Demystifying Vaginoplasty

Monique Ramsey (00:01):
Welcome everyone to The La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey, and today I'm welcoming back Dr. Johan Brahme. Welcome Dr. Brahme.

Dr. Brahme (00:11):
Thank you, Monique.

Monique Ramsey (00:12):
So today we're going to talk a little bit about vaginal health and some women have no trouble opening up about that. But first, most people, it might be an uncomfortable conversation to have, especially with a male surgeon. And so I want to start out today with a consultation review from one of your patients. So after her consultation for vaginoplasty, here's what she said. "This is the sensitive procedure, and I appreciate the level of professionalism and how both doctor and nurse communicated direct and with intent. There was no beating around the bush or anything left up for interpretation. I left feeling educated and prepared to make a decision about the procedure." So how do you help make this conversation easy for women?

Dr. Brahme (01:05):
Well, first of all, I think that that's a very, very nice compliment, and I think it's a very common sort of response after a consultation regarding vaginoplasty. Most people go, oh, that wasn't so hard. And really, we treat it, we treat any other body part. It can by some people seem to be a little bit embarrassing and so on and so forth. But we just treat it, like I said, like any other body part. And the patient has a concern. We talk about the anatomy, we talk about what other people, what their concerns are. We tell them what we do an examination and we take pictures to discuss what their needs and wants are, and we take the stress off. And that really allows them to sort of relax and talk about what the problem is. And I think that that's a very valuable conversation to have. And a lot of this really comes from a ton of experience. I've done over 500 vaginoplasty over the last 10 years. And I think that having had that experience in communicating with the patients really puts them at ease.

Monique Ramsey (02:34):
Yeah, I would think that knowing you've done it and you're trusted and you've helped so many other women with the issues that they have, that would be comforting. So is there any particular age group or group of people that you're seeing wanting help in this area?

Dr. Brahme (02:54):
You know, most people obviously who come in for a vaginoplasty, and maybe I should explain what a vaginoplasty is.

Monique Ramsey (03:01):
Oh, that'd be good. Yeah, let's start there.

Dr. Brahme (03:05):
So that people know what we're talking about. Basically, vaginoplasty involves tightening up the vagina and the vaginal muscles to make sexual intercourse and intimacy more effective and more pleasurable for both partners. And that's the reason that most people come in for a vaginoplasty. And in technical terms, it's the pelvic floor that we sort of reconstruct because everything gets stretched out with childbirth. And those are really the patients that I see, the patients who've had multiple or sometimes one, but often multiple vaginal births and everything has been stretched out. The vagina itself has been stretched out, the vaginal muscles have been stretched out, and sometimes there just isn't the right contact for the pleasure of intimacy that was there before childbirth.

Monique Ramsey (04:08):
Right. And are there any sort of motivating events or occurrences that all of a sudden would make a woman decide it's time to fix this or have you been able to figure out any common theme?

Dr. Brahme (04:24):
Well, I think it's something that people don't talk about and even partners don't talk about it. But when they do start talking about it and then they can go online and read about it. And there's a lot more in the news about it now than there used to be. When I started doing these procedures vaginoplasty, it was something that was sort of hush hush and nobody talked about, and I went and got special training in doing this, and now it's a much more common theme, but still there are very few surgeons who specialize in this like I do. And so it can take a little searching and it's important that you find somebody to do this surgery who's done it before because it can be a little tricky and there's a lot of judgment involved and every woman is different and every woman has a different need. But I think it's a communication between the two partners that really spur people to come on in. And often women come in with their husbands and their husbands have questions and so on and so forth.

Monique Ramsey (05:45):
Now, since a lot of things for women's health, we go to our OBGYN for a lot of this stuff. And so is there a reason why a woman might choose a plastic surgeon over an OBGYN or do those doctors even do this procedure?

Dr. Brahme (06:02):
It's quite shocking to me that most OBGYNs don't do this procedures, and most OBGYNs don't even know anybody who does these procedures. So I occasionally but rarely get referrals from a gynecologists. I mostly get referrals from patients who've had friends who had this done or patients who read about it on our website or in popular magazines, popular Vogue has articles about it and so on. So it is not something that's done by gynecologists, which is surprising to me.

