Cosmetic and asthetic gynaecology

Cosmetic and asthetic gynaecology by Dr Narendra Malhotra

1. PROF.NARENDRA MALHOTRA
M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S.
•Prof. Dubrovnick International University
•V.P. WAPM(world association of prenatal medicinne)
•President ISAR
•Presiddent Elect ISPAT
•Sec Gen SAFOG
•Member FIGO guidelines committee
•President FOGSI (2008-2009)
•Dean I.C.M.U. (2008)
•Director Ian Donald School of Ultrasound
•National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course
•Managing Director GLOBAL RAINBOW HEALTH CARE
•Director ART-RAINBOW –IVF
•Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy
and Infertility, ART & Genetics
•Member and Fellow of many Indian and international organisations
•Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award,
Corion award, Man of the year award, Best Citizens of India award
•Over 50 published and 200 presented papers
•Over 100 guest lectures given in India & Abroad and 24 ORATIONS
•Organised many workshops, training programmes, travel seminars and conferences
•Editor 18 books, many chapters, on editorial board of many journals
•Editor of series of STEP by STEP books
•Revising editor for Jeatcoate’s Textbook of Gynaecology 7
th
and 8
th
edition (2015)
•Very active Sports man, Rotarian and Social worker
MALHOTRA NURSING & MATERNITY HOME PVT. LTD.
GLOBAL RAINBOW HEALTH CARE,AGRA


84, M.G. Road, Agra- 282 010
Phone : (O) 0562- 2260275/ 2260276/ 2260277, (R) 0562- 2260279, (M) 98370- 33335; Fax : [phone]
www.malhotrahospitals.com,www.rainbow hospitals.org

2. HER UNSPOKEN PROBLEMS
NARENDRA MALHOTRA
MANPREET SHARMA
JAIDEEP MALHOTRA
NEHARIKA MALHOTRA BORA
SHEMI BANSAL
GLOBAL RAINBOW HEALTH CARE AGRA
[email protected]
Cosmetic and Asthetic Gynaecology

3. Common UNSPOKEN problems
•Pelvic organ prolapse—symptomatic / Asymptomatic
•Urinary dysfunction
•Stress urinary incontinence
•Sexual dysfunction
•Overactive bladder
•Faecal incontinence
•Pelvic pain
•Vulval /vaginal itching and pain
•Abnormal Vaginal discharge
•Cosmetic issues of looking good/sagging breasts
•Pregnancy stria marks and other moles and scars
•Vulval diseases like LICHEN,WARTS and others

4. New subspecialities emerging

certified subspeciality……
1.Female Pelvic Medicine
2.Reconstructive Surgery
3.Cosmetic and Asthetic gynaecology

5. •Vaginal tightening
•Post delivery
rehabilitation
•SUI
•Vaginal dryness
•Vulvar rejuvenation
•Scars
•Vulvodynia/
Vestibulitis
•Lichen sclerosis
•Vaginal infections
•Bleaching

6. Causes of Tissue Aging &
Laxity
Genetics
Menopause
Low Estrogen States
Pregnancy & Childbirth
Smoking
Obesity
Significant Weight Fluctuation

7. Tip of the iceberg

8. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
18-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485-89>90
Prevalence
Age (years)
pPrevalence by Aage
Hunskaar S, Lose G, Sykes D, Voss S
The prevalence of urinary incontinence in women in four
European countries
BJU Int 2004 Feb;93(3):32430

9. laughing and other stress are more
stress

10. Stress incontinence
A QOL Problem!

urine leakage
triggered by
coughing,
sneezing,
laughing, lifting,
exercising,
straining


Pads for incontinence – world market
P&G's -incontinence an attractive $7 billion
global
category growing 7% annually.
Compared baby diapers, feminine care products
and tissue
incontinence demonstrates the fastest
growth


Age and Parity
Pelvic floor muscle
denervation and
endopelvic fascial
disruption
Physical activity level
Individual impact is
variable

11. Types of Urinary Incontinence
Stress Urinary Incontinence
Urge Incontinence
Mixed Incontinence
Overflow Incontinence
Atypical Incontinence

