For centuries, hair removal has long shaped  gender roles , served to signify  social status  and defined notions of femininity and the ideal " body image ". [ 2 ] [ 3 ]  In early periods, the condition of being hairless was mostly done as a way to keep the body clean, using flint, seashells, beeswax and various other depilatory utensils and exfoliator substances, some highly questionable and highly caustic. [ 3 ] [ 4 ]   Ancient Rome  also associated hair removal with status: a person with smooth skin was associated with purity and superiority. Removing body hair was done by both men and women [ 2 ] [ 3 ] [ 5 ] [ 6 ]
Psilothrum or psilotrum ( Ancient Greek :  ψίλωθρον ) and dropax (Ancient Greek:  δρῶπαξ ) were depilatories in ancient Greece and Rome. [ 7 ] [ 8 ] [ 9 ]


In  Ancient Egypt , besides being a fashion statement for affluent Egyptians of all genders, [ 3 ] [ 10 ]  hair removal served as a treatment for  louse infestation , which was a prevalent issue in the region. [ 11 ]  Very often, they would replace the removed head hair with a  Nubian wig , which was seen as easier to maintain and also fashionable. [ 11 ]  Ancient Egyptian priests also shaved or depilated all over daily, so as to present a "pure" body before the images of the gods. [ citation needed ]


In ancient times, one highly abrasive depilatory paste consisted of an admixture of  slaked lime , water, wood-ash and yellow  orpiment  ( arsenic trisulfide ); In rural India and Iran, where this mixture is called  vajibt , it is still commonly used to remove  pubic hair . [ 3 ] [ 4 ] [ 12 ]  In other cultures, oil extracted from unripe olives (which had not reached one-third of their natural stage of ripeness) was used to remove body hair. [ 13 ]


During the  medieval period ,  Catholic  women were expected to let their hair grow long as a display of femininity, whilst keeping the hair concealed by wearing a  wimple  headdress in public places. [ 2 ]  The face was the only area where hair growth was considered unsightly; 14th-century ladies would also pick off hair from their foreheads to recede the hairline and give their face a more oval form. From the mid-16th century, it is said when Queen  Elizabeth I  came to power, she made  eyebrow  removal fashionable. [ 2 ]


By the 18th century, body hair removal was still considered a non-necessity by European and American women. But in 1760, when the first safety  straight razor  appeared for men to safely shave their beard and not inadvertently cut themselves, some women allegedly used this safety razor too. [ 2 ]  It was invented in Paris by the French master cutler  Jean-Jacques Perret  [ fr ] , author of  La pogonotomie, ou L'art d'apprendre à se raser soi-même  ( Pogonotomy , or The Art of Learning to Shave). [ 2 ]


It was not until the late 19th century that women in Europe and America started to make hair removal a component of their  personal care  regime. According to  Rebecca Herzig , the modern-day notion of body hair being unwomanly can be traced back to  Charles Darwin 's book first published in 1871 "The Descent of Man and Selection in Relation to Sex". Darwin's theory of natural selection associated body hair with "primitive ancestry and an atavistic return to earlier less developed forms", writes Herzig, a professor of gender and sexuality studies at Bates College in Maine. [ 2 ]  Darwin also suggests having less body hair was an indication of being more evolved and sexually attractive. [ 2 ]  As Darwin's ideas polarized, other 19th century medical and scientific experts started to link hairiness to "sexual inversion, disease pathology, lunacy, and criminal violence". Those connotations were mostly applied to women's and not men's body hair. [ 2 ]


By the early 20th century, the upper- and middle-class  white America  increasingly saw smooth skin as a marker of femininity, and female body hair as repulsive, with hair removal giving "a way to separate oneself from cruder people, lower class and immigrant". [ 2 ]


Harper's Bazaar , in 1915, was the first women's fashion magazine to run a campaign devoted to the removal of  underarm hair  as "a necessity". Shortly after,  Gillette  launched the first safety razor marketed specifically for women—the "Milady Décolleté Gillette", one that solves "...an embarrassing personal problem" and keeps the underarm "...white and smooth". [ 2 ]


Body hair characteristics such as thickness and length vary across human populations, some people have less pronounced  body hair  and others have more conspicuous body hair characteristics.


Each  culture  of human  society  developed  social norms  relating to the presence or absence of body hair, which has changed from one time to another. Different standards of  human physical appearance  and  physical attractiveness  can apply to females and males. People whose hair falls outside a culture's aesthetic  body image  standards may experience real or perceived  social acceptance  problems, psychological distress and  social pressure . For example, for women in several societies, exposure in public of body hair other than head hair, eyelashes and eyebrows is generally considered to be  unaesthetic , unattractive and  embarrassing . [ 14 ]


With the increased popularity in many countries of women wearing  fashion  clothing,  sportswear  and  swimsuits  during the 20th century and the consequential exposure of parts of the body on which hair is commonly found, there has emerged a popularization for women to remove visible  body hair , such as on legs, underarms and elsewhere, or the consequences of  hirsutism  and  hypertrichosis . [ 2 ] [ 15 ]  In most of the  Western world , for example, the vast majority of women regularly shave their legs and armpits, while roughly half also shave hair that may become exposed around their  bikini  pelvic area (often termed the "bikini line"). [ 2 ]


In Western and Asian cultures, in contrast to most Middle Eastern cultures, a majority of men are accustomed to shaving their facial hair, so only a minority of men reveal a  beard , even though fast-growing facial hair must be shaved daily to achieve a  clean-shaven  or beardless appearance. Some men shave because they cannot genetically grow a "full" beard (generally defined as an even density from cheeks to neck), their beard color is genetically different from their scalp hair color, or because their facial hair grows in many directions, making a  groomed  or contoured appearance difficult to achieve. Some men shave because their beard growth is excessive, unpleasant, or coarse, causing skin irritation. Some men grow a beard or  moustache  from time to time to change their appearance or visual style.


Some men  tonsure  or  head shave , either as a religious practice, a fashion statement, or because they find a shaved head preferable to the appearance of  male pattern baldness , or in order to attain enhanced cooling of the skull – particularly for people suffering from  hyperhidrosis . A much smaller number of Western women also shave their heads, often as a fashion or political statement.


Some women also shave their heads for cultural or social reasons. In India, tradition required widows in some sections of the society to shave their heads as part of being  ostracized  (see  Women in Hinduism § Widowhood and remarriage ). The outlawed custom is still infrequently encountered mostly in rural areas. Society at large and the government are working to end the practice of ostracizing widows. [ 16 ]  In addition, it continues to be common practice for men to shave their heads prior to embarking on a pilgrimage.


The  unibrow  is considered a sign of beauty and attractiveness for women in  Oman  and for both genders in  Tajikistan , often emphasized with  kohl . [ 2 ]  In Middle Eastern societies, regular trimming or removal of female and male  underarm hair  and pubic hair has been considered proper personal  hygiene , necessitated by local customs, for many centuries. [ 3 ] [ 17 ] [ 18 ]  Young girls and unmarried women, however, are expected to retain their body hair until shortly before marriage, when the whole body is depilated from the neck down. [ 3 ]


In China, body hair has long been regarded as normal, and even today women are confronted with far less  social pressure  to remove body hair. [ 2 ]  The same attitude exists in other countries in Asia. While hair removal has become routine for many of the continent's younger women, trimming or removing pubic hair, for instance, is not as common or popular as in the  Western world , [ 2 ]  where both women and men may trim or remove all their pubic hair for  aesthetic  or  sexual reasons . This custom can be motivated by reasons of potentially increased personal cleanliness or hygiene, heightened sensitivity during  sexual activity , or the desire to take on a more exposed appearance or visual appeal, or to boost  self-esteem  when affected by excessive hair. In Korea, pubic hair has long been considered a sign of fertility and sexual health, and it has been reported in the mid-2010s that some Korean women were undergoing pubic hair transplants, to add extra hair, [ 2 ]  especially when affected by the condition of pubic atrichosis (or  hypotrichosis ), which is thought to affect a small percentage of Korean women. [ 19 ]


Unwanted or excessive hair is often removed in preparatory situations by both sexes, in order to avoid any perceived  social stigma  or prejudice. For example, unwanted or excessive hair may be removed in preparation for an intimate encounter, or before visiting a public beach or swimming pool.


