Cosmetic Dermatology

Noninvasive Vaginal Rejuvenation

Cutis. 2018 October;102(4):243-246

References

Koning M, Zeijlmans IA, Bouman TK, et al. Female attitudes regarding labia minora appearance and reduction with consideration of media influence. Aesthet Surg J. 2009;29:65-71.
Rowen TS, Gaither TW, Shindel AW, et al. Characteristics of genital dissatisfaction among a nationally representative sample of U.S. women. J Sex Med. 2018;15:698-704.
Berman L, Berman J, Miles M, et al. Genital self-image as a component of sexual health: relationship between genital self-image, female sexual function, and quality of life measures. J Sex Marital Ther. 2003;29(suppl 1):11-21.
Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Menopause. 2014;21:1063-1068.
Goodman MP, Placik OJ, Benson RH 3rd, et al. A large multicenter outcome study of female genital plastic surgery. J Sex Med. 2010;7(4 pt 1):1565-1577.
Ostrzenski A. Vaginal rugation rejuvenation (restoration): a new surgical technique for an acquired sensation of wide/smooth vagina. Gynecol Obstet Invest. 2012;73:48-52.
Singh A, Swift S, Khullar V, et al. Laser vaginal rejuvenation: not ready for prime time. Int Urogynecol J. 2015;26:163-164.
Iglesia CB, Yurteri-Kaplan L, Alinsod R. Female genital cosmetic surgery: a review of techniques and outcomes. Int Urogynecol J. 2013;24:1997-2009.
Dobbeleir JM, Landuyt KV, Monstrey SJ. Aesthetic surgery of the female genitalia. Semin Plast Surg. 2011;25:130-141.
US Food and Drug Administration. FDA warns against use of energy-based devices to perform vaginal ‘rejuvenation’ or vaginal cosmetic procedures: FDA safety communication. July 30, 2018. https://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm615013.htm. Accessed September 10, 2018.
Patil UA, Dhami LD. Overview of lasers. Indian J Plast Surg. 2008;41(suppl):S101-S113.
Qureshi AA, Tenenbaum MM, Myckatyn TM. Nonsurgical vulvovaginal rejuvenation with radiofrequency and laser devices: a literature review and comprehensive update for aesthetic surgeons. Aesthet Surg J. 2018;38:302-311.
Zerbinati N, Serati M, Origoni M, et al. Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment. Lasers Med Sci. 2015;30:429-436.
Salvatore S, Nappi RE, Zerbinati N, et al. A 12-week treatment with fractional CO₂ laser for vulvovaginal atrophy: a pilot study. Climacteric. 2014;17:363-369.
Eder SE. Early effect of fractional CO₂ laser treatment in post-menopausal women with vaginal atrophy. Laser Ther. 2018;27:41-47.
Perino A, Calligaro A, Forlani F, et al. Vulvo-vaginal atrophy: a new treatment modality using thermo-ablative fractional CO₂ laser. Maturitas. 2015;80:296-301.
Filippini M, Del Duca E, Negosanti F, et al. Fractional CO₂ laser: from skin rejuvenation to vulvo-vaginal reshaping. Photomed Laser Surg. 2017;35:171-175.
Cruz VL, Steiner ML, Pompei LM, et al. Randomized, double-blind, placebo-controlled clinical trial for evaluating the efficacy of fractional CO₂ laser compared with topical estriol in the treatment of vaginal atrophy in postmenopausal women. Menopause. 2018;25:21-28.
Preissig J, Hamilton K, Markus R. Current laser resurfacing technologies: a review that delves beneath the surface. Semin Plast Surg. 2012;26:109-116.
Kaushik SB, Alexis AF. Nonablative fractional laser resurfacing in skin of color: evidence-based review. J Clin Aesthet Dermatol. 2017;10:51-67.
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Lee MS. Treatment of vaginal relaxation syndrome with an erbium:YAG laser using 90 degrees and 360 degrees scanning scopes: a pilot study & short-term results. Laser Ther. 2014;23:129-138.
Gaspar A, Brandi H, Gomez V, et al. Efficacy of erbium:YAG laser treatment compared to topical estriol treatment for symptoms of genitourinary syndrome of menopause. Lasers Surg Med. 2017;49:160-168.
Gambacciani M, Levancini M, Cervigni M. Vaginal erbium laser: the second-generation thermotherapy for the genitourinary syndrome of menopause. Climacteric. 2015;18:757-763.
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Lasers

CO₂ Laser
The infrared CO₂ laser utilizes 10,600-nm energy to target and vaporize water molecules within the target tissue. This thermal heating extends to the dermal collagen, which stimulates inflammatory pathways and neocollagenesis.¹¹ The depth of penetration ranges from 20 to 125 μm.¹² Zerbinati et al¹³ demonstrated the histologic and ultrastructural effects of a fractional CO₂ laser on atrophic vaginal mucosa. Comparing pretreatment and posttreatment mucosal biopsies in 5 postmenopausal women, the investigators found that fractional CO₂ laser treatment caused increased epithelial thickness, vascularity, and fibroblast activity, which led to augmented synthesis of collagen and ground substance proteins.¹³