12. Urgency
Frequency
Nocturia / Enuresis
Dysuria



Symptoms of Urinary
Incontinence

13. Urinary Tract Infection
Medications
Abnormal Growths (Polyps, Stones, Cancer)
Urinary Tract Abnormalities (Fistula, Diverticulum)
Neuromuscular Problems
Pelvic Support Problems


Causes of Urinary Incontinence

14. Understanding pelvic supports

15. Treatment of Urinary
Incontinence
Lifestyle Changes
Bladder Training
Physical Therapy
Pessary
Medications
Bulking Agents
Surgery
NEW: Laser Vaginal Rejuvenation

16. General measures
•Reduce weight
•Stop smoking, treat chronic
cough
•Treat constipation
•Advice regarding pads and
garments

17. SUI- treatment

•Pelvic floor exercises
•Electrical Stimulation

Conservative
•Implants
•Medications?



•Surgery

18. Kegel Master ?
•Helps a woman perform proper and effective Keigel
exercises by applying adjustable targeted resistance
against the muscles of the female pelvic floor.
•The Kegelmaster™ has 15 levels of resistance with a
maximum of 4.5lbs of pressure required to close the
unit.
•The Advanced Kegelmaster has 64 levels of
resistance with a maximum of 9.5lbs of pressure
required to close the unit.
20

19. 21
Kegelmaster

20. Surgery for Stress
Incontinence
Vaginal
Anterior repair
Needle suspension
Slings
MUS


Urethral
Bulking agents
Abdominal
MMK
Colposuspension Slings Artificial sphincter

Laparoscopic
Colposuspension Slings

21. Colposuspension
Cure rate 60-90%
”Gold standard”???
Complications
•Voiding difficulties (10%)
•De Novo Detrusor
instability (3-15%)
•Prolapse (14%)
Colposuspension Complications

22. STRESS URINARY INCONTINENCE
minimal invasive surgery
TVT
Ulmsten, 1996
“Integral theory”
Monofilament
Prolene
Midurethral support
No fixation of the
tape

23. Tension-free vaginal
tape
Cure rate 60 - 90%
Indications
•Primary and failed surgery
•Concomitant prolapse
surgery
Complications
•Bladder perforation
•Retention
•Urgency

24. Bladder injury at TVT
Bladder perforation rates 2 - 10%
Rates ↑ with previous retropubic
surgery
Remove TVT and site more laterally no
IDC required

25. Transurethral route Periurethral route
Urethral
bulking agents
Cure rate 50 –
70%
Temporary

26. IMPLANTS UNWANTED
EFFECTS


•UTI
•Urinary retention 1.9%
•Urge incontinence 12.6%
(21% did not respond to
anticholinergics)
•Haematuria 5%

Stothers L et al J Urol (1998)

28. Treatment of Pelvic Prolapse
Lifestyle Changes
Bladder Training
Physical Therapy
Pessary
Vaginal Mesh
Surgery
NEW: Laser Vaginal Rejuvenation

32. Surgical Complications
Surgical Injuries (Organ Damage)
Voiding Dysfunction
Bladder Perforation
Pelvic Visceral Injuries & Hemorrhage
Mesh Erosion & Extrusion
Urinary Tract Infections
Groin Pain
Dyspareunia

35. Symptoms of Vaginal Atrophy
Vaginal Dryness
Vaginal Burning / Irritation
Decreased Lubrication During Sexual Activity
Painful Intercourse
Vaginal Bleeding or Vulvar Fissures
Vaginal Discharge
Pelvic Pressure or Vaginal Bulging
Urinary Tract Symptoms
Frequency, Pain, Bleeding or Incontinence

36. LUBRICANTS

LOCAL ERT
Vaginal dryness/atrophy

37. Treatments of Vaginal Atrophy
Hormonal Medications
Estrogens
Estrogen Agonist-Antagonist (Osphena)
Non-Hormonal
Vaginal Lubricants
Vaginal Moisturizers
Regular Sexual Activity
NEW: Laser Vaginal Rejuvenation