Though traditionally in Western culture women remove body hair and men do not, some women choose not to remove hair from their bodies, either as a non-necessity or as an act of rejection against  social stigma , while some men remove or trim their body hair, a practice that is referred to in modern society as being a part of "manscaping" (a  portmanteau expression  for  male-specific grooming ).


The term " glabrousness " also has been applied to human fashions, wherein some participate in culturally motivated hair removal by depilation (surface removal by  shaving ,  dissolving ), or  epilation  (removal of the entire hair, such as  waxing  or  plucking ).


Although the appearance of secondary hair on parts of the human body commonly occurs during  puberty , and therefore, is often seen as a symbol of adulthood, removal of this and other hair may become fashionable in some cultures and subcultures. In many modern  Western cultures , men are encouraged to shave their beards, and women are encouraged to remove hair growth in various areas. Commonly depilated areas for women are the underarms, legs, and pubic hair. Some individuals depilate the forearms. In recent years, bodily depilation in men has increased in popularity among some subcultures of Western males. [ citation needed ]


For men, the practice of depilating the pubic area is common, especially for aesthetic reasons. Most men will use a razor to shave this area, however, as best practice, it is recommended to use a body trimmer to shorten the length of the hair before shaving it off completely.


In ancient Egypt, depilation was commonly practiced, with  pumice  and  razors  used to shave. [ 20 ] [ 21 ]  In both  Ancient Greece  and  Ancient Rome , the removal of body and pubic hair may have been practiced among both men and women. It is represented in some artistic depictions of male and female nudity,  [ citation needed ]  examples of which may be seen in  red figure pottery  and sculptures like the  Kouros  of Ancient Greece in which both men and women were depicted without body or pubic hair. Emperor  Augustus  was said, by Suetonius, to have applied "hot nutshells" on his legs as a form of depilation. [ 22 ]


In the  clothes free movement , the term "smoothie" refers to an individual who has removed their body hair. In the past, such practices were frowned upon and in some cases,  forbidden: violators could face exclusion from the club. Enthusiasts grouped together and formed societies of their own that catered to that fashion, and smoothies became a major percentage at some nudist venues. [ 23 ]  The first Smoothie club (TSC) was founded by a British couple in 1991. [ 24 ]  A Dutch branch was founded in 1993 [ 25 ]  in order to give the idea of a hairless body greater publicity in the  Netherlands . Being a Smoothie is described by its supporters as exceptionally comfortable and liberating. The Smoothy-Club is also a branch of the World of the Nudest Nudist (WNN) and organizes nudist ship cruises and regular nudist events.


Head-shaving ( tonsure ) is a part of some  Buddhist ,  Christian ,  Muslim ,  Jain  and  Hindu  traditions. [ 26 ]  Buddhist and Christian  monks  generally undergo some form of tonsure during their induction into monastic life. [ citation needed ]


Within  Amish  society, tradition ordains men to stop shaving a part of their facial hair upon marriage and grow a  Shenandoah  style beard which serves the significance of wearing a  wedding ring ,  moustaches  are rejected as they are regarded as martial (traditionally associated with the  military ). [ 27 ]


In  Judaism  (see  Shaving in Judaism ), there is no obligation for women to remove body hair or facial hair, unless they wish to do so. However, in preparation for a woman's immersion in a  ritual bath  after concluding her days of purification (following her menstrual cycle), the custom of Jewish women is to shave off their pubic hair. [ 28 ]  During a  mourning  ritual, Jewish men are restricted in the  Torah  and  Halakha  to using scissors and prohibited from using a razor blade to shave their beards or sideburns, [ 29 ]  and, by custom, neither men nor women may cut or shave their hair during the  shiva  period. [ 30 ] [ 31 ]


The  Baháʼí Faith  recommends against complete and long-term head-shaving outside of medical purposes. It is not currently practiced as a law, contingent upon a future decision by the  Universal House of Justice , its highest governing body.  Sikhs  take an even stronger stance, opposing all forms of hair removal. One of the " Five Ks " of Sikhism is  Kesh , meaning "hair". [ 32 ]  Baptized Sikhs are specifically instructed to have unshorn Kesh (the hair on their head and beards for men) as a major tenet of the Sikh faith. To Sikhs, the maintenance and management of long hair is a manifestation of one's piety. [ 32 ]


The majority of Muslims believe that adult removal of pubic and axillary hair, as a hygienic measure, is religiously beneficial. Under Muslim law ( Sharia ), it is recommended to keep the beard. [ citation needed ]  A Muslim may trim or cut hair on the head. In the 9th century, the use of  chemical depilatories  for women was introduced by  Ziryab  in  Al-Andalus . [ citation needed ]


The body hair of surgical patients is often removed beforehand on the skin surrounding  surgical sites . Shaving was the primary form of hair removal until reports in 1983 showed that it may lead to an increased risk of infection.  [ 33 ]   Clippers  are now the recommended pre-surgical hair removal method. [ 34 ] [ 35 ]  A 2021  systematic review  brought together evidence on different techniques for hair removal before surgery. This involved 25 studies with a total of 8919 participants. Using a razor probably increases the chance of developing a surgical site infection compared to using clippers or hair removal cream or not removing hair before surgery. [ 36 ]  Removing hair on the day of surgery rather than the day before may also slightly reduce the number of infections. [ 36 ]


Some people with  trichiasis  find it medically necessary to remove ingrown eyelashes. [ 37 ]


The shaving of hair has sometimes been used in attempts to eradicate  lice  or to minimize  body odor  due to the accumulation of odor-causing  micro-organisms  in hair. In extreme situations, people may need to remove all body hair to prevent or combat infestation by  lice ,  fleas  and other parasites. Such a practice was used, for example, in  Ancient Egypt . [ 38 ]


It has been suggested that an increasing percentage of humans  removing  their pubic hair has led to reduced  crab louse  populations in some parts of the world. [ 39 ] [ 40 ]


A  buzz cut  or completely shaven haircut is common in military organizations where, among other reasons, it is considered to promote uniformity and neatness. [ 41 ] [ 42 ]  Most militaries have  occupational safety and health  policies that govern the hair length and hairstyles permitted; [ 41 ]  in the field and living in close-quarter environments where bathing and sanitation can be difficult, soldiers can be susceptible to parasite infestation such as  head lice , that are more easily propagated with long and unkempt hair. [ 43 ]  It also requires less maintenance in the field and in adverse weather it dries more quickly. Short hair is also less likely to cause severe burns from flash flame exposure (as a result of  flash fires  from  explosions ) which can easily set hair alight. [ 41 ]  Short hair can also minimize interference with safety equipment and fittings attached to the head, such as  combat helmets  and  NBC suits . [ 41 ]  Militaries may also require men to maintain clean-shaven faces as facial hair can prevent an air-tight seal between the face and  military gas masks  or other  respiratory  equipment, such as a  pilot's oxygen mask , or  full-face diving mask . [ 41 ]  The process of testing whether a mask adequately fits the face is known as a " respirator fit test ".


In many militaries, head-shaving (known as the  induction cut ) is mandatory for men when beginning their  recruit training . However, even after the initial recruitment phase, when head-shaving is no longer required, many soldiers maintain a completely or partially shaven hairstyle (such as a " high and tight ", " flattop " or " buzz cut ") for personal convenience or neatness. Head-shaving is not required and is often not permitted for women in military service, although they must have their hair cut or tied to regulation length. [ 42 ]  For example, the shortest hair a female soldier can have in the U.S. Army is 1/4 inch from the scalp. [ 44 ]


It is a common practice for professional  footballers (soccer players)  and  road cyclists  to remove leg hair for a number of reasons. In the case of a crash or tackle, the absence of the leg hair means the injuries (usually  road rash  or scarring) can be cleaned up more efficiently, and treatment is not impeded. Professional cyclists, as well as professional footballers, also receive regular leg  massages , and the absence of hair reduces the friction and increases their comfort and effectiveness. [ citation needed ]  Football players are also required to wear shin guards, and in case of a skin rash, the affected area can be treated more efficiently.


It is also common for  competitive swimmers  to shave the hair off their legs, arms, and torsos (and even their whole bodies from the neckline down), to reduce drag and provide a heightened "feel" for the water by removing the exterior layer of skin along with the body hair. [ 45 ]


In some situations, people's hair is shaved as a punishment or a form of humiliation. After World War II, head-shaving was a common punishment in France, the Netherlands, and Norway for women who had collaborated with the Nazis during the occupation, and, in particular, for women who had sexual relations with an occupying soldier. [ 46 ]


In the United States, during the  Vietnam War , conservative students would sometimes attack student radicals or "hippies" by shaving beards or cutting long hair. One notorious incident occurred at  Stanford University , when unruly fraternity members grabbed  Resistance  founder (and student-body president)  David Harris , cut off his long hair, and shaved his beard.


