaped incision is made on

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Bugeja et al.

Table 3. Procedures performed for labia minora reduction16

Clitoral reduction
Clitoral reduction procedures can reduce the prepuce or the
Procedure Description frenulum. When it involves the prepuce, either a triangular
segment of epithelium on the anterior aspect of the prepuce
is excised and reapproximated, or elliptical spheres are
Direct excision Removal of the distal portion of the labia
(edge resection) minora with suture closure resected, and linear closure performed.19 The proximity of
the surgical field to the neurovascular bundle of the clitoris
Wedge excision Triangular segment of the labia minora is means that patients undertaking clitoral surgery should be
removed centrally or posterior/laterally
counselled about potential damage to nerves and blood
De-epithelialisation Segments of central epithelium on the medial supply to erectile tissue, which could have an impact on their
and lateral aspects of the labia minora are sexual function.8
resected and sutured closed with underlying Frenuloreduction usually forms part of a labia minora
subcutaneous tissue remaining intact for
reduction procedure to achieve symmetry. Clitoral
reapproximation of the dissected edges
subdermal hoodoplasty and hydrodissection with reverse V-
W-plasty Intersecting W incisions on the medial and plasty are less well-established procedures.
lateral labia minora are resected and joined
“valley to peak”
Clitoral augmentation
Composite Involves a labial reduction with a clitoral hood Clitoral augmentation is performed using fillers, such as PRP,
reduction lift with removal of tissue located cranial or which are injected into the corpus cavernosa of the clitoris.
caudal to the clitoris

Z-plasty Two Z incision lines are made beginning near

Vaginal
the base of the central labia minora and The vagina extends from the cervix to the vulva. The Grafenberg
fanning out distally. This central segment is spot (“G-spot”) is at the distal anterior portion of the vagina wall
resected with the remaining tissue re- and is believed to be rich in sensation. Stimulation of the G-spot
approximated
is believed to result in arousal and orgasm.
Fenestration This obtains reductions in both height and
length of the labia and is performed in the Vaginal reduction
shape of a “bicycle helmet” Vaginal reduction refers to the surgical reconstruction of the
Bidimensional This combines a wedge resection and central
vaginal canal. This procedure can be performed for aesthetic
(flask labiaplasty) de-epithelisation purposes or functional reasons. Women with vaginal laxity
may report symptoms of sexual dysfunction, including loss of
sensation, dyspareunia and loss of libido. They may also
describe difficulty retaining a tampon. In their study,
Campbell et al.20 reported that one-quarter of women
presenting to a urogynaecology clinic described symptoms
the inner aspect of the labia majora to remove excess skin and of vaginal laxity. Risk factors included vaginal parity, young
adipose tissue, if required. age, urogenital prolapse and wider genital hiatus on Valsalva,
which may indicate levator ani hyperdistensibility.5 The
Labia majora tightening IUGA recommends use of the POP-Q scoring system when
Energy devices (CO2, Erbium:Yag or radiofrequency examining these patients, with the addition of the suffix ‘L’ to
devices18) have been used for skin tightening. denote the symptom of vaginal laxity. If significant prolapse
is noted, then this should be addressed first.8
Clitoral Surgical procedures for vaginal reduction aim to narrow
The clitoris is an organ composed of erectile tissue, which is either the genital hiatus and/or the entire vaginal calibre.
partially covered by a layer of keratinised squamous Treatments include posterior vaginal wall repair with perineal
epithelium called the clitoral hood. It comprises a glans, repair, isolated perineal repair, and lateral colporrhaphy
body, crura, suspensory ligament and vestibular bulbs, of (bilateral excision of vaginal epithelium from the posterior
which only the glans is visible externally. The prepuce of the lateral walls). A colpoperineorrhaphy aims to tighten the
clitoris, also called the clitoral hood, is formed by the more vaginal introitus while addressing the vaginal laxity. There is,
anterior folds of the labia minora, which unite to form a fold however, a paucity of good quality evidence for these
over the glans. This partially or completely covers the glans. procedures for cosmetic indications or improvement in
The posterior folds of the labia minora insert into the sexual function.8 A systematic review21 noted that, despite
underside of the glans as the frenulum of the clitoris. patient-reported satisfaction following surgery being high,