38. Atrophic Vaginitis
•Pre-pubertal – lactating –
postmenopausal
•Reduced endogenous estrogen
•Causing thinning of the vaginal
epithelium
•Vaginal epithelium susceptible
to trauma and infection
•pH high

pH 5-7 d/t reduction in lactic acid
production and decrease in
lactobacilli decreasing h2o2

39. Symptoms of Vaginitis
•Abnormal vaginal discharge
•Pruritus
•Irritation
•Burning
•Soreness
•Odor
•Dyspareunia
•Bleeding
•Dysuria

40. Patient Complaints
•Genital
Dryness/Itching/Burning
Dyspareunia
Vulvar pruritus
Feeling of pressure
Yellow malodorous discharge /leukorrhea
Spotting
Irritation/tear
•
Urinary
Dysuria/ Frequency/Hematuria
Urinary tract infection
Stress incontinence

41. Treatment for Atrophic Vaginitis
•Treated with estrogen replacement (vaginal/oral)
•Oral BCP (ethinyl estradiol up to 50 ug)
•Conjugated estrogen up to 1.25 mg in combo
w/medroxyprogesterone acetate to prevent
endometrial hyperplasia
•Vaginal cream 1 g daily qhs x1m then ½ dose
2X/week (1g vaginal cream=.625mg conjugated
estrogen)
–should give w/ 2.5mg medrxyprogesterone
x14d
•Estrogen vaginal ring (change q3m) (Estring)
delivers 6-9ug estrodiol daily
•Vagifem 1tab intravaginally x2w then 3 x/w for 3-6m

42. VRS – Vaginal Relaxation
Syndrome
it is a quite common
medical condition
described as a loss of
optimal vaginal
structure and is
usually associated
with vaginal delivery
and natural aging..

43. VRS leads to…….
•Sexual dysfunction
•Urinary incontinence
(Specially stress urinary
incontinence)
•
Urogenital syndrome of menopause

44. Vestibulodynia
vulvodynia
unexplained pain around introitus
1 million cases per year,all
ages,hypersenstivity to touch
infections and local cause
for unexplained tt very diff

45. Lichen sclerosus
•Comprises 70% of benign epithelial disorders
→ epithelial thinning, inflammation &
histological changes in the dermis.
•Aetiology: unknown
•Sx: Itching (commonest), vaginal soreness +
Dyspareunia. Burning and pain are uncommon.
•Signs: crinkled skin, L. minora atrophy,
constriction of V. orifice, adhesions,
ecchymoses & fissures.
•Dx: Biopsy is mandatory
•Rx: - emollients, topical steroids.
- Testosterone: not effective than petroleum jelly
& → pruritus, pain & virilization.
- Surgery: avoided unless malignant changes

46. Lichen Planus
•General Appearance
–Erosive lesions at
vestibule w/without
adhesions resulting in
stenosis
–May have associated oral
mucotaneous lesions and
desquamative vaginitis
–Patient c/o irritating
vaginal , vulvar soreness,
intense burning, pruritus,
and dyspareunia w/post-
coital bleeding
–Types: Papulosquamous
LP/Hypertrophophic LP
/Errosive LP

47. Treatment
• Intravaginal
hydrocortisone
suppositories BID x 2m
•Steroid creams (medium-
high potency)
•Vaginal estrogen cream if
atrophic epithelium
present
•Vaginal dilators for
stenosis
•Surgery for severe vaginal
synechiae
•Vulvar hygiene
•
Emotional support

48. Vulvar Psoriasis
•Physical Appearance
–Red moist lesions w/without
scales

•Treatment: Topical
corticosteroids

49. Squamous Cell Hyperplasia
(Atopic Eczema/Neurodermatitis)




Physical Appearance
Benign epithelial thickening and
hyperkeratosis
◦Acute phase with red/moist
lesions
◦Causing pruritus leading to
rubbing & scratching
◦Circumscribed, single or
unifocal
◦Raised white lesions on vulva
or labia majora and clitoris
Treatment: Sitz baths,
lubricants, oral
antihistamines, Medium
potency topical steroid twice
daily

50. Lichen Simplex Chronicus
•Physical Appearance
–Thickened white
epithelium on vulva
–Generally unilateral
and localized
•Treatment:
Medium potency
steroid twice daily
prn

51. Benign Vulval lumps
•Bartholin’s cyst.
•Epidermal inclusion cyst.
•Skene’s duct cyst.
•Congenital mucous cysts: arise from mesonephric ducts remnants.
•Cyst of the canal of Nuck: can give rise to hydrocele in labia maqjora.
•Sebaceous cyst.
•Papillomatosis (solid).
•Fibroma (solid).
•Lipoma (solid).
•Condylomata (solid).
Cysts are either congenital or arise from obstructed glands.
Manifestations arise from the cysts (cosmotic) or from infection.