New devices seek to translate these histologic improvements to the aesthetic appearance and function of female genitalia. The MonaLisa Touch (Cynosure), a new fractional CO₂ laser specifically designed for treatment of the vaginal mucosa, uses dermal optical thermolysis (DOT) therapy to apply energy in a noncontinuous mode at 200-μm dots. Salvatore et al¹⁴ examined the use of this device in a noncontrolled study of 50 patients with GSM, with each patient undergoing 3 treatment sessions at monthly intervals. Intravaginal treatments were performed at the following settings: DOT (microablative zone) power of 30 W, dwell time of 1000 μs, DOT spacing of 1000 μm, and SmartStack parameter of 1 to 3. The investigators used the Vaginal Health Index (VHI) to objectively assess vaginal elasticity, secretions, pH, mucosa integrity, and moisture. Total VHI scores significantly improved between baseline and 1 month following the final treatment (mean score [SD], 13.1 [2.5] vs 23.1 [1.9]; P<.0001). There were no significant adverse events, and 84% of patients reported being satisfied with their outcome; however, the study lacked a comparison or control group, raising the possibility of placebo effect.¹⁴

Other noncontrolled series have corroborated the benefits of CO₂ laser in GSM patients.^15,16 In one of the largest studies to date, Filippini et al¹⁷ reviewed the outcomes of 386 menopausal women treated for GSM. Patients underwent 3 intravaginal laser sessions with the MonaLisa Touch. Intravaginal treatments were performed at a DOT power of 40 W, dwell time of 1000 μs, DOT spacing of 1000 μm, and SmartStack of 2. For the vulva, the DOT power was reduced to 30 W, dwell time of 1000 μs, DOT spacing of 1000 μm, and SmartStack of 1. Two months after the final treatment session, patients completed a nonvalidated questionnaire about their symptoms, with improved dryness reported in 60% of patients, improved burning in 56%, improved dyspareunia in 49%, improved itch in 56%, improved soreness in 73%, and improved vaginal introitus pain in 49%. Although most patients did not experience discomfort with the procedure, a minority noted a burning sensation (11%), bother with handpiece movement (6%), or vulvar pain (5%).¹⁷

Recently, Cruz et al¹⁸ performed one of the first randomized, double-blind, placebo-controlled trials comparing fractional CO₂ laser therapy, topical estrogen therapy, and the combination of both treatments in patients with GSM. Forty-five women were included in the study, and validated assessments were performed at baseline and weeks 8 and 20. Intravaginal treatments were performed at a DOT power of 30 W, dwell time of 1000 μs, DOT spacing of 1000 μm, and SmartStack of 2. Importantly, the study incorporated placebo laser treatments (with the power adjusted to 0.0 W) in the topical estrogen group, thereby decreasing result bias. There was a significant increase in VHI scores from baseline to week 8 (P<.05) and week 20 (P<.01) in all study arms. At week 20, the laser group and laser plus estrogen group showed significant improvements in reported dyspareunia, burning, and dryness, whereas the estrogen arm only reported improvements in dryness (all values P<.05).¹⁸

Erbium-Doped YAG Laser
The erbium-doped YAG (Er:YAG) laser is an ablative laser emitting light at 2940 nm. This wavelength provides an absorption coefficient for water 16 times greater than the CO₂ laser, leading to decreased penetration depth of 1 to 3 μm and reduced damage to the surrounding tissues.^19,20 As such, the Er:YAG laser results in milder postoperative discomfort and faster overall healing times.²¹

In a noncontrolled study of vaginal relaxation syndrome, Lee²² used an Er:YAG laser fitted with Petit Lady (Lutronic) 90° and 360° vaginal scanning scopes. Thirty patients were divided into 2 groups and were treated with 4 sessions at weekly intervals. In group A, the first 2 sessions were performed with the 360° scope, and the last 2 sessions with the 90° scope in multiple micropulse mode (3 multishots; pulse width of 250 μs; 1.7 J delivered per shot). Group B was treated with the 90° scope in all 4 sessions in multiple micropulse mode (same parameters as group A), and during the last 2 sessions patients were additionally treated with 2 passes per session with the 360° scope (long-pulsed mode; pulse width of 1000 μs; 3.7 J delivered per shot). Perineometer measurements taken 2 months after the final treatment showed that the combined patient population experienced significant increases in both maximal vaginal pressure (P<.01) and average vaginal pressure (P<.05). Roughly 76% of patients’ partners noted improved vaginal tightening, and 70% of patients reported being satisfied with their treatment outcome. Histologic specimens taken at baseline and 2 months postprocedure showed evidence of thicker and more cellular epithelia along with more compact lamina propria with denser connective tissue. The sessions were well tolerated, with patients reporting a nonpainful heating sensation in the vagina during treatment. Three patients from the combined patient population experienced a mild burning sensation and vaginal ecchymoses, which lasted 24 to 48 hours following treatment and resolved spontaneously. There was no control group and no reports of major or long-term adverse events.²²

Investigations also have shown the benefit of Er:YAG in the treatment of GSM.^23,24 In a study by Gambacciani et al,²⁴ patients treated with the Er:YAG laser FotonaSmooth (Fotona) every 30 days for 3 months reported significant improvements in vaginal dryness and dyspareunia (P<.01), which lasted up to 6 months posttreatment, though there was no placebo group comparator. Similar results were seen by Gaspar et al²³ using 3 treatments at 3-week intervals, with results sustained up to 18 months after the final session.

Noninvasive Vaginal Rejuvenation

References

Lasers

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