



Image from Flickr via Infinite Jeff

By Kirsten O’Regan

Editor’s note: All patient names have been changed to protect their privacy.

I am perched on the edge of an examination table, naked except for an open-backed, pink hospital gown. The garment is appropriately girly for The Manhattan Center for Vaginal Surgery, and isn’t the only feminine touch in the consultation room. Behind me on the bed is a plump, red brocade cushion; glancing to my right, I catch sight of myself in an ornate, gold-framed mirror. A pink curtain hangs ready to surround the bed. Against these carefully chosen comforts, the surgical gloves, lubricant and anatomical diagrams of female genitalia distributed throughout the room seem incongruous and vaguely sinister. A poster on the wall shows a female body swathed in a gauzy fuchsia material. “Rejuvenate. Repair. Rejoice,” it commands.

The door opens abruptly and Dr. Ronald Blatt bustles into the room, garbed in surgical scrubs and trailed by an eager young nurse. Blatt is all reassuring smiles, firm handshake and businesslike manner.

“Righteo, what are you interested in?” he asks.

“Labiaplasty,” I say.

“Oh yes, you’re not alone.”

Labiaplasty is a procedure which trims the labia minora (the inner lips of the vulva) to fit neatly within the outer lips. (“Neatness counts,” Dr. Blatt’s website proudly proclaims.) It is just one of a number of increasingly popular “vaginal rejuvenation” surgeries offered by discerning plastic surgeons and gynecologists across America and the globe. Also known as cosmetic gynecology, this field includes procedures designed to reduce the size of the labia minora and the labia majora (the outer lips), tighten the vagina (known as vaginoplasty), reduce the size of the clitoral hood, reconstruct the hymen and even enlarge the g-spot.

The surgery is relatively unregulated and frequently botched, as indicated by the staggering number of clinics that advertise discreet revisions of bungled previous surgeries.

The American College of Aesthetic Plastic Surgeons recorded 2,140 vaginal rejuvenation surgeries in 2010. The International Society of Aesthetic Plastic Surgeons estimates that 5,200 procedures are performed annually. While this is markedly less than breast augmentation surgeries, over 300,000 of which were performed in 2011, the figures are alarming given the relative newness of vaginal rejuvenation procedures—the first recorded labiaplasty occurred in 1984, but the surgery remained relatively obscure until the late 90s—and the lack of auditing and regulation in the field. According to the American Society for Aesthetic Plastic Surgery, the vaginal rejuvenation industry was worth around $6.8million in 2009. This number is now undoubtedly much higher and does not take into account any procedures performed by gynecologists.

Labiaplasty is the most popular vaginal rejuvenation procedure. In 2012, the BBC reported that Britain had seen a fivefold increase in the surgery in the last five years. Dr. Blatt recalls that seven years ago, when he first began performing the procedure in New York, there were only two such clinics in the city. “When we started, no one else was doing it,” he says. “Now everyone is.”

While labiaplasty is increasingly popular, it remains controversial, sparking debate within the medical profession broadly, among specialists, and in wider society. The surgery is relatively unregulated and frequently botched, as indicated by the staggering number of clinics that advertise discreet revisions of bungled previous surgeries. At the same time, detractors claim that women have been manipulated by the media to believe in a mythical “perfect vagina.” Some women undergo labiaplasty for medical or practical reasons—large labia can cause irritation and pain during sex and exercise—but the vast majority elect to undergo the surgery for cosmetic purposes, anxious to achieve a more attractive genital area. The desired “look” is consistently that of a smaller, less obtruding vulva, with “neat,” even labia, and this “streamlined” ideal is becoming increasingly minimalist.

“But I kept getting patients who wanted almost all of it off. They would come in and say, I want a ‘Barbie.’ So I developed a procedure that would give them this comfortable, athletic, petite look, safely.”

Dr. Red Alinsod, a urogynecologist in Laguna Beach, California, claims that his most requested surgical procedure is the Barbie: a procedure that excises the entire labia minora. This results in a “clamshell” aesthetic: a smooth genital area, the outer labia appearing “sealed” together with no labia minora protrusion. Alinsod tells me he invented the Barbie in 2005. “I had been doing more conservative labiaplasties before then,” he says. “But I kept getting patients who wanted almost all of it off. They would come in and say, I want a ‘Barbie.’ So I developed a procedure that would give them this comfortable, athletic, petite look, safely.”

Dr. Gary Alter, a urologist and plastic surgeon who practices in both Beverly Hills and Manhattan, is dismissive of Alinsod’s aesthetic. “He and I have completely different philosophies and techniques,” he says. “His Barbie thing, I completely disagree with.” I am seated with Alter in the cavernous lobby of the Grand Hyatt Hotel: all polished marble, glass, and shimmering pools of water. The besuited conference-goers milling around would no doubt be disturbed by the piles of surgical snapshots that Alter—wearing an open-necked yellow shirt, square black-framed glasses, and more hair gel than is usual in a middle-aged man—uses to illustrate his comments.