52. So what NEW can
we offer to HER ?

53. Non-Invasive Measures
External Energy Application
CO
2 Laser (with certain settings)
Er: YAG
Radiofrequency
Ultrasound

54. WHAT IS THERMI Va
•It’s a Non- invasive temperature controlled
radiofrequency device .

•RF energy delivered deeply into vulva ,vagina

•Tissue tightening immediately

•Newer and tighter collagen stimulation – new
softer and smoother skin

55. THERMI Va
Non – surgical
No anesthesia
Painless
OPD procedure
Immediate results

56. No pain
Treat outside
(labia)
Treat inside
(vagina)
No downtime
For any age

For loose vagina
For loose labia
For dry vagina
For leaky bladder
For orgasmic
problems

57. Heating of the skin and mucosa promotes 3 different kinds
of effect:
• Immediate contraction of collagen
• Immediate collagen remodeling and elasticity
• Long term stimulation of production of new collagen
HOW WORKS

58. HOW WORKS
THERMAL
NEUROGENESIS
increases
blood flow and restores
nerve signaling resulting
in normal vaginal
lubrication.
- Red Alinsod, MD

59. TREATMENT TIME : what it takes ??
•External labia : 5 -10 min, atrophy/lax
•Full vagina : 30 min
•SUI &OAB :10-15min
•Atrophic vaginitis: 10 min
•Cystocele : 7-10 min
•Rectocele : 7-10min
•Orgasmic dysfunction : 15- 20 min

60. NEWER MODALITY
Vaginal Laser Therapy

Clinical Solution For A
Better Feminine Life

61. HOW ARE LASERS
DIFFERENT

62. Alma FemiLift
Key Differentiator: Treatment Time and Efficiency
The Alma FemiLift allows Selective Targeted
Treatment Areas meaning practitioners can
target specific areas or zones 45 degrees at a
time i.e. protocol choosing between 11 o’clock
and 2 o’clock for maximum thermal efficacy and
penetration depth.
ThermiVA
ThermiVA uses a disposable wand to deliver RF
energy to the external and internal vagina. Requires
time to increase temperature into the “therapeutic
range” of 40-45° C. Thermal reaction only, no
ablative reaction reduces long term neocollagenisis.
Requires topical numbing cream for external use
(30-45 min)

63. 3. ThermiVA has a single use probe which times
out after 1 treatment and can’t be reused on the
same patient for treatments 2 & 3. Per patient
costs are $450 vs $120 for Femilift. Femilift has a
much better ROI.
ThermiVA is Monopolar and also requires a
grounding pad. Push downside of “old” mono RF
technology and importance of positioning
grounding pad in the correct spot.
How are we different?

64. FemiLift Probe
Key Differentiator
ThermiVA Wand
Small shape – can’t be reused – slow
with small spot size
Slim Shape – ease of use. Comfortable
for practitioner and patient.

65. Femilift™ is an FDA- approved pixel CO
2 laser designed and
invented by Alma Lasers™ to treat

vulvo-vaginal dryness,
vaginal laxity
mild to moderate urinary incontinence,
mild prolapse
Vulval diseases
Definition

66. Rationale for using laser therapy
•1970

•Late 80s’-90s’
Full field ablation for facial rejuvenation

•2004
Fractional phothermolysis

•2009
Vaginal Fractional phothermolysis

•2014
FDA approves vaginal fractional co2 for:
Skin tightening
Vaginal atrophy

67. Effect of Laser on
Tissues
Photostimulation
Photodianamic Reaction
Photothermolytic Action

68. What is Vaginal Laser
•Vaginal Laser Stimulates
Production Of Collagen,
Elastin And Fibroblast
Activity.
•Treat And Improve: Stress
Urinary Incontinence ,
Vaginal Laxity And
Dryness.