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Cosmetic gynaecology

there was little information regarding complications and overhang or drooping, and weight changes can make the
long-term effects. Given the limited data, it is important to overlying skin lax.
make clear to these women the uncertainties inherent in these
procedures and the potential for new onset dyspareunia.22 Mons pubis reduction
When documenting preoperative discussions, it is important Mons pubis reduction can be performed surgically or by
to clearly state whether this is a medically indicated liposuction. In surgical reduction, an elliptical piece of skin
procedure for prolapse or intervention to narrow the and fat is excised from the mons pubis, whereas liposuction is
vagina for laxity.23 performed using a cannula or ultrasound-assisted lipectomy.
This can cause adverse effects, such as oedema, haematoma
Vaginal tightening and loss of sensation.
Energy-based techniques for vaginal tightening include
radiofrequency devices, CO2 lasers or Erbium:YAG lasers.18 Mons pubis tightening
Radiofrequency devices are the most widely studied and have Energy devices are used to achieve tightening of the loose
been investigated in randomised trials. Other treatments with skin over the mons pubis. The effect will be less marked than
less evidence for vaginal rejuvenation include high-intensity surgical reduction.
focused ultrasound (HIFU). High-intensity focused
electromagnetic (HIFEM) devices and functional magnetic Genital hyperpigmentation
stimulation (FMS), on the other hand, are used for pelvic Hyperpigmentation can affect the vulva, perineum and anus.
floor strengthening. It can occur spontaneously, or following pregnancy, in
These procedures have shown overall improvement in certain medical conditions or induced by medication.
sexual function compared with placebo for sexual arousal,
lubrication and orgasm. Complications occur infrequently Depigmentation
and resolve spontaneously. However, there is no defined Depigmentation can be achieved by using energy devices18 or
optimum treatment regime or information about duration of topical treatments, such as chemical peels, glycolic acid peels
effect.8 Further work is required to define optimal treatment or use of agents, such as lactic acid or mandelic acid.
regimens and frequency of maintenance therapy, if required,
as well as continued monitoring of long-term Other procedures: hymenoplasty
complications.23 The US Food and Drug Administration Hymenoplasty is a surgical procedure involving
(FDA) has released warnings regarding the use of energy reconstruction of the hymen. It has been illegal to perform
devices in gynaecology given the potential for serious hymenoplasty in the UK since 2022. The procedure could be
complications. Such complications include burns, scarring, performed under local anaesthetic. It involved identifying the
altered sensation, dyspareunia, adhesions or vaginal stenosis, edges of the hymen and suturing them together, allowing
which may develop over time and may lead to a significant enough space for menstrual blood and vaginal fluid to pass.19
deterioration in sexual function.21 For all treatments Women seeking hymenoplasty were commonly seeking to
described above, this uncertainty of long-term impact must regain ‘virginity,’ especially in societies where women are
be discussed thoroughly with the patient and clearly expected to not have engaged in sexual activity before
documented before proceeding. marriage. In a study in the Netherlands,24 almost all the
women in the study who had opted for hymenoplasty had a
Vaginal augmentation fear of repercussions if they were perceived not to be virgins.
The G-spot, also known as the Grafenberg spot, is an area in The GMC’s advice about decision-making and consent for
the vagina that can lead to sexual arousal and orgasm when these procedures explains how medical professionals should
stimulated. G-spot amplification, or ‘G-shot,’ is designed to approach situations where there is concern that a patient is
enhance the erogenous area using a human collagen product. not making a decision freely. In situations where coercion
Effects of the treatment are thought to last for up to is suspected, seek advice from a medical defence union
4 months. There is no specific literature on how the or legal team.
procedure is performed, nor any studies exploring
outcomes or complications. Various fillers, including PRP,
Complications
hyaluronic acid and autologous fat transfer is used for G-spot
amplification. The evidence of efficacy is very limited. Complications that can arise after FGCS, and of which
women should be warned, are shown in Table 4. These can
Mons pubis range from minor complications not requiring medical
The mons pubis refers to the fat pad overlying the pubic intervention, to those requiring medical hospitalisation and
symphysis. Excessive skin or fat can give the appearance of an surgical reintervention, to catastrophic, potentially life-

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Bugeja et al.