During European  witch-hunts  of the  Medieval  and  Early Modern periods , alleged  witches  were stripped naked and their entire body shaved to discover the so-called  witches' marks . The discovery of witches' marks was then used as evidence in trials. [ 47 ]


Inmates have their heads shaved upon entry at certain prisons. [ citation needed ]


"Depilation", or temporary removal of hair to the level of the skin, lasts several hours to several days and can be achieved by


"Epilation", or removal of the entire hair from the root, lasts several days to several weeks and may be achieved by


Electrology  has been practiced in the United States since 1875. [ 56 ]  It is approved by the  FDA . This technique permanently destroys germ cells [ citation needed ]  responsible for hair growth by way of the insertion of a fine probe into the hair follicle and the application of a current adjusted to each hair type and treatment area. [ citation needed ]  Electrology is the only permanent hair removal method recognized by the FDA. [ 57 ]


A 2006 review article in the journal "Lasers in Medical Science" compared intense pulsed light (IPL) and both alexandrite and diode lasers. The review found no statistical difference in effectiveness, but a higher incidence of side effects with diode laser-based treatment. Hair reduction after 6 months was reported as 68.75% for alexandrite lasers, 71.71% for diode lasers, and 66.96% for IPL. Side effects were reported as 9.5% for alexandrite lasers, 28.9% for diode lasers, and 15.3% for IPL. All side effects were found to be temporary and even  pigmentation  changes returned to normal within 6 months. [ 58 ]


A 2006 meta-analysis of randomized controlled trials found that alexandrite and diode lasers caused 50% hair reduction for up to 6 months, while there was no evidence of hair reduction from intense pulsed light, neodymium-YAG or ruby lasers. [ 59 ]


Many methods have been proposed or sold over the years without published clinical proof they can work as claimed.


There are several disadvantages to many of these hair removal methods.


Hair removal can cause issues: skin inflammation, minor burns, lesions, scarring, ingrown hairs, bumps, and infected hair follicles ( folliculitis ).


Some removal methods are not permanent, can cause medical problems and permanent damage, or have very high costs. Some of these methods are still in the testing phase and have not been clinically proven.


One issue that can be considered an advantage or a disadvantage depending upon an individual's viewpoint, is that removing hair has the effect of removing information about the individual's hair growth patterns due to  genetic  predisposition, illness,  androgen  levels (such as from pubertal hormonal imbalances or drug side effects), and/or  gender  status.


In the hair follicle, stem cells reside in a discrete microenvironment called the bulge, located at the base of the part of the follicle that is established during morphogenesis but does not degenerate during the hair cycle. The bulge contains multipotent stem cells that can be recruited during wound healing to help repair the epidermis. [ 61 ]


Hairline lowering  (alternately, a  scalp advancement  or  forehead reduction ) is a  surgical  technique that allows an individual to have their frontal hairline advanced certain distances depending on variables such as pre-operative hairline height,  scalp  laxity, and patient preference. [ 1 ]  It can be used to address a congenitally high hairline or  sometimes a hairline that has recessed from  hair loss . It is performed mostly on women. [ 2 ]


Hairline lowering surgery is also recommended to many patients undergoing  facial feminization surgery  (FFS). The shape of the hairline is altered, creating a low, feminine hairline. For MTF (male to female) patients who have very prominent brow bones, brow bone shaving may be performed additionally.


Satisfactory hairline lowering is a balance between patient expectations and anatomical limitations. Scalp laxity is a primary determinant of extent of hairline advancement. When scalp laxity is insufficient for the desired amount of advancement, use of  tissue expanders  can greatly increase the possible advancement. [ 3 ]


Hairline lowering is typically performed on an outpatient basis with local anesthesia and intravenous sedation. The surgeon marks the anticipated postoperative hairline prior to surgery. The new hairline can be tailored to the patient's preferences and is often wavy to mimic a natural hairline. During the surgery, the excess forehead and/or scalp is excised and the scalp is advanced to the new hairline. The incisions are made in such a manner (trichophytic) so that hair regrows through and in front of the eventual hairline scar making it undetectable. [ 4 ]   The scalp has to be separated from the skull going far back almost to the neck. [ 3 ]    Additional scalp advancement can be achieved by incising the galea (the deep fibrous inelastic scalp layer)  which allows the scalp to stretch. [ 3 ]  Sometimes the surgeon will use implantable devices or sutures to secure the scalp to the bone at its new forward location. The surgeon will usually close the wound with two layers of  sutures or surgical clips. [ 3 ]


The resultant scar from hairline advancement is typically hidden by regrowth of hair, in some cases with  cowlicks , the scar can be seen. In such cases  hair transplants  can totally disguise the scar. In males with progressive baldness, the surgical scar may become more visible as balding advances. Hair thinning from "shock loss" can occur and is usually temporary. [ 5 ]  Infections are rare. Follicular unit hair transplants can be done as an alternative treatment although the results take up to two years to get enough hair length and density to compare with the near instantaneous results of the hairline lowering operation. [ 3 ]


Hand surgery  deals with both surgical and non-surgical treatment of conditions and problems that may take place in the hand or  upper extremity  (commonly from the tip of the hand to the shoulder) [ 1 ]  including injury and infection. [ 2 ]  Hand surgery may be practiced by post graduates of  orthopedic surgery  and  plastic surgery  and  MCh Hand surgery . [ 1 ]


Plastic surgeons  and orthopedic surgeons receive significant training in hand surgery during their residency training. Also, some graduates do an additional one-year hand fellowship. Board certified general, plastic, or orthopedics surgeons who have completed approved fellowship training in hand surgery and have met a number of other practice requirements are qualified to take the "Certificate of Added Qualifications in Surgery of the Hand" examination, formerly known as the CAQSH, it is now known as the SOTH." [ 3 ] [ 4 ] [ 5 ]  Now super speciatity training called MCh Hand Surgery required to be a qualified hand surgeon. Regardless of their original field of training, once candidates have completed an approved fellowship in hand surgery, all hand surgeons have received training in treating all injuries both to the bones and soft tissues of the hand and upper extremity. Among those without additional hand training, plastic surgeons have usually received training to handle traumatic hand and digit amputations that require a "replant" operation. Orthopedic surgeons are trained to reconstruct all aspects to salvage the appendage:  tendons ,  muscle ,  bone . As well, orthopedic surgeons are trained to handle complex fractures of the hand and injuries to the  carpal bones  that alter the mechanics of the wrist.


The historical context for the three qualifying fields is that both plastic surgery and orthopedic surgery are more recent branches off the general surgery main trunk. Modern hand surgery began in  World War II  as a military planning decision.  US Army Surgeon General , Major General Norman T. Kirk, knew that hand injuries in  World War I  had poor outcomes in part because there was no formal system to deal with them. [ 6 ]  Kirk also knew that his civilian general surgical colleague Dr. Sterling Bunnell had a special interest and experience in hand reconstruction. Kirk tapped Bunnell to train military surgeons in the management of hand injuries to treat the war casualties, and at that time hand surgery became a formal specialty.


Orthopedic surgeons continued to develop special techniques to manage small bones, as found in the wrist and hand. [ 7 ]  Pioneering plastic surgeons developed microsurgical techniques for repairing the small nerves and arteries of the hand. Surgeons from all three specialties have contributed to the development of techniques for repairing tendons and managing a broad range of acute and chronic hand injuries. Hand surgery incorporates techniques from orthopaedics, plastic surgery, general surgery,  neurosurgery ,  vascular  and  microvascular surgery  and  psychiatry . A recent advance is the progression to 'wide awake hand surgery.' [ 8 ]


In a few countries such as  Sweden ,  Finland  and  Singapore , hand surgery is recognized as a clinical specialty in its own right, [ 9 ]  with a formal four to six years hand surgery resident training program. Hand surgeons going through these programs are trained in all aspects of hand surgery, combining and mastering all the skills traditionally associated with "Orthopedic hand surgeons" and "Plastic hand surgeons" to become equally adept at handling tendon, ligament and bone injuries as well as microsurgical reconstruction such as reattachment of severed parts or free tissue transfers and transplants.