69. Er:YAG laser
•2940 Nm Wavelength
•Maximum Absorption By
Water
•Minimal Penetration Depth
•Short Thermal Relaxation
Time
•A Short Pulse Width Can
Provide Precise Control With
Minimum Damag
•
Can Be Used To Be Ablative In High Fluence Ranges –Either
Very Superficial Or Very Aggressive And Deep In Turbo
Mode

70. Some Satisfied and
Happy customers
contacts:
1. MRS. REENA JAJPURIYA
99260- 44117
2. MRS. GARIMA VYAS
98264- 23061
3. MRS. NARMADA SEPTA
99934- 40608
4. MRS. ANITA JIRATI
83191- 85301
5. MRS. NIRMALA GOSWAMI
88899- 97235
6. MRS. LALITA PANCHOLIA
99260- 71802
6. MRS. JYOTI ARYA
97558- 98762
7. MRS. ANJALI DEMBLE
95454- 00085
8. MISS. SONAM RAJPUT
96442- 21056
9. MRS. BINDU MANDLOI
94259- 93231
10. MRS. KANCHAN
ARORRA
88899- 78620
11. MRS. TANYA
WADHWANI
89624- 76347
Successfully
Completed
INCONTINENCE THERAPY FOR STRESS
URINERY INCONTINENCE = 67
INTIMALASE THERAPY FOR VAGINAL
TIGHTENING = 16
RENOVALASE THERAPY FOR
UROGENITAL SYNDROME = 17
TOTAL THERAPY= 100
Therapy at INDORE centre on
Erb laser INTILASE

71. What is
• vaginal CO2 laser stimulates production of collagen,
elastin and fibroblast activity.
•Treat and improve: stress urinary incontinence ,
vaginal laxity and dryness.
•Utilizing CO2 Pixel Laser Technology:
Long term thermal effect
Micro ablative effect
Gold standard in Face Treatment & Skin
Tightening

72. 74
The
Technology of
FEMILIFT
BEING USED WIDELY IN INDIA BY DEMRA
ABOUT 10 GYNAECS USING FEMILIFT IN INIDA
KOLKATA
BANGLORE
JAIPUR
AGRA
SURAT
DELHI
NASIK
NELLORE
MUMBAI

73. 75
Pixel CO2 laser
Deep Thermal
Heating
and Micro-ablation
•Laser energy is delivered to
the vaginal tissue through a
DOE - Diffractive Optical
Element
•DOE pixelates the beam to
81 microscopic pixels in a
9x9 pattern
•Pixel pattern promoting
faster healing
•
Deep thermal effect for
vaginal collagen
remodeling without causing

74. 76
Pixel CO2 laser vs. Scanner
1 Laser Beam 81 Micro Beams

75. 77
Pixel CO2 laser vs. Scanner
1 Laser Beam 81 Micro Beams
At the same fluence the
Pixel CO2 is 81 times longer than the
Scanner
30W * T = 100
mj/Pixel
T=100/30
T=3.33 msec
(Pick Power ;
Ablative)

30W/81 Pixel * T =
100 mj/Pixel
T=100*81/30
T=270 msec
Thermal Effect

Treatment Energy 80-120 mj/Pixel
Enhanced thermal effect

76. 78
Pixel CO2 laser
Strong and
Impactful Thermal
Effect
•High- powered laser
•Utilization of much higher energy levels by longer
pulse duration
•Microscopic columns of thermal zone penetrates
deep into the submucosa, leaving the surrounding
tissue intact, with minimal ablation

77. structural support

How does the FemiLift Pixel CO2 Works?