evidence surrounding this conclusion and lack of long-term

Table 4. Complications after female genital cosmetic surgery
follow up.21,22
Common Rare FGCS procedures are not without risks and complications.
Immediate complications, such as bleeding or infection are
well acknowledged, yet long-term effects of scarring, and its
Infection Dyspareunia
effect on function and quality of life of these women, are
Bleeding Changes in sexual arousal unknown. Furthermore, some women may experience
psychological harm from complications, or dissatisfaction
Swelling Difficulty giving birth with the outcome of these procedures, with subsequent
Wound breakdown Difficulty with urination and bladder feelings of regret and negative impact on their life. Patients
(dehiscence) control should be fully informed about the potential risks and
benefits of FGCS procedures, as well as any alternative
Persistent sutures Need for revision surgery
treatments or nonsurgical options available. Providing
Scarring and keloid Sepsis information – and being honest with women about the
formation lack of evidence for these procedures – is crucial.
Emphasising that change to anatomy may not necessarily
Asymmetry/distortion Blood transfusion
bring positive change to function is important, especially in
Dissatisfaction women seeking surgical modification for anatomy within
normal limits. Medical professionals should ensure that
Altered sensation patients are undergoing FGCS for the right reasons and not
because of societal pressure or unrealistic beauty standards.
Patients’ physical and emotional wellbeing should be
prioritised and compassionate care provided throughout
the FGCS process. Clinicians performing FGCS must be
threatening complications. In their joint report on the aware that they do so without a clear evidence base. Women
terminology of FGCS, the IUGA and AUGS developed a should be advised accordingly. Fully informed consent is of
classification for complications and revisions.7 utmost importance when offering FGCS.
Education on normal anatomy and various appearances of
the labia and perineum can help women understand their
Ethics and the law
body better and alleviate concerns and anxieties surrounding
The popularity and demand for FGCS has grown appearance. A key ethical consideration is the impact that
considerably in recent years. However, the ethical FGCS can have on a woman’s body image and self-esteem.
implications of these procedures have been debated widely. Some argue that FGCS promotes unrealistic and narrow
There remains a paucity of information regarding the benefits ideals of the female genitalia, which can lead to feelings of
of certain procedures, risks and potential long-term inadequacy and shame for women who do not fit this ‘ideal’.
complications, the impact on body image and self-esteem, These procedures may also objectify women’s bodies and
and the role of medical professionals in providing informed reinforce harmful societal attitudes towards female sexuality.
consent and ethical care. Ultimately, the decision to undergo FGCS should be a
Advocates of FGCS argue that it can provide several personal one, made in consultation with a trusted medical
potential benefits for women with functional problems professional and with careful consideration of the potential
related to the size or appearance of their genital area. For risks and benefits of treatment and alternative options.
instance, women with enlarged labia or excess skin around
the clitoral hood may experience discomfort during activities,
Genital surgery in adolescents
such as exercise or sexual intercourse. These women may
benefit from labiaplasty or clitoral hood reduction. However, Labiaplasty is the commonest genital cosmetic surgical
women seeking labiaplasty often have labia within the normal procedure and refers to alteration of the structure and
limits of size and their primary reason for seeking surgery is (potentially) function of a healthy vulva. Perceptions of
aesthetic concern.25 Additionally, women with vaginal laxity perfect genitalia, including that the labia should be
following childbirth and who are experiencing sexual symmetrical, are among the most prominent aesthetic
dysfunction, may benefit from vaginoplasty, which can concerns in young women seeking surgical intervention.26
improve their quality of life. However, the same surgery The British Association of Aesthetic and Plastic Surgeons
can also lead to dyspareunia. High short-term rates of (BAAPS) and the British Society for Paediatric and
satisfaction have been reported; however, there is no robust Adolescent Gynaecology (BritSPAG) discourage any form

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Cosmetic gynaecology

of cosmetic labial surgery in young females aged under to practice in this subspecialty.19 A multidisciplinary team
18 years. In their code of conduct, they state that there is no (MDT) approach to care for women seeking genital cosmetic
scientific evidence to support labial reduction surgery in surgery would ensure adequate management and care for
children under 18, and that the risk of harm would outweigh the patient and may help avoid future problems such as
the benefits.18 Any surgery in those aged under 18 would litigation and patient dissatisfaction. Such standardised care
must only be performed in exceptional circumstances, with is not yet established in the field of FGCS, and there remains
adequate governance arrangements in place, and advice taken a lack of guidance on training and requirements for service
from hospital ethics and legal teams. accreditation from the relevant surgical professional bodies.
The labia continue to develop as part of normal pubertal FGCS should be undertaken by clinicians with the
growth. This development is completed once adulthood is appropriate training and expertise, adequate caseload and
reached. Given the continuing change in labial appearance and willingness to audit and report outcomes.
anatomy in adolescence, genital cosmetic surgery in this patient
cohort is likely to cause more harm than benefit. Any request
Disclosure of interests
for FGCS in an adolescent should be treated in a sensitive
There are no conflicts of interest.
manner and managed conservatively, with the option for
surgical intervention being revisited after 18 years of age.
Contribution to authorship
SJ instigated the manuscript. RB, JM and SJ researched, wrote
FGCS and female genital mutilation (FGM) and edited the manuscript. All authors approved the
FGCS and FGM are two distinct processes that involve altering final version.
of the female genitalia. FGCS is a voluntary surgical procedure
aimed at improving the aesthetic appearance of the external References
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14 ª 2023 Royal College of Obstetricians and Gynaecologists.

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ª 2023 Royal College of Obstetricians and Gynaecologists. 15