Hand surgeons perform a wide variety of operations such as fracture repairs, releases, transfer and repairs of tendons and reconstruction of injuries, rheumatoid deformities and congenital defects. [ 10 ]  They also perform microsurgical reattachment of amputated digits and limbs, microsurgical reconstruction of soft tissues and bone, nerve reconstruction, and surgery to improve function in paralysed upper limbs. There are two medical societies that exist in the United States to provide continuing medical education to hand surgeons: the  American Society for Surgery of the Hand  and the American Association for Hand Surgery. In Britain, the medical society for hand surgeons is the:  British Society for Surgery of the Hand  (BSSH). In Europe, several societies are brought together by the Federation of European Societies for Surgery of the Hand (FESSH). [ 11 ]


The following conditions can be indications for hand surgery:


Some complications of hand surgery include:


Hand transplantation,  or simply a  hand transplant,  is a surgical procedure to  transplant  a  hand  from one human to another. The donor hand, usually from a  brain-dead  donor, is transplanted to a recipient amputee. Most hand transplants to date have been performed on below-elbow amputees, although above-elbow transplants are gaining popularity. Hand transplants were the first of a new category of transplants where multiple organs are transplanted as a single functional unit, now termed vascularized composite  allotransplantation  (VCA).


The operation is quite extensive and typically lasts from 8 to 12 hours. In comparison, a typical  heart transplant  operation lasts 6 to 8 hours. Surgeons usually connect the bones first, followed by tendons, arteries, nerves, veins, and skin.


For a hand transplant to succeed the recipient is required to take  immunosuppressive drugs , [ 1 ]  as in other organ transplants such as kidney or liver, to minimize rejection, or risk destruction of the hand by the recipient's natural  immune system . These drugs risk weakening the recipient's immune system, which may increase the risk of infections and some cancers. Many recent advances in solid organ transplantation have made these medications more tolerable.


A period of extensive hand therapy/rehabilitation after transplantation helps the recipient gain function of the transplanted hand. [ 2 ]  Compliance with immunosuppressive medications and intensive physical therapy after hand transplants is associated with significant success in regaining the function of the new hands/arms.


A hand transplant was performed in Ecuador in 1964, but the patient experienced transplant rejection after only two weeks due to the primitive nature of the immune-suppressing medications at that time. [ 3 ]


The first short-term success in human hand transplant surgery occurred with Clint Hallam, [ 4 ]  from New Zealand. Hallam lost his hand in an accident while in prison. [ 5 ] [ 6 ] [ 7 ]  The operation was performed on September 23, 1998, [ 8 ]  in  Lyon ,  France , by a team assembled from different countries around the world led by French Professor  Jean-Michel Dubernard , including Professor  Nadey Hakim , from the UK. [ 7 ] [ 5 ] [ 9 ]


A microsurgeon on the team,  Earl Owen  from Australia, was privy to the detailed basic research, much of it unpublished, that had been carefully gathered by the team in Louisville. [ 8 ]  After the operation, Hallam wasn't comfortable with the idea of his transplanted hand and failed to follow the prescribed post-operative drug and physiotherapy regime. [ 6 ] [ 8 ]  His inaccurate expectations became a vivid example of the necessity of a fully committed team of caregivers, including psychologists, who can correctly select and prepare the potential transplant recipients for the lengthy and difficult recovery and for the modest functional restoration of a transplanted hand to be expected. [ 6 ] [ 5 ] [ 4 ]


Hallam's transplanted hand was removed [ 10 ]  at his request by the transplant surgeon  Nadey Hakim  on February 2, 2001, following another episode of rejection that was, at least in part, caused by his stopping the anti-rejection medication. [ 11 ] [ 8 ]


The first hand transplant to achieve prolonged success was directed by a team of Kleinert Kutz Hand Care surgeons including  Warren C. Breidenbach , Tsu-Min Tsai, Luis Scheker, Steven McCabe, Amitava Gupta, Russell Shatford, William O'Neill, Martin Favetto and Michael Moskal in cooperation with the Christine M. Kleinert Institute,  Jewish Hospital  and the  University of Louisville  in  Louisville, Kentucky . The procedure was performed on  New Jersey  native Matthew Scott on January 14, 1999. Scott had lost his hand in a fireworks accident at age 24. Later in 1999, the Philadelphia Phillies baseball team asked him to do the honors of throwing out the ceremonial first pitch. The Louisville group went on to perform the first five hand transplants in the United States and have performed 12 hand transplants in ten recipients as of 2016. [ citation needed ]


In contrast to the earlier attempts at hand transplantation, the Louisville group had performed extensive basic science research and feasibility studies for many years before their first clinical procedure (for example, Shirbacheh  et al. , 1998). [ 12 ]  There was also considerable transparency and institutional review board oversight involved in the screening and selection of prospective patients. [ citation needed ]


In March 2000, a team of surgeons at the  University of Innsbruck  in  Austria  began a series of three bilateral hand transplants over six years. The first was an Austrian police officer who had lost both hands attempting to defuse a bomb. He has completed an around-the-world solo motorcycle trip using his transplanted hands. [ citation needed ]


University of Louisville doctors also performed a successful hand transplant on Michigan native Jerry Fisher in February 2001, and Michigan resident David Savage in 2006. [ 13 ]


On 14 January 2004, the team of Professor  Jean-Michel Dubernard  (Edouard-Herriot Hospital, France) declared a five-year-old double hand transplant a success. The lessons learned in this case, and in the 26 other hand transplants (6 double) which occurred between 2000 and 2005, encouraged other transplant operations of such organs as the  face , abdominal wall, and  larynx . [ citation needed ]


On 4 May 2009  Jeff Kepner , a 57-year-old Augusta, Georgia resident underwent the first double hand transplant in the United States at the  University of Pittsburgh Medical Center  by a team led by  W.P. Andrew Lee , who also had been performing careful basic research on such transplants for many years. A CNN story on his follow up demonstrated the limited functional restoration to be expected, particularly following bilateral transplantation. [ 14 ]


On 18 February 2010, the first female in the United States underwent hand transplantation at Wilford Hall Medical Center in San Antonio, Texas. The procedure was performed by surgeons from The Hand Center of San Antonio and US Air Force. [ 15 ]


On 22 June 2010, a  Polish  soldier received two new hands from a female donor, after losing them three years earlier while saving a young recruit from a bomb. [ citation needed ]


On 8 March 2011, 26-year-old Emily Fennell underwent an 18-hour surgery to attach a right hand. This was performed in the  Ronald Reagan UCLA Medical Center . [ 16 ] [ 17 ]


On 12 March 2011 Linda Lu became the recipient of a hand transplant, performed at Emory University Hospital, [ 18 ]  from a donor Leslie Sullivent. [ 19 ]


In the fall of 2011, 28-year-old Lindsay Ess received a double hand transplant at the  Hospital of the University of Pennsylvania  in an 11 1/2 hour surgery. [ 20 ]


On 27 December 2012, 51-year-old Mark Cahill received a right hand transplant at  Leeds General Infirmary  in the UK. The recipient's hand was removed during the same 8 hour operation, reportedly allowing very accurate restoration of nerve structures, believed to be an international first. [ 21 ] [ 22 ]


On 27 February 2013, 38-year-old Eskandar Moghaddami received hand transplant surgery by the 15th of Khordad Hospital plastic surgery team in Tehran, Iran. [ citation needed ]


On 13 January 2015, doctors at the  Kochi -based  Amrita Institute of Medical Sciences and Research Centre  (AIMS) successfully conducted India's first hand transplant. A 30-year-old man, who had lost both his hands in a train accident, received the hands of a 24-year-old accident victim. [ 23 ]


On 28 July 2015, doctors at the  Children's Hospital of Philadelphia  performed the first successful bilateral hand transplant on a child. [ 24 ]  At the age of 2, Zion Harvey lost his hands and feet to a life-threatening infection. Six years later, at age 8, he had both of his hands replaced in a double hand transplant. [ 25 ]


On 2 August 2016, the reconstructive transplantation team at the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, performed the first intergender hand transplantation in India on a 16-year-old boy who had lost both his hands in an electrocution injury. The donor was a 54-year-old lady who was brain dead following a road traffic accident. [ 26 ] [ 27 ]