Alma Pixel CO2 surgical laser utilizes fractional technology to
create micro-ablation and thermal damage to the mucosa and sub-mucosa



• fractional laser through holographic lenses
pixelating the beam to 81 microscopic beams (pixels)


• ablated mucosa and microscopic columns
of thermal damage that penetrate deep into the sub-
mucosa


• Strongly stimulates the growth of new collagen


• Collagen remodeling allows tissue re- firming, causing
CO2 Laser

78. Effective Mechanism
Thermal Damage
Superficial Shrinkage
Deep Asceptic Wound
Collagen Remodeling

79. Collagen Remodeling &
Stimulation-Mechanism of Action
Acute Thermal Damage Phase (48-72 hours)
Edema
Release of Chemical Mediators
Collagen Shrinkage
Proliferation Phase (30 days)
Fibroblastic Recruiting
New Dermal Molecular Matrix
New Collagen Fibers
Remodeling Phase (? months)
Mature Collagen Fibers
New Elastic Fibers

80. Beam Splitter – Alma’s CO2 Pixel Solution
• Fractional CO 2 combines
micro-ablative approach
with longer pulse for deep
thermal effect
• Allows short, easy and
efficient treatment protocol
reducing procedure time

81. 83
Mechanism of Action


The Action Process Has Three Phases:
Edema
Release of chemical mediators
Shrinkage of collagen and elastic
fibers
Early thermal
effect
Phase I
Within 48-72
hr.

Fibroblastic recruiting
New extracellular matrix
New collagen fibers
Proliferation
Phase II
In the
following 30
days
Mature collagen fibers
Increase of collagen fiber strain
Neovascularization: new blood
vessel

formation
Improved lubrication, pH (acidity)
Remodelling
Phase III
After 30- 40
days
Physiologic and functional recovery of the
vaginal mucosa.

82. +Normal tissue is comprised of a thin
top layer (the epidermis) that rests on a
deeper layer (the dermis). The dermis
contains a matrix of collagen (the basic
building block of skin) and elastin that
provides structure and support to the
vaginal tissue.
Dermis
Epidermis
Elastin Fibers Collagen Fibers
+Aging and obesity degrades the
vaginal tissue’s normal collagen and
replaces it with abnormal tissue that
does not stretch and recoil. This
creates tissue laxity.
Elastosis
+CO
2 laser removes the abnormal
upper tissue layers, and stimulates new collagen growth in the dermis to effectively restructure and restore it to a state that resembles undamaged tissue.
New
Collagen
Collagen
Remodeling Process

83. Vaginal wall coloscopic image immediately post
FemiLift treatment

84. Micro Ablative Effect

Colposcopic picture of vaginal wall post FemiLift treatment
•
Smooth
treatment

without
damages
or

carbonizat
ion
Immediately post
treatment

















Two weeks post
treatment

85. Histology
histological HE samples

from the time just after the ablative effect (A), the
filling of the

vaporized space" as a column shape (B) at 72-96 h,
the progress of

healing in the vaporized area (C) (D) at 14 and 28
days

respectively, and finally the rejuvenated fascia at two
months (E).

86. Collagen re-growth 6 months
post FemiLiftTreatment
Before After

87. 89
Histologies
Thick vaginal epithelium, rich in
glycogen
Atrophic vaginal mucosa.
Thin epithelium with mild
parakeratosis
Neovascularizatio
n in the
sub-epithelial,
lamina propria
Courtesy of Jorge Alberto Eias, MD , Buenos Aires, Argentina
Pre-treatment Post laser treatment Post laser treatment

88. Menopause: The Journal of The North American Menopause
Society Vol. 22, No. 8

Histological study on the effects of
microablative fractional CO2 laser on
atrophic vaginal tissue: an ex vivo
study

Stefano Salvatore, Umberto Leone Roberti Maggiore,
,Stavros Athanasiou, et al

89. Advantages

• non invasive procedure
•Office procedure
• “coffee break” procedure -lasting approximately
between 10-20 min

•Easy and safe procedure

•Minimal discomfort and pain


•Effective

•Rapid healing

•Single use and hygienic vaginal
probe

90. To achieve safe and effective collagen
remodeling for vaginal tissue
rejuvenation, it is important to have
thermal effect and avoid ablative
damage.
FemiLift™ Safety

91. HOW DOES
FEMILIFT WORKS

92. Operating the system

93. FemiLift™

94. Objectives
Improving Vaginal Dryness & Pain
Vaginal Tightening & Improving Sexual Experience
Treating Mild to Moderate Stress Incontinence