Monique Ramsey (06:43):
And now as we are thinking about you have a consultation, can you help us picture what that appointment looks like? And then how do you visualize em? You can't really look at before and after pictures of the vaginal canal since it's interior. So how do you help women decide what the right approach is and plan the surgery?

Dr. Brahme (07:07):
Yeah, so usually what happens is that the patient makes a phone call, makes an appointment for a vaginal plastic consultation, and usually they're seen by Christina, my nurse, and she has been with me and hundreds of consultations, so she knows exactly what I'm going to say, and she goes through and shows pictures that we have sort of diagrams of what we do of the musculature and the anatomy and so on and so forth. Then she gets me and I come in, introduce myself and basically asked the patient what their concern is. And I encourage them to really just treat this as, like I said, any other body part that we operate on that usually puts them at ease. And then what we do is that we do an examination to make sure that everything is okay, that there isn't anything else that needs attention, like uterine prolapse or bladder prolapse or things like that. And then we take a picture and then we discuss the picture. And there are external changes because the perineum, the area between the posterior vagina and the rectum does get stretched out. And we do close that up. So there are visible changes after a vaginoplasty too. And then I answer any questions they may have. And I usually say, well, that wasn't so bad, was it? And most people feel comfortable and that it was not a stressful situation afterwards.

Monique Ramsey (09:00):
Yeah, I can't imagine it being harder than a regular OBGYN visit at your normal yearly. Yeah,

Dr. Brahme (09:10):
And it's definitely less clinical and more attentive to their needs and answering their questions and so on and so forth, because this is elective surgery that they choose to do. And the satisfaction rate, I must say is remarkably high.

Monique Ramsey (09:37):
Now, how do you know how loose your vaginal canal is or how tight it should go? Is there some device that you use to help measure that or

Dr. Brahme (09:47):
No, not really. It's a match match between the partners and I always ask whether their partner is large or what they consider average or small and so on and so forth. And usually we try to make the vaginal canal and it's the first about two inches of the vaginal canal that we tighten because that's where the muscles are. And we tried to make that about two finger breaths in diameter, and that seems to be about right for most couples.

Monique Ramsey (10:27):
Now, speaking of the muscles, and you were talking about the pelvic floor. So could a woman say, yeah, I'm just going to do 500 Kegels a day and that'll get me to where I want to be? Would that work?

Dr. Brahme (10:42):
Sadly, for most patients who have this surgery, no. You can do kegels till the cows come home and it may bulk the muscles a little bit, but the muscles have separated, so the muscles need to really come back together. By doing the Kegels, you bulk up the muscles, but it doesn't tighten that gap in between the muscle. To do that, you really need to sew the muscles together, even though people say, oh, just do Kegels, you'll be fine maybe for a small number, but for most patients who really need this kegels are not going to solve the problem.

Monique Ramsey (11:25):
Do you think it's common for women to have no idea what's going on down there so they don't even know what to ask? Or do you feel like most women now with information on the web, they're more in tune to know what questions to ask you?

Dr. Brahme (11:40):
I think that with the information on the web, it opens the door, but I think it's still sort of a black box down there. And we were thinking about calling this podcast What's Up down there, which is the title of a book by a friend of mine. But in any case, first of all, most women don't know a what's normal. And I tell patients everything that I see is normal. It's just that they may not like it. The labia may be too large for them or they may be too loose, or there may be other things that are completely normal but they don't like, and those are the things that we address.

Monique Ramsey (12:31):
And what are those complaints that people typically come in with?

Dr. Brahme (12:35):
Well, probably the most common is that people come in with large or asymmetrical labia. And that's a very easy, and I'm not going to say totally painless, but almost painless, just some trimming of the labia and then closing it in an artful way. But in terms of vaginoplasty, the concern is almost always that there's a mismatch between the two partners. Although I have had patients who don't have a partner who have a vaginoplasty, maybe they're in between, they've gone through a divorce and they want to sort of rejuvenate. We also do this a lot as a part of sort of a quote mommy makeover. So this is sort of the crowning jewel on the mommy makeover.