On 26 October 2016, the Director of hand transplantation at  UCLA , Dr.  Kodi Azari , and his team, [ 28 ]  performed a hand transplant on 51-year-old entertainment executive from Los Angeles,  Jonathan Koch  at  Ronald Reagan UCLA Medical Center . Koch underwent a 17-hour procedure to replace his left hand, which he lost to a mysterious, life-threatening illness that struck him in January 2015. [ 29 ]  On June 23, 2015, Koch had the amputation surgery, also performed by Dr. Kodi Azari, which was designed to prep him to receive a transplanted limb. This included severing the left hand closer to the wrist than the elbow. Azari kept all the nerves and tendons long and extended, which would give him plenty to work with later. Then he sutured them together and attached them to the stump of bone to keep them from retracting. [ 30 ]  This is the first known hand transplant case in which the hand was amputated in preparation for a hand transplant, as opposed to previous hand transplant patients who have undergone typical amputation surgeries. Azari's theory about prepping the hand for a transplant during the initial amputation surgery would later be supported by Koch when he was able to move his thumb only two hours after he woke up from the 17-hour transplant surgery [ 31 ]  and move his entire hand only two days after surgery. [ 32 ]


On 15 January 2021, Icelander  Guðmundur Felix Grétarsson  underwent the first double-arm and double-shoulder transplant from doctors in France. [ 33 ]  The transplant was deemed successful. [ 34 ]


The long-term functionality varies patient to patient and is affected by several factors including level of amputation and transplant and participation in occupational therapy post hand transplant surgery. Hand transplant recipient Jonathan Koch was able to pick up a napkin and a tennis ball with his newly transplanted hand 7 days after his 17-hour surgery and by day 9, he was able to pick up a bottle of water and take a drink. 3 months after surgery, Koch was able to use his transplanted hand to tie his shoe. [ 35 ]


Although the one-year survival rate of transplanted hands has been excellent at institutions that are fully committed to the procedure, the number of hand transplants performed after 2008 has been small due to drug-related side effects, uncertain long-term outcome, and the high costs of surgery, rehabilitation and immunosuppression. [ 36 ]


The Johns Hopkins University School of Medicine Hand and Arm Transplant Program was approved by the Johns Hopkins Medicine Institutional Review Board in July 2011. This is one of only two programs in the United States approved to perform hand/arm transplants using an immunomodulatory protocol, which enables patients to take one drug (instead of three) after the transplant to maintain the hand or arm. The program is funded by the US Army Medical Research and Materiel Command (MRMC) Armed Forces Institute of Regenerative Medicine (AFIRM) to transplant up to six Wounded Warriors or civilians who have a hand or arm amputation on one or both sides. [ citation needed ]


The Southern Illinois University School of Medicine Hand Transplant Program is located in  Springfield, Illinois . The program was officially launched in January 2014 after receiving IRB approval and grant funding to transplant five patients, unilateral or bilateral, at minimal cost to the patients.


The UCLA Hand Transplant Program, located in  Los Angeles, California , was launched July 28, 2010. At the time, it was the only one on the West Coast and one of only four in the country. [ 37 ]


In 2016, it was announced that  NHS  patients in  England  were to become some of the first in the world to benefit from publicly funded pioneering hand and upper arm transplants delivered by a specialist team at Leeds General Infirmary. [ 38 ]


Hao Lulu  ( Chinese :  郝璐璐 , born 9 January 1979) is a  Manchu  Chinese woman who has become well known for having undergone extensive  cosmetic surgery  in 2003 to alter her appearance, tagged "The Artificial Beauty" ( 人造美女 ).


Born in  Beijing , Hao entered the  China University of Geosciences  in 1999. After graduation in 2001, she studied for a  master's degree  in  gemology  in the  United Kingdom  until 2003.


She became a freelance fashion writer briefly until July 19, 2003, to August 14, 2003, when she started a series of operations to modify her eyes, nose, chin, breasts, abdomen, buttocks, legs, and skin, at just 24 years old.


In before-and-after photographs widely circulated in the media, her appearance was indeed radically altered, in particular her eyes, which were given double eyelids to give her a more  occidental  appearance (see  Asian blepharoplasty ). The color of her skin was also lightened.


The transformation of Lulu, the "Beauty Dreamwork Project" ( 治造美人 ), was organized by EverCare ( 伊美尔 ), a Beijing cosmetic surgery clinic, to promote its business, which had been languishing in the aftermath of the  SARS  epidemic. Evercare organized a press conference around Lulu to promote the company's cosmetic surgery services. The clinic came out with numerous ads, that claimed they have the confidence and capacity to help Chinese women create new physiques through the use of advanced technologies and surgical skills. After her surgeries, Hào then worked as a spokesperson for the cosmetic surgery clinic that transformed her body. [ 1 ]


The company's actions have been criticized in China by doctors, who deplored it as a publicity stunt. However, it led to a great upsurge in interest in cosmetic surgery among China's  nouveau riche . After her transformation, news stories on body alternations increased tremendously in China's mainstream media, marginalized tabloids, and cyberspace, from a number of different beauty companies. [ 1 ]


Hao's diary, published on the clinic's website, stated the pain and numbness she felt after certain procedures. She also constantly expressed her wish to go home tomorrow, where "freedom" is. In the second last entry, she concluded, however, that all pain is gone and that it was such a relief: "How wonderful all these things are; I have no regret for my very first choice!" ( 这一切是多么的美好，我无悔我最初的选择！ )


Hirudo medicinalis , or the  European medicinal leech , is one of several  species  of  leeches  used as  medicinal leeches .


Other species of  Hirudo  sometimes also used as medicinal leeches include  H. orientalis ,  H. troctina , and  H. verbana . The Asian medicinal leech includes  Hirudinaria  manillensis , and the North American medicinal leech is  Macrobdella  decora .


Medicinal leech populations were reduced significantly in many countries during the 19th century due to the high demand in medical contexts, and remain endangered in many countries today. [ 3 ]


The general  morphology  of medicinal leeches follows that of most other leeches. Fully mature adults can be up to 20 centimeters in length, and are green, brown, or greenish-brown with a darker tone on the  dorsal  side and a lighter  ventral  side. The dorsal side also has a thin red stripe. These organisms have two suckers, one at each end, called the  anterior  and  posterior  suckers. The posterior is used mainly for leverage, whereas the anterior sucker, consisting of the  jaw  and  teeth , is where the feeding takes place. Medicinal leeches have three jaws (tripartite) that resemble saws, on which are approximately 100 sharp edges used to incise the host. The incision leaves a mark that is an inverted Y inside of a circle. After piercing the skin, they suck out  blood  while injecting blood thinners similar to  Anophelins ;  anticoagulants  ( hirudin ). [ 4 ]  Large adults can consume up to ten times their body weight in a single meal, with 5–15 mL being the average volume taken. [ 5 ]  These leeches can live for up to a year between feedings. [ 6 ]


Medicinal leeches are  hermaphrodites  that reproduce by  sexual  mating, laying eggs in clutches of up to 50 near (but not under) water, and in shaded, humid places. A study done in Poland found that medicinal leeches sometimes breed inside the nests of large aquatic birds, noting that conservation efforts directed at bird habitats may also indirectly help preserve dwindling leech populations. [ 7 ]


Their range extends over almost the whole of  Europe  and into  Asia  as far as  Kazakhstan  and  Uzbekistan . The preferred  habitat  for this species is muddy freshwater pools and ditches with plentiful weed growth in temperate climates.


Over-exploitation  by  leech collectors  in the 19th century has left only scattered populations, [ 3 ]  and reduction in natural habitat through drainage has also contributed to their decline. Another factor includes the replacement of  horses  - medicinal leeches' preferred host species - by motor vehicles and mechanical farming equipment, and the provision of artificial water supplies for cattle. As a result, this species is now considered  near threatened  by the  IUCN , and European medicinal leeches are legally protected through nearly all of their natural range. They are particularly sparsely distributed in  France  and  Belgium , and in the UK there may be as few as 20 remaining isolated populations (all widely scattered). The largest, located at  Lydd, England , is estimated to contain several thousand individuals; 12 of these areas have been designated  Sites of Special Scientific Interest . There are small, transplanted populations in several countries outside their natural range, including the USA. The species is protected under Appendix II of  CITES  meaning international trade (including in parts and derivatives) is regulated by the CITES permitting system. [ 2 ]


Medicinal leeches have been found to secrete  saliva  containing about 60 different  proteins . [ 8 ]  These achieve a wide variety of goals useful to the leech as it feeds, helping to keep the blood in liquid form and increasing blood flow in the affected area. Several of these secreted proteins serve as  anticoagulants  (such as  hirudin ),  platelet aggregation  inhibitors (most notably  apyrase ,  collagenase , and calin),  vasodilators , and  proteinase  inhibitors. [ 9 ]   It is also thought that the saliva contains an  anesthetic , [ 10 ]  as leech bites are generally not painful.