95. Hygienic Procedure

96. 98
Pixel CO2
Integrating Technology and
Convenience for Optimal Results
•Uses an 10,600 nm CO2
laser
•Power up to 30W/ 70W
•Intuitive, user friendly
interface
•Adaptable to most
surgical microscopes and
colposcopes

97. FemiLift Single Use Hygienic Vaginal Probe:
Femilift reusable hand-piece with a single-use sheath

98. All in One, Multi Package
FemiLift Probe FemiLift Slim Probe FemiLift Smart
FemiTight LiteScan FemiCam

99. Protocol
•Femilift probe
•Apply liquid lidocaine 2% on the
introitus, Waite 3 minutes
•The inner part of the introitus 25 mj/p ,
3 passages
•Outer part of the introitus. 15 mj/p , 3
passages
•Repeat if necessary after one month

100. Treatment Protocol

101. 103
Vaginal Tightening
•Powerful thermal heating and micro-ablation is
applied to the various layers of the vaginal tissue
in a 360 degree pattern
•Vaginal tissues remodelling
The Treatment

102. Objectives
Improving Vaginal Dryness & Pain
Vaginal Tightening & Improving Sexual Experience
Treating Mild to Moderate Stress Incontinence

103. Vaginal Wall Tightening
Remodeling tissue throughout the vagina

104. Collagen Remodeling process
Dermis
Epidermis
Collagen Fibers Elastin Fibers

+ Normal tissue is comprised of a thin
top layer (the epidermis) that rests on a
deeper layer (the dermis). The dermis
contains a matrix of collagen (the basic
building block of skin) and elastin that
provides structure and support to the
vaginal tissue.
+ Aging and overweight degrades the
vaginal tissue’s normal collagen and
replaces it with abnormal elastic
fibers that do not stretch and recoil.
This creates tissue laxity.
Elastosis
+ Co2 laser removes the abnormal
upper tissue layers, and stimulates
new collagen growth in the dermis
to effectively restructure and restore
it to a state that resembles
undamagedtissue.
New
Collagen

105. Fractional microablative CO2 laser
for vulvovaginal atrophy in women
treated with chemotherapy and/or
hormonal therapy for breast cancer:
a retrospective study.
Menopause 2016 Oct;23(10):1108-13
Pagano T et al
Fractional microablative CO2 laser treatment is associated
with a significant improvement of VVA symptoms in women
affected by hormone-driven breast cancer.
This procedure has the advantage of relieving
iatrogenic/physiological VVA symptoms without resorting to
contraindicated estrogen preparations, which have been the
most effective therapy thus far.

106. Urethra Support – can be
achieved with FemiLift
URINE URINE
Normalsupport
under the
muscle
URINARY INCONTINENCE



Loose collagen fibers
NO URINARY INCONTINENCE



Firmed collagen fibers
Loss of support
under the
muscle

107. The effect of microablative
fractional CO2 laser on
vaginal flora of
postmenopausal women
Climacteric 2016 Oct;19(5):512-8.
Athanasiou S et al
MFCO2-Laser therapy increased Lactobacillus (p < 0.001)
and normal flora (p < 0.001) after the completion of the
therapeutic protocol, which decreased vaginal pH from a
mean of 5.5 ± 0.8 (initial value) to 4.7 ± 0.5 (p < 0.001). The
prevalence of Lactobacillus changed from 30% initially to
79%

108. 110
FemiTight
For Labia Majora Tightening
•Treatments conducted with
this probe use a low fluence
beam laser that gently heats
the tissue
•Effectively restoring and
reviving collagen growth

109. 111
LiteScan
For Labia Majora Rejuvenation
•Char-free tissue ablation with
multiple scanning patterns
•Promotes accelerated re-
epithelization, allowing for faster
healing and tissue regeneration
•Significantly improved overall
skin tone, elasticity and texture,
and reduced superficial
pigmentation

