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A DELICATE SUBJECT Gynecological surgery is generally employed for vaginal laxity, while device-based treatments offer relief from external aesthetic concerns, urinary incontinence and lack of regional sensitivity. Experts on vaginal rejuvenation typically concur that each patient presents unique challenges, therefore com- bination treatment methods are most likely to achieve optimal outcomes. Treatm icat The term "vaginal rejuvenation" encompasses all proce- dures developed to improve and restore the natural youth- ful state of the vagina, but the generality of the term belies the wide range of concerns with which patients present. "Let me start out by saying that it's the worst, God-awful term," says Michael Goodman, MD, a gynecologist in Davis, California. "If someone wants vaginal rejuvenation— and by that they mean vaginal tightening—then they are not going to get that from any machine." Duxbury, Massachusetts-based plastic surgeon Christine Hamori, MD, agrees: "Vaginal tightening is not synonymous with vaginal rejuvenation, even though many equate the two terms." She explains that only surgical vaginoplasties can help to rebuild the muscles of the pelvic fl oor that become loose or slack due to age or childbirth. Recovery from this type of surgery is painful and sexual activity is restricted for up to six weeks. Noninvasive vaginal rejuve- nation, on the other hand, refers to the improvement of vaginal health. As women age, they may develop dryness, urinary incontinence, decreased orgasm strength and decreased sexual satisfaction. Laser and radiofrequency (RF)-based devices have been shown to improve these symptoms but the jury is still out on vaginal tightening. "CO 2 laser devices create columns of coagulation of the mucosa extending to the lamina propria. New collagen formation has been prov- en by histological studies, and women report decreased stress incontinence and improved sexual satisfaction," says Dr. Hamori. RF devices also stimulate collagen production and can be used internally and externally to temporarily tighten tissue. "The RF energy gently heats the tissue to revive feminine wellness with no discomfort or downtime," says Dima Ali, MD, of WellMedica Aesthetic & Anti-Aging Medicine in Reston, Virginia, who works with the ThermiVa RF device in her practice. "A specially designed handpiece is applied externally to the labia and vulvar tissues to restore normal tissue tone and function; as well as to the inside of the vagina to revive atrophic tissue and other structures." "In the beginning, we looked at RF devices as a way to tighten the vaginal canal but now we are using them for far more," says Red Alinsod, MD, a gynecologist in Laguna Beach, California, who helped develop the second-gener- ation ThermiVa device. "We're addressing the appearance of the entire vulval/vaginal structure and how it functions. With RF, we can treat all the way to the top of the vaginal canal, and treat the bladder side and the rectal side to obtain feminine restoration. It's not just skin tightening, it's improvement of blood fl ow and tissue softness." Dr. Goodman offers a range of vaginal tightening and re- juvenation treatments. He fi nds that lasers are effective for urinary incontinence issues; vaginoplasties are necessary to restore the pelvic fl oor; and patients with very thin skin due to lichen sclerosis benefi t from a combination of hormone cream, platelet-rich plasma (PRP) and laser resurfacing. "RF energy and laser energy resurface the skin but don't help if you just want to tighten the vagina or if you want to bulk up the opening," he says. "If you perform laser or RF treatments up at the very top of the vagina underneath the base of the bladder, it helps to strengthen the area, improves incontinence and it may help with widening way up at the top." For patients with excess external tissue, Dr. Goodman recommends surgery or RF treatments, though he notes that the results with the latter are temporary. "With these cases, I can surgically remove that excess skin, charge $5,000 and once it's done, it's done. Or I can adminis- ter RF treatments if the patient does not want surgery," he says. "Noninvasive RF can 'shrink' skin. This typically requires three to four sessions about a month apart, and it gives pretty decent shrinkage that will last about a year—if they're lucky." This method costs about $1,000 to $1,500, and the majority of Dr. Goodman's patients opt for the one-time surgery despite the higher cost. 30 MAY/JUNE 2017 | Med Esthetics " i h i s o ith t quate the two terms." © GETTY IMAGES