The first recorded use of leech therapy was 3,500 years ago in Ancient Egypt. [ 11 ]  The next recorded uses of leeches in medicine come in the last few centuries BCE, by the Greek physician  Nicander  in  Colophon [ 5 ]  and in the ancient Sanskrit text  Sushruta Samhita . [ 12 ]  Leech therapy is mentioned a few hundred years later in  Shennong Bencaojing , a 3rd-century CE book of traditional Chinese medicine. [ 13 ]


Medical use of leeches was discussed by  Avicenna  in  The Canon of Medicine  (1020s), and by  Abd al-Latif al-Baghdadi  in the 12th century. [ citation needed ]


These sources indicated leech therapy for a wide variety of ailments, including  edema , [ 12 ]  "blood stasis", [ 13 ]  and skin diseases. [ 14 ]


In medieval and early modern European medicine, the medicinal leech ( Hirudo medicinalis  and its congeners  H. verbana ,  H. troctina , and  H. orientalis ) was used to remove blood from a patient as part of a process to balance the  humors  that, according to  Galen , must be kept in balance for the human body to function properly. (The four humors of ancient medical philosophy were blood,  phlegm ,  black bile , and  yellow bile .) Any sickness that caused the subject's skin to become red (e.g.  fever  and inflammation), so the theory went, must have arisen from too much blood in the body. Similarly, any person whose behavior was strident and sanguine was thought to be suffering from an excess of blood. Leeches, by removing blood, were thought to help with these kinds of conditions — a wide range which included illnesses like  polio  and  laryngitis . [ 5 ]  Leeches were often gathered by leech collectors and were eventually farmed in large numbers. A unique 19th-century " Leech House " survives in  Bedale ,  North Yorkshire  on the bank of the Bedale Beck, used to store medicinal leeches until the early 20th century.


Manchester Royal Infirmary  used 50,000 leeches a year in 1831. The price of leeches varied between one penny and threepence halfpenny each. In 1832 leeches accounted for 4.4% of the total hospital expenditure. The hospital maintained an aquarium for leeches until the 1930s. [ 15 ]  The use of leeches began to become less widespread towards the end of the 19th century. [ 5 ]


Medicinal leech therapy (also referred to as  Hirudotherapy  or  Hirudin therapy ) made an international comeback in the 1970s in  microsurgery , [ 16 ] [ 17 ] [ 18 ]  used to stimulate circulation in tissues threatened by postoperative venous congestion, [ 16 ] [ 19 ]  particularly in finger reattachment and  reconstructive surgery  of the ear, nose, lip, and eyelid. [ 17 ] [ 20 ]  Other clinical applications of medicinal leech therapy include  varicose veins , muscle cramps,  thrombophlebitis , and  osteoarthritis , among many varied conditions. [ 21 ]  The therapeutic effect is not from the small amount of blood taken in the meal, but from the continued and steady bleeding from the wound left after the leech has detached, as well as the anesthetizing, anti-inflammatory, and vasodilating properties of the secreted leech saliva. [ 5 ]  The most common complication from leech treatment is prolonged bleeding, which can easily be treated, but more serious allergic reactions and bacterial infections may also occur. [ 5 ]  Leech therapy was classified by the US  Food and Drug Administration  as a medical device in 2004. [ 22 ]


Because of the minuscule amounts of  hirudin  present in leeches, it is impractical to harvest the substance for widespread medical use. Hirudin (and related substances) are synthesized using  recombinant  techniques. Devices called "mechanical leeches" that dispense  heparin  and perform the same function as medicinal leeches have been developed, but they are not yet commercially available. [ 23 ] [ 24 ] [ 25 ] [ 26 ]


Hydradermabrasion  is a  dermatological  procedure which combines simultaneous dermal infusion of medicinal products and crystal-free  exfoliation . Hydradermabrasion's mechanism of actions includes: (a) mechanical stimulation activates the basal layer, and (b) thickening and smoothing the  epidermis .  Fibroblast  activity results in  extracellular matrix  deposition and dermal thickening.  Antioxidants  introduced through the procedure hydrate and decrease  inflammation  in the skin, reversing photo damage, while protecting lipid membranes, collagen fibers, and enzyme systems. [ 1 ]


It is considered to be a relatively new procedure which combines microdermabrasion with the pneumatic application of antioxidant-based serums. [ 2 ]  The addition of  polyphenolic  antioxidants through hydradermabrasion to a  phototherapy  regimen enhanced the clinical, biochemical, and histological changes seen following phototherapy alone. [ 3 ]


"Hydradermabrasion has the same indications for use as  microdermabrasion , making it an excellent choice for persons with darker skin tones, aging skin, sensitive skin areas, oily, and dry skin complexions". [ 4 ]  A study on the efficacy of hydradermabrasion for facial rejuvenation was conducted comparing volunteers who received hydradermabrasion facial treatments using an antioxidant serum or who just received the same antioxidant serum manually applied to the skin. [ 4 ]


Skin treated with Hydradermabrasion demonstrated "significantly increased epidermal and papillary dermal thickness, and increased fibroblast density (p<0.01)”. [ 5 ]  A study on the efficacy of hydradermabrasion for facial rejuvenation was conducted comparing volunteers who received hydradermabrasion facial treatments using an antioxidant serum or who just received the same antioxidant serum manually applied to the skin. Six treatments were conducted on a 7- to 10-day interval to determine whether antioxidant levels could be increased in the skin and skin quality improved with this technique. Results of this study demonstrated that hydradermabraded skin possessed increased epidermal and papillary dermal thickness as well as greater antioxidant levels. Further histological examination saw a replacement of elastic dermal tissue, collagen hyalinization, and fibroblast density correlating with a decrease in the appearance of fine lines, pore size, and hyperpigmentation in hydradermabrasion treated areas 6 weeks post-treatment with no patient complications. [ 4 ]


Hymenorrhaphy  or " hymen reconstruction surgery " is the  surgical  alteration of the  hymen , with the goal of producing bleeding on intercourse and a tight  vaginal introitus , falsely believed to indicate virginity. The term comes from the Greek words  hymen  meaning "membrane", and  raphḗ  meaning " suture ". It is also known as  hymenoplasty , although strictly this term would also include  hymenotomy . [ citation needed ]


The normal aim is to cause  bleeding  during post-nuptial  intercourse , which in some cultures is wrongly considered  proof of virginity . Roughly half of women having vaginal intercourse for the first time do not bleed; a small study found that of 19 women who underwent hymenorrhaphy and attended follow-up, 17 did not have bleeding at the next intercourse. [ 1 ]


It is also based on the false belief that there are "intact" and "broken" hymens, distinct in appearance or feel. It is not possible to determine whether someone is a virgin by the appearance of their hymen or the tightness of the vagina. [ 2 ] [ 1 ]


Hymenorrhaphies are not generally regarded as part of mainstream  gynecology , but are available from some  plastic surgery  centers, particularly in the United States, Middle East,  South Korea  and  Western Europe , generally as  outpatient surgery . [ citation needed ]  Hymenorraphy is considered a form of cosmetic surgery, and is not generally accepted, taught, or regulated by the medical profession. [ 1 ]


Hymenorraphy is based on the false belief that all women bleed when first having vaginal intercourse; in fact, only about half bleed; [ 1 ]  as few as a third in one informal survey. [ 3 ]  Hymens have few blood vessels and may not bleed significantly even when torn, and vaginal walls may bleed significantly when torn. Blood on the sheets on first intercourse is more likely to be due to lacerations to the vaginal wall caused by inadequate  vaginal lubrication  or forced penetration. [ 2 ]  This false belief is ancient; it is found in  Deuteronomy . [ 4 ]


Despite common cultural beliefs, there are not distinct "intact" and "broken" states for the hymen, and the state of a hymen cannot be used to  prove or disprove virginity . [ 2 ] [ 1 ]  Medical professionals therefore recommend against describing hymens as "intact" or "broken". [ 2 ]