110. 112
The System
Our
experience
USING SINCE 6 MONTHS AGRA
35 SUI CASES
10 VAGINAL TIGHTENING :4 post delivery
5 GENITAL PROLAPSE UNFIT FOR SURGERY
1 WARTS
1 RESHAPING
1 LICHEN LIKE
3 VULVAL VAGINAL ITCHING
2 VAGINAL DRYNESS
ALSO BEING USED BY COSMETIC DEPPT
COLLECTIVE INDIAN EXPERIENCE OF OVER A YEAR WITH OVER 200 CASES OF SUI

111. Pre-Treatment Consultation
Complete Health History Questionnaire
Vaginal / Bladder Questionnaire
Complete OB/GYN History, Including Pap Smear Results
Pelvic Exam

112. Contraindications
Active HPV / Herpes
Abnormal Pap Smear
Active Vaginal Infection
GYN Cancer
Undiagnosed Vaginal Bleeding
Uncontrolled Diabetes
Pregnancy
Recent Vaginal Injury
Any Active Bleeding (Including Menses)

113. Treatment Protocol
Office Procedure
No Anesthesia
2-3 Passes of Entire Vaginal Canal
3 Sessions
1 Month Interval
1 Memory Session After 1 Year
May Repeat Full Course After 2 Years

114. NON GYN USES IN WOMEN
•PREGNANCY STRETCH MARKS
•FACIAL LASER
•WARTS ANYWHERE
•DARK SPOTS AND MOLES
•SCAR MARKS POST C.S. KELOIDS
•EVOLVING INDICATIONS
•OPERATIVE EXTERNAL ALSO WITH CUT LASER

115. Case 1
•45 y, G3P2, nurse, patient zero
•Healthy, no operations
•For 2 years pain in the introitus on 12
o'clock. Affect work, avoidance from sex.
trial of various local treatment -failed.
Work up - no infection, normal
colposcopy, diverticula-ruled out
•Started femilift
•Before tx VAS 90, after first tx VAS 60 ,
after second tx VAS 40, after third tx VAS
1/2,resumed sexual activity
VISUAL ANALOG SCORE FOR PAIN SEVERE 75-100 45- 74 MODERATE 5-44 MILD 0-4 NO PAIN

116. Case 2
•32 y, G1 P1
•Healthy no operation
•Since delivery Vulvodynia , local tx,
behavioral tx, physiotherapy, local
anesthetics - no improvement . Infection-
ruled out, normal colposcopy
•Started femilift
•VAS before tx 10, after one tx 7 /8, after
second tx,5 after. Third 3

117. Case 3
•36 y G2P2
•Healthy no operations
•2 years pain during intercourse, siting
•No infection normal colposcopy
•Vas before 9 after one tx 7 after second 4

118. Case 4
•28 y G0
•Healthy no operations
•5 y pain in introitus , no infection, normal
colposcopy
•Trial of various local tx , behavioral tx,
physiotherapy - no improvement refers for
vestibulectomy
•VAS before tx 9, after one tx 3 satisfied

119. •Vaginal tightening
•Post delivery
rehabilitation
•SUI
•Vaginal dryness
•Vulvar rejuvenation
•Scars
•Vulvodynia/
Vestibulitis
•Lichen sclerosis
•Vaginal infections
•Bleaching


THE NEED IS REAL
THE NEED …NEEDS TO BE RESPECTED
SHE SHOULD DECIDE
ITS HER WHICH MATTERS
WHY SHOULD SHE SUFFER IN SILENCE

120. Domestic & International
Experience
87% of patients report significant improvement
in Vaginal Rejuvenation and Tightening
78% of patients report improvement of Stress
Incontinence
88% reported complete dryness afterwards
12% have less leakage afterwards
22% with insignificant or no improvement

121. There is no such thing as
PERFECT or COMPLETE…
only continuous improvement.
GIVE H.E.R. WINGS AND LET H.E.R.SOAR
PRACTICE WITH QUALITY,ETHICS AND DIGNITY

122. FOGSI 2018 IS FOR H.E.R.WITH Q.E.D.

124. Thank you
Acknowledgements to prof ronen gold,dr ruby ruprai,dr carolyn ,dr vidya pancholy
Dr rashmi chaar khandelwal,dr lila vyas and ALMA lasers
FOR HELPING TO MAKE THIS PRESENTATION AND SHARING DATE AND SLIDES