Monique Ramsey (13:29):
Right. And that would make sense. I would think as we women go through life and you have childbirth and your kids get older, and then you start to look at yourself, things are quieter in the house, you have more time and you can think about yourself and you can think about what are the things that kind of bug you and how do we fix them. And do you find also that age plays a factor in any of this in terms of with our faces they get looser and skin gets more aged. Is that true also in the lady bits?

Dr. Brahme (14:07):
I see patients from late twenties up until their sixties. So it's not a certain age group. I would say probably most women have finished having children. I encourage that you can have vaginal childbirth after a vaginoplasty, but then you sort of undo all the work that's been done. So I recommend that people are done with childbirth.

Monique Ramsey (14:38):
You were talking about the extra skin for the labia, but then is also the clitoral hood. Is that something you can kind of trim at the same time? If there's a lot of skin right there,

Dr. Brahme (14:49):
And so that be part of it, or you have to be very careful not to expose the clitoris because if you do, it becomes very uncomfortable to walk. So you have get rubbing and it's just a very sensitive area. So yes, we can do a certain amount, but you certainly don't want to overdo it. But it becomes a part of, I would say 50% of the labia plasty that I do. We do some form of alteration of the clitoral hood so that it just looks natural. It would look weird if you just took the labia off and left the clits. It would just look abnormal. We try to make it look as if somebody has not had surgery.

Monique Ramsey (15:39):
Okay. So that leads me to an interesting question. Are there visible signs after the surgery that anything has been done?

Dr. Brahme (15:47):
That area has such great blood supply, it heals so well. I've had maybe one or two patients who had little problems healing, a little delayed healing, but I've never had anybody who didn't heal, never had anybody who had prolonged pain after intercourse. It's a very satisfying procedure both for me and for the patient.

Monique Ramsey (16:16):
And for maybe the partner.

Dr. Brahme (16:18):
And for the partner too. Yeah, absolutely. Oh yeah. This is something that keeps giving to everybody,

Monique Ramsey (16:24):
Right. The gift that keeps on giving. So do you have specific instructions for a patient preparing for vaginoplasty or is it more that you have more specific things for them to do after?

Dr. Brahme (16:38):
It's more after. We don't want people to be constipated, and we go through all of these in the pre-op and how to prepare them and so on. But obviously we prefer them not to be on their period when they have their surgery. But we've done that too and it turns out well. So there's not a lot of preparation, but we go through all that so that the patients are very well prepared prior to surgery, so they know what's going to happen to them, they know what to expect. It's very rare that we have any complications or anything like that.

Monique Ramsey (17:20):
Now, what is the downtime involved in something like this?

Dr. Brahme (17:23):
So the downtown for labiaplasty, I would say it's about a weekend. So you can have this done on Friday and go to work on Monday. For a vaginoplasty, it's a little more uncomfortable because we're tightening the muscles, and so it feels very, very tight down there. And so I tell people, give yourself a good week to relax. And in terms of resuming sexual intercourse, usually between six to two, eight weeks afterwards. And then we give them instructions on how to use lubrication and sort of minimize the discomfort. And we see the patients fairly frequently after surgery to keep an eye on them and reassure them that everything is okay and make sure that everything is healing well and so on. And in terms of scars, I can tell you you're hard pressed to see any scars at all after this. It heals so well.

Monique Ramsey (18:35):
And do you have any restrictions for them besides sexual intercourse, which makes total sense? What about going to the gym and heavy lifting or anything?

Dr. Brahme (18:45):
Yeah. Heavy lifting I don't like in the early periods because it raises the blood pressure and can cause some bleeding. So I tell patients, no heavy lifting for about two weeks at a month, they can go to the gym, they can be pretty active, and then at six to eight weeks they can start having sex again.

Monique Ramsey (19:06):
And then for the consultation, is it possible to do a Zoom consult for something like this, or do you need to see them in person?

Dr. Brahme (19:15):
We can do a Zoom consult, but I insist on seeing every patient before, you know, we don't have a Zoom consult and then do surgery on the basis of that. We can do a Zoom consult and talk about it. Obviously we can't do an examination and so on, so that would have to be done in person.