Hymens vary greatly in appearance.  Imperforate hymens , completely covering the vagina, can cause medical problems and are fortunately rare. Septate, cribriform, and microperforate hymens may also cause medical difficulties. Labiate, carunculate, redundant, fimbriate, crescentic, and annular hymens are naturally-occurring variations. [ 1 ] [ 5 ] [ 2 ]  The most common form of hymen is a crescent-shaped band along the back edge of the vaginal opening. [ 2 ]  Bumps, mounds, clefts, and notches in the edge of the hymen are normal, even in newborns. [ 2 ]


Inserting objects (including penises) into the vagina may or may not affect the  hymen . [ 2 ]  Penile penetration does not lead to predictable changes to female genital organs; after puberty, hymens are highly elastic and can stretch during penetration without trace of injury. Females with a confirmed history of sexual abuse involving genital penetration may have normal hymens. Young females who say they have had consensual sex mostly show no identifiable changes in the hymen. Hymens naturally have irregularities in width, and hymens can heal spontaneously without scarring. Visible breaks in the hymen, including complete hymenal clefts, are also common in girls and women who have never been sexually active. [ 2 ] [ 6 ]


It is not possible to tell by feel or tightness whether someone has previously had vaginal intercourse. Tightness of the vagina during first intercourse is mostly caused by an involuntary clenching the muscles of the  pelvic floor  due to nervousness. [ 1 ]  Such involuntary clenching can be strong enough to make intercourse difficult, painful, or impossible; when this occurs in a woman who has previously been able to have vaginal intercourse, it is called secondary  vaginismus . [ 7 ]


In a purely cosmetic procedure, a membrane without blood supply is created, sometimes including a  gelatine  capsule of an artificial bloodlike substance. This operation is intended to be performed within a few days before an intended  marriage . [ 3 ]  Operations have grown more sophisticated over time. [ 8 ]


Because there is no standard "intact" appearance of a hymen, the surgeon must creatively shape a hymen that conforms to social expectations. [ 1 ]


Some hymen reconstruction operations are legal in some countries, while other countries ban all hymenorrhaphy. [ 9 ]  For example, in 2020 in the  Netherlands  the professional surgeon associations adjusted their codes to prohibit hymenorrhaphy, and the government stated it would consider a legal ban if practice continues. The number of women undergoing the operation in the country at the time was estimated as several hundreds per year. [ 10 ]  The  United Kingdom  criminalised the procedure (referred to as "hymenoplasty") even with consent, along with  aiding and abetting  it or offering to carry it out, with the  Health and Care Act 2022 . The same Act also banned  virginity testing . [ 11 ] [ 12 ]


The operation is popular in Middle Eastern countries, in particular in Iran, where women are expected to keep virginity until their wedding night. Grand Ayatollah  Sayyid Sadeq Rohani  has issued a  fatwa  which says that a woman who has undergone hymenorrhaphy is a virgin, and a man marrying her cannot divorce her on the grounds that she is not a virgin. [ 8 ]


Injectable filler  is a special type of substance made for injections into connective tissues, such as  skin ,  cartilage  or even  bone , for cosmetic or medical purposes. The most common application of injectable fillers is to change one's facial appearance, but they also are used to reduce symptoms of osteoarthritis, treat tendon or ligament injuries, support bone and gum regeneration, and for other medical applications. Injectable fillers can be in the form of  hydrogel  or gels made from pulverized  grafts .


Injectable fillers have risen in popularity mostly due to the wide application of dermal fillers in 80's. Their premise is to help fill in facial  wrinkles , provide facial volume, and augment facial features. Side effects include bruising or infections from improper sterilisation. This may include  HIV infection , also allergic reactions, which may cause scarring and lumps. Blindness due to retrograde (opposite the direction of normal blood flow)  embolization  into the  ophthalmic  and  retinal arteries  can occur.


Injection of dermal fillers is the second most common nonsurgical cosmetic procedure in the USA, used for addressing volume deficiency,  scars ,  wrinkles , and enhancing facial features and specific anatomical sites like the  lips . The variety of available dermal fillers increases annually, requiring dermatologists and cosmetic surgeons to stay informed about the latest options to ensure safe and effective treatments.  [ 1 ]


Fillers are made of  polysaccharides  such as  hyaluronic acids , a naturally occurring in skin and cartilage, [ 2 ]   collagens  which may come from pigs, cows, cadavers, or may be generated in a laboratory, [ 3 ]  the person's own transplanted fat tissue, and/or biosynthetic polymers. Examples of the latter include  calcium hydroxylapatite ,  polycaprolactone ,  polymethylmethacrylate , and  polylactic acid . [ 4 ]  In 2012, "Artiste Assisted Injection System" was launched in the US market to assist in the delivery of dermal fillers. A study in 2013 concluded that the injecting device can achieve reductions in patient discomfort and adverse events by controlling the rate of flow of injection of the filler the practitioner is using to fill in the lips and frown lines. [ 5 ]


Soft-tissue augmentation has grown in popularity recently, particularly with the use of  hyaluronic acid  (HA) based dermal fillers. These non-permanent injectables can restore lost volume, smooth fine lines and wrinkles, and enhance facial contours. Despite their widespread use since the late 1990s, there is limited comparative data and literature on the diverse range of HA fillers and their tissue performance.


The studies explore various methods and parameters for characterizing dermal fillers, providing key insights for clinicians to select the most suitable products for their patients. The aging face undergoes complex changes due to  bone resorption ,  gravity , fat redistribution, and skin damage, which dermal fillers aim to counteract. HA fillers are considered medical devices rather than medicines, thus lacking stringent regulatory requirements for safety and efficacy data.


The scientific community emphasizes the importance of understanding the physico-chemical properties of fillers, such as their behavior under stress and deformation, and their performance over time. These properties are influenced by different crosslinking technologies used in manufacturing.


A literature search identified key studies on the rheological properties of HA fillers, focusing on FDA-approved products and others like Revolax. The review analyzes methodologies and critiques the existing literature to provide a comprehensive understanding of HA fillers' properties.
 [ 6 ]


Dermal fillers, also known as "injectables" or "soft-tissue fillers," fill in the area under the skin, and have some non-cosmetic uses, such as non-surgical  facial cleft  repair or cleft modification, treating fat loss secondary to  HIV : [ 7 ]  Fillers were found to give a temporary acceptable therapeutic effect in  HIV ‐infected patients with severe facial  lipodystrophy  caused by highly active  antiretroviral  therapy. [ 8 ] [ 9 ]  A 2009 review concluded that injectable fillers resulted in high satisfaction, but further research was needed to determine safety of its use. [ 10 ] [ 11 ]


Most wrinkle fillers are temporary because they are eventually metabolized by the body. Some people may need more than one injection to achieve the wrinkle-smoothing effect. The effect lasts for about six months. Results depend on health of the skin, skill of the health care provider, and the type of filler used. Regardless of material (whether synthetic or organic) filler duration is highly dependent on amount of activity in the body area where it is injected. Exercise and high intensity activities such as manual labor can stimulate blood flow and shorten the lifespan of fillers. [ 12 ]


Risks of an improperly performed dermal filler procedure commonly include bruising, redness, pain, or itching. Less commonly, there may be infections or allergic reactions, which may cause scarring and lumps that may require surgical correction. [ 13 ]  In 2024, a cluster of  HIV infections  was described amongst clients receiving microneedling facials at a Spa. [ 14 ]  More rarely, serious adverse effects such as blindness due to retrograde (opposite the direction of normal blood flow)  embolization  into the  ophthalmic  and  retinal arteries  can occur. [ 15 ]  Delayed skin necrosis can also occur as a complication of embolization. [ 16 ]  Embolic complications are more frequently seen when  autologous  fat is used as a filler, followed by  hyaluronic acid . Though rare, when vision loss does occur, it is usually permanent. [ 17 ]


In the US, fillers are approved as medical devices by the  Food and Drug Administration  (FDA) and the injection is prescribed and performed by a provider. What defines a qualified dermal injection provider varies by country and is a point of debate between  board-certified doctors  and injectors who operate under cosmetic or aesthetician licenses. [ citation needed ]


