INTRODUCTION

Physiologic and anatomic changes occur in the female reproductive system from birth to

menopause and are directly influenced by hormonal levels. These changes can lead to

laxity of the female reproductive organs that can cause significant symptoms in women.

[4ri]

Aging, menopause, childbirth, obesity, and many other factors contribute to vulvovaginal

laxity (VVL) and vaginal atrophy. These changes can significantly impact quality of life,

but women rarely discuss them, even with their physicians. [1 RI]

As women age, the external genitalia and labia majora undergo changes in elasticity due

to decreases in collagen and elastin. The labia majora becomes smaller in size, while the

labia minora enlarge. Decreased subcutaneous fat can also be observed. [2 RI]

Surgical procedures give patients the option to modify, enhance, or improve the

appearance of their external genitalia. However, surgery of the labia majora has been

found to be complicated by bleeding and considerable down time [4] [8 RI]

Dermal fillers have a broad range of use in dermatology and aesthetic medicine including

facial rejuvenation and volume restoration, the correction of wrinkles, facial defects, acne

scars, and for lipodystrophy, including HIV-associated lipoatrophy. [8 RI]

As with other parts of the body there is now an increasing demand for genital

rejuvenation procedures; [1 RI] Soft tissue augmentation with biostimulators have been

used off label to alleviate volume loss and laxity in the labia majora and mons pubis.
Rejuvenation of the labia majora is able to improve the aesthetic aspect of the external

genitalia, producing a more youthful appearance, while augmentation of the mons pubis

could improve discomfort during intercourse reducing trauma along the pubic bone [3 RI]

Poly-L- lactic acid (PLLA) is a biocompatible, biodegradable, synthetic polymer able to

be tailored into various desired morphologic features. (2,3) [6 RI]

In 2004, injectable PLLA received food and drug administration (FDA) approval under

the trade name Sculptra® (Galderma, Lausanne, Switzerland) for the treatment of HIV-

associated lipoatrophy. (4) [6 RI]

The mechanism through which it stimulates neocollagenesis, is by triggering a foreign

body reaction to the injected material, succeeded by a cellular inflammatory response

which leads to the formation of vascularized, connective tissue.(1,5,6,7) PLLA is

presented as freeze-dried preparation of 150mg per vial and, according to consensus, the

recommendation on your preparation is hydrate in sterile water for injection (SWFI) or

bacteriostatic water at room temperature for ≥24 hours. (8) [6RI]

Calcium hydroxyapatite filler (CaHA) consists of 30% calcium hydroxyapatite

microspheres and 70% sodium carboxy- methylcellulose (CMC) gel. 8 Following

injection, the gel starts to be slowly absorbed, whereas the microspheres are free to

stimulate collagenesis.9 Thus, the first volume effect gradually occurs as long as the gel

is absorbed. Collagen production increases, and laxity becomes lighter. Thus, the ller is

slowly replaced by autologous connective tissue (eg, neocollagen and elastic bers) via

biostimulation.10
Both products are not approved for gynecological indication in Brazil.

ANATOMY

Structures

An understanding of the anatomy of the external female genitalia is critical to

successfully administering rejuvenation therapies in this area. [1 RI]

The vulva comprises several major structures: the mons pubis, labia majora, labia minora,

clitoris, vag- inal introitus, and the urethral orifice (Figure 1). [1 RI]

The vaginal wall is composed of four layers: nonkera- tinized strati ed squamous

epithelium, lamina propria, mus- cular layer, and adventitia. The nonkeratinized strati ed

squamous epithelium is rich in glycogen, while the lamina propria is composed of dense

connective tissue, collagen, elastin, and blood vessels. The muscular layer is comprised

of smooth muscle, and the adventitia contains loose connec- tive tissue, collagen, and

elastin. [2 RI]
Vasculature/Innervation

Blood supply to the vulva is mainly from branches of the pudendal artery, although the

mons pubis is sup- plied by the inferior epigastric artery, a branch of the external iliac

artery (Figure 2). The blood supply to the vagina is primarily derived from the vaginal

artery, which is a branch of the anterior division of the internal iliac artery. The vagina

also receives some of its vascu- lature from branches of the pudendal arteries. [1 R1]

The anterior vulva is innervated by the ilioinguinal nerve medially, over the mons pubis,

and the genital branch of the genitofemoral nerve laterally. The pos- terior vulva receives

its innervation from the pudendal nerve and the posterior cutaneous nerve of the thigh.