Monique Ramsey (19:38):
And then in that in-person consultation, who's with you in that room?

Dr. Brahme (19:44):
Okay, that's a very good question because, so it's just me, it's the patient, and then usually Christina who's my nurse and maybe the husband or significant other. But from the office, it's just me and a nurse.

Monique Ramsey (20:02):
So it's nice and private.

Dr. Brahme (20:04):
It's very private. Yeah, it's very private. We try to make it as low stress as possible, and I think we succeed.

Monique Ramsey (20:13):
What advice would you give to a woman who's considering this?

Dr. Brahme (20:17):
To speak to somebody who's experienced to make sure that this is something that they do frequently and then get maybe some referrals. Look at reviews. Reviews are always very helpful. I look at reviews before I do anything, and then meet the surgeon, make sure they're board certified, make sure that the office is qualified and that they use anesthesiologist, and just that everything is above board. And then see how you click with your surgeon. And we have photos in the office so we can show both vaginoplasty and labiaplasty and other vaginal rejuvenation surgery. You should feel good and confident about your surgeon when you leave the office.

Monique Ramsey (21:10):
Yeah, I think that you're all on the same team feeling. As a patient, I feel I've been heard and that you have acknowledged what I've said and that we sort of have a good plan as a team. I think that's a good feeling to have.

Dr. Brahme (21:27):
And I think it's important also that you see somebody who does this often and not just somebody who does this every once in a while twice a year or something like that. This can be a tricky operation and it requires care and precision. If you've done it many times, it's not that hard, but if you haven't, you can run into trouble.

Monique Ramsey (21:56):
And I don't think any woman out there, at least if there are anything like me, we don't want to be the Guinea pig. We'd rather know that you've done it hundreds and hundreds of times and you've seen it.

Dr. Brahme (22:10):
Right? And it's the same with everything. It's just the level of experience that's important.

Monique Ramsey (22:16):
That expertise and you specializing in it and having done so many over such a long period of time. I think that's really reassuring for women out there to know that not only is this something that can be fixed, that you can have things tightened and trimmed up and looking much better and feeling much better, but that there's somebody out there who's really good at that for them.

Dr. Brahme (22:42):
Yeah. Yeah, I agree with you. I agree with you. I enjoy it. I enjoy my patients. I enjoy their success and their feeling good about themselves, and I get thank yous every day from patients saying it was the best thing I ever did. So it's a good procedure. I'm happy to be doing it. I'm glad we have this talk so that we can demystify it for the prospective audience and patients.

Monique Ramsey (23:16):
So on our website, we have everything in terms of information about the procedures we have before and after pictures, except for this procedure. We don't have those online. Those are private, but you see them at your consultation. But then there's also information on healing, and you can read reviews of patients, read more about Dr. Brahme and his expertise, and then we'll have all the links in the show notes for you so that know how to reach out if and when you're ready for that consultation. We're here every day, and we've been here every day for 35 years, so at 35 years, we're not going anywhere. And I think that's also something that as a patient, you want to know that worst case, if something isn't going right, that you're still around.

Dr. Brahme (24:06):
We're going to be here.

Monique Ramsey (24:07):
You're going to be here. Exactly. Exactly.

Dr. Brahme (24:09):
Yeah. And in one month I will have been here for 20 years.

Monique Ramsey (24:14):
I love that.

Dr. Brahme (24:15):
Yeah.

Monique Ramsey (24:16):
I love that. Yeah.

Dr. Brahme (24:17):
I'm going to be here for another few more, so

Monique Ramsey (24:20):
Yeah. Yeah. We're not going to let you retire yet.

Dr. Brahme (24:24):
No, no, not anytime soon.

Monique Ramsey (24:25):
Well, thanks for joining us, Dr. Brahme, and for helping to demystify and share about vaginoplasty and vaginal rejuvenation surgery and sort of make it more normal, cuz it is normal.

Dr. Brahme (24:40):
It is normal.

Monique Ramsey (24:41):
And so thank you again, and we'll see you all on the next show.

Dr. Brahme (24:45):
Thank you. Thank you, Monique, and happy new year to everybody.

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