“Women wanna reduce as much as possible while still looking normal,” he says. To this end, he developed the “Alter labia contouring” procedure. Rather than simply trimming or amputating the labia, this technique removes a wedge-shaped segment of tissue from the central section of each inner lip, then sutures the upper and lower edges of the excision together, creating smaller labia from the remaining tissue. The idea is to reduce the size of the labia while preserving the normal color and contour of the labia edge. “If you do it my way it takes much more skill and time, but you can’t over-remove,” he says. It’s not entirely foolproof though. “It can fall apart,” admits Alter, referring to the stitches keeping the upper and lower portions of each labia together. “But I haven’t had one fall apart in about a thousand.”

Back in the consultation room of the Manhattan Center for Vaginal Surgery, Dr. Blatt also mentions this potential complication: he advises against doing any “lower body exercise” post-surgery because “we don’t want you to be doing anything that might pop the stitches.” His preferred technique is a ‘wedge’ procedure similar to Alter’s, and he describes what this involves by gesturing at anatomical posters, before taking a look at the labia in question. My feet go into furry pink stirrups, knees pointing straight up. The nurse gives me a small hand-mirror to better observe the proceedings. Blatt uses both hands to tweak and tug the lips, folding them down to demonstrate his vision. “Basically, if you can imagine it’ll be a straight line down from your clitoris,” he says. “Nice and tidy.”

…I will recover in boudoir-esque quarters which Diane points out to me, opening the door for a quick peek. The room is dimly lit, filled by a vast bed with luxurious red brocade covers.

The consult is brisk. Afterward, an enthusiastic nurse named Diane bustles in. “Don’t you just love Dr. Blatt?” she asks. “Oh, he’s such a gem!” She outlines the surgical procedure. “We put you straight to sleep,” she assures, “and Dr. Blatt does all the cutting and sewing himself.” The surgery takes around an hour and a half, and I will recover in boudoir-esque quarters which Diane points out to me, opening the door for a quick peek. The room is dimly lit, filled by a vast bed with luxurious red brocade covers. Wall-mounted mirrors give the illusion of expanse. “I like my ladies to be comfortable!” trills Diane. After resting I will be fed snacks (“We do treat our ladies well!”). Pain medication is provided for a few days, but “the ladies tell me that after the second day, they stop taking it.”

The ladies, however, are not always so lucky. Diane recounts a story of a woman who came for a consult, but went to a cheaper surgery for the procedure. “She came back and said, I don’t look like your pictures! He had gone and cut the labia right off! And there was nothing the doctor could do for her.” Diane looks aghast, her earnest face uncomfortably close to mine. “We all cried for that girl.” She cheers up when she considers my own situation. “I guarantee you’re gonna be so pleased!”

Unfortunately, the labia-less woman Diane describes is hardly the only victim of inexperienced or insensitive surgeons. Alter estimates that 20 percent of his labiaplasties are performed to rectify the mistakes of previous surgeries. “I’m not mentioning names,” he says, “but some of the famous gynecologists—I’ve done a lot of revisions on their surgery.” Many women, he claims, are given Barbie-style surgeries without their consent, resulting in the amputation of the entire inner labia. Alinsod concurs. “The Barbie’s a great procedure if that’s what the patient wants,” he says. “The problem with this surgery, frankly, is that it looks easy, but there’s a lot of finesse involved. If you don’t know those nuances, you’re going to have dog-ears, or complete removal of the labia when that’s not what’s requested. That’s when the lawsuits occur.”

Alter confirms that there is a lot of suing in the business, and attributes widespread malpractice to inexperienced surgeons seduced by the money. The financial situation of many doctors has become increasingly less cushy due to diminishing insurance reimbursements, increasing drug costs, and changing regulations. In response, Alter says, “A lot of doctors start doing stuff they haven’t been trained in because it’s a way to supplement income.” The average labiaplasty procedure can cost anywhere from $2000 to $6000. One New York City office quotes a price of $5900, before informing me of their October special: were I to come in the next day, the procedure would cost only $2000. An anesthesiologist puts it plainly: “Plastic surgery in private practice is really about money-farming.”

The lack of collaboration between gynecologists and plastic surgeons is one explanation for the dearth of labiaplasty training and regulation. “There are too many specialties doing it,” says Alter. “There’s more doctors doing it, more demand for it.” He implies that gynecologists are mostly to blame for botched surgeries, as there is no peer review of cosmetic procedures within that specialty.

In 2007, the American College of Obstetrics and Gynecology opined that vaginal rejuvenation procedures “are not medically indicated, and the safety and effectiveness of these procedures have not been documented.” They concluded, “It is deceptive to give the impression that… any such procedures are accepted and routine surgical practices.” The American Board of Obstetrics and Gynecology (the accrediting institution) does not recognize cosmetic gynecology as a valid sub-specialty, thus surgeons need not obtain certification. This rejection may gradually be being rescinded. At its annual meeting in Rome last year, the Federation of International Gynecologists and Obstetricians included for the first time, to the surprise and displeasure of some, an extended presentation on cosmetic gynecology.

Please check back tomorrow for Part II of Kirsten O’Regan’s investigation.

Kirsten O’Regan is a freelance writer and student. She was born in England, raised in South Africa and New Zealand, and is currently completing a master’s degree at New York University.