Most of the innervation to the vagina is from the autonomic nervous system, although the

distal vagina is innervated by the pudendal nerve. [1RI]

INFILTRATION TECHNIQUE

CaHA reconstitution

CaHA was diluted 1:1 with two sterile polypropylene syringes to mix 1.5 ml of CaHA

(Radiesse, Merz) with 1.0 ml of sodium chloride 0.9% and 0.5 ml lidocaine (2%) using a

female-to- female Luer lock connector, a total of 3 mL of CaHA,

Immediate PLLA reconstitution

Rubber cover was clean with an antiseptic solution (0.5% alcoholic chlorhexidine) and at
room temperature, it was added 5mL SWFI to the powder, on the side of the vial and

followed by immediate vigorous 1 minute agitation. This suspension was aspirated

through hypodermic needle 40mm X 12mm blunt tip to a 20 ml luer lock syringe and it

was added 5mL SWFI and 2mL 2% lidocaine without vasoconstrictor and it was mixed at

1-minute intervals until a uniform translucent suspension was obtained, producing a total

of 12ml of PLLA. This suspension was transferred to four 3 ml syringes.

Technique

Labia Majora

Before injection, the entry points for the cannula were marked 1 cm above the superior

border of both labia majora and a local anesthetic (0.1 ml lidocaine 1% with adrenalin

1:200.000) was injected at the entry points for anesthesia and hemostasis. A 21G needle

was used to make an opening through the skin and the 22G cannula was introduced

through this aperture. Using a retrograde fanning technique, the product was evenly

distributed along both labia majora (1.5 ml each side) at the junction of the dermal-

subdermal plane (Figure 3). To ensure correct injection depth, the skin was stretched in

the direction of the cannula, while the exibility of the cannula was used to point the tip

towards the dermis while advancing. A rolling technique, where the syringe was rolled

between thumb and index finger, was used to overcome any resistance to the trajectory of

the cannula. e patient reported no discomfort during the procedure. After injection, the

product was manipulated to ensure homogenous distribution in the labia majora.

Mons Pubis

To aesthetically improve the mons pubis, in particular, the area directly superior to the

clitoral hood to further hide the clitoral hood. An entrance point was selected in the

midline approximately 2 cm inferior to the skin fold and pubic hairline. Using the same

fanning technique, the area of the mons pubis and the superior part of the labia majora

were treated (Figure 4).

Once infiltration is complete, the operator can homogeneously distribute the filler with a

mild massage.

In order to avoid intravascular injection, the product should be injected slowly and

gently. Some injectors prefer to administer a topical antimicrobial and antimycotic

prophylactic treatment due to the frequent contamination of the vulvar area by yeast and

bacteria from the vagina and anus. [3 RI]

ADVERSE EVENTS AND COMPLICATIONS

Generic complications of HA infiltration include herpes simplex and herpes zoster

reactivation after filler injection. This issue should be prevented with an adequate

prophy- lactic therapy.18 Furthermore, when intravascular infiltration of hyaluronic acid

is administered, cutaneous necrosis and distant embolization could occur. 19,20 On the

other hand, the risk of infection is low and could be minimized by accurate disinfection

of the area.21 However there are no data in the literature concerning the infective risk for
HA in- filtration in this region.

Erythema, edema and bruising may be observed immediately after infiltration, which

resolve spontaneously. Allergies are rare but could occur within hours from injection,

although late allergic reactions, granulomas and chronic inflammations are described.21

Bumps could occur in cases of superficial infiltration or injection of excessive quantities

in a single location. [3 RI]

Due to PLLA crystalloid microparticles, the most common adverse effect is papules and

nod- ules caused by material accumulation, usually due to inadequate re- constitution. 2

For apparent or persistent nodules, vigorous massage, intralesional corticosteroid

injection, or surgical excision may be options.3

CONCLUSION

The increasing demand for female genital rejuvenation requires that the dermatologic

surgeon be familiar with office-based nonsurgical devices and procedures that can safely

and effectively address these concerns. [1 RI]