Fillers are not to be confused with  neurotoxins  such as  Botox . Fillers are not approved for certain parts of the body where they can be unsafe, including the penis. [ 18 ]  In Europe and the UK, fillers are non-prescription medical devices that can be injected by anyone licensed to do so by the respective medical authorities. They require a CE mark, which regulates adherence to production standards, but does not require any demonstration of medical efficacy.  As a result, there are over 140 injectable fillers in the UK/European market and only six approved for use in the US. [ 19 ]  In China, the market of cosmetic surgery increase in recent 10 years, NMPA (formerly CFDA) also has issued several guidance to regulate injectable filler. [ 20 ]


Injection lipolysis  is a controversial cosmetic procedure in which drug mixtures are injected into patients with the goal of destroying fat cells. This practice, using drugs generally based on  phosphatidylcholine  and  deoxycholate  (PCDC), evolved from the initial intravenous use of those drug formulations to treat blood disorders. [ 1 ] [ 2 ]


While no placebo-controlled studies have demonstrated the safety or efficacy of this therapy, numerous retrospective studies of Lipostabil injections have reported the efficacy of this practice. [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ]   The mixture is injected directly into the subcutaneous fat through multiple microinjections administered over multiple treatment sessions.  The desired result is the removal of localized fat deposits. [ 2 ]


In 1966, investigators noted that the intravenous infusion of PC-containing solutions could remove fat emboli. [ 11 ]   Later, a drug formulation called Lipostabil containing 5% PC and 2.5% deoxycholate (DC) was approved in Germany and used in the treatment of fat embolism, [ 12 ] [ 13 ]  dyslipidemia, [ 14 ]  and alcohol-induced liver cirrhosis. [ 15 ]   The first report of Lipostabil injection for fat removal demonstrated that infra-orbital ("under the eyelid") fat could be removed by Lipostabil injection. [ 16 ]


In 2015, the US  Food and Drug Administration  approved deoxycholic acid (branded as Kybella) for use as an injection lipolysis product when used to reduce moderate to severe submental fullness ( double chin ). [ 17 ] [ 18 ] [ 19 ]   While the procedure is generally considered safe when performed by a qualified healthcare professional, potential side effects may include swelling, bruising, numbness, and rarely, nerve injury in the treated area. [ 17 ] [ 18 ] [ 20 ]


Three medical associations have issued health warnings cautioning against the use of injection lypolysis, including the  American Society of Plastic Surgeons  (ASPS), the  American Society for Aesthetic Plastic Surgery  (ASAPS), and the  American Society of Dermatologic Surgery  (ASDS).The Aesthetic Surgery Education and
Research Foundation has funded on behalf of the American Society for Aesthetic Plastic Surgery a half side comparison study with interesting results [ 21 ]


On April 7, 2010, the US Food and Drug Administration issued  Warning Letters  to six U.S. based  medspas  and a company in Brazil for making false or misleading statements on their Web sites about drugs they claimed will eliminate fat in a procedure called "lipodissolve", or for otherwise misbranding lipodissolve products. "We are concerned that these companies are misleading consumers", said Janet Woodcock, M.D., director of the FDA's Center for Drug Evaluation and Research. "It is important for anyone who is considering this voluntary procedure to understand that the products used to perform lipodissolve procedures are not approved by the FDA for fat removal".


For the complete FDA statement, see here  [1] . To see the warning letter, see  [2] .


The FDA received reports of adverse effects in persons who had the procedure using these drugs, including permanent scarring, skin deformation, and deep painful knots under the skin in areas where the lipodissolve products have been injected.  The warning letters were issued to the following U.S. companies: Monarch Medspa, King of Prussia, Pa; Spa 35, Boise, Idaho; Medical Cosmetic Enhancements, Chevy Chase, Md.; Innovative Directions in Health, Edina, Minn PURE Med Spa, Boca Raton, Fl.; and All About You Med Spa, Madison, Ind. The Brazilian company receiving a warning letter markets lipodissolve products on two Web sites: zipmed.net and mesoone.com.


The FDA is requesting a written response from the U.S. companies within 15 business days of receipt of the warning letters stating how they will correct these violations and prevent similar violations in the future. Each U.S. company has been informed in its warning letter that failure to promptly correct the violations may result in legal action.
Each of the companies involved has been cited for a variety of regulatory violations, including making unsupported claims that the products have an outstanding safety record and are superior to other fat loss procedures, including liposuction. Additionally some of the letters indicate that the companies have made claim that lipodissolve products can be used to treat certain medical conditions, such as male breast enlargement, benign fatty growths known as lipomas, excess fat deposits and surgical deformities. The FDA is not aware of clinical evidence to support any of these claims. [ citation needed ]


The  Medicines and Healthcare products Regulatory Agency , the governmental body regulating the manufacture and commercialization of drugs in the United Kingdom, issued a similar warning to physicians considering the use of these substances for cosmetic purposes, stating these drugs "are being unlawfully advertised in the UK as a cosmetic product for the reduction of fat."  The MHRA also pointed out that considerable safety concerns remain because these agents have not been tested in controlled clinical trials. While British physicians can still inject Lipodissolve for fat removal, the drug cannot be promoted as a drug for that purpose.  As of July, 2005, The  Medical Protection Society , the organization that provides British doctors with legal advice and coverage against litigation costs and damages, ceased offering malpractice insurance for use of Lipodissolve because of safety concerns. [ 22 ]
On the other hand, the therapy is very often administered especially in German speaking countries because the drug Lipostabil N has been approved in Germany for more than 40 years. A physicians' network, the NETWORK-Lipolysis with 3,000 members worldwide amongst them 1,000 alone in German speaking countries has collected safety data. The latest published so-called Lipolysis Report 2015 has been published in 2016. [ 23 ]  4% of the members have answered the survey. 29,889 patient results have been collected with in total ca. 76,000 treatment sessions. Nowadays the composition is compounded by pharmacies in Germany and  Switzerland. [ citation needed ]


Jaw reduction  or mandible angle reduction is a type of surgery to narrow the lower one-third of the face—particularly the contribution from the  mandible  and its muscular attachments. There are several techniques for treatment—including surgical and non-surgical methods. A square lower jaw can be considered a masculine trait, especially in Asian countries. [ 1 ]  As a result, whereas square lower jaws are often considered a positive trait in men, a wide mandible can be perceived as discordant or masculine on women, or sometimes in certain men, particularly when there is asymmetry. [ 2 ]


A wide lower face can primarily be caused by a wide  mandibular bone  or large  masseter muscle . A large masseter muscle can be reduced in apparent size with the use of botox injections whereas having a wide mandibular bone requires surgical intervention to reduce the size of the bones.


A facial structure with a larger mandible arch and wide zygoma is common, particularly among Asians, although it is also present in other populations. It can also be the result of certain developmental disorders such as  acromegaly .


Prior to selection of a treatment, the patient is examined to determine whether the wide jaw is due to the  bone  size, the masseter muscle or both. Three-dimensional analysis of the clinical photos,  X-rays  and  3D CT scans  from the front, lateral, oblique, basal and overhead views are required for a detailed evaluation. [ 3 ]  The level of protrusion of the mandible angle, the size of the masseter muscle and the overall structure of the jaw are evaluated. Based on the analysis and face-to-face consultation, the surgery plan can be created to produce the desired aesthetic results. [ 1 ]


Surgical techniques are used to directly reduce the size of a large mandible. Depending on the candidate's individual facial structure, either mandibular resection can be performed alone or in conjunction with a sagittal mandibular reduction. [ 4 ]


The surgery is performed under  general anesthesia  through  tracheal intubation . The standard surgical procedure uses an intraoral approach, as it leaves no visible scars. [ 5 ]


A guarded oscillating saw is first used to mark the proposed osteotomy line to avoid excessive resection of the mandibular bone. Following this process, the bone resection is then performed with the appropriate size of oscillating saws. [ 1 ]  Additional sagittal split ramus resection can be performed using a burr. [ 4 ]


Inferior alveolar nerve is the most important anatomic structure during mandible reduction surgery and great care should be taken to avoid injury to this nerve. [ 6 ]  Potential complications include injury to the  inferior alveolar nerve  which provides permanent numbness and damage to the lower lip and even death.


Another factor to consider is the  mentalis muscle  which elevates the lower lip and chin. During the surgery, the mentalis muscles should be carefully reattached after the mandible bone has been excised. Failure to reattach the mentalis muscles will lead to the chin and lower lip to sag, causing permanent damage. [ 1 ]


Common symptoms include  haematoma , infection, asymmetry, over- or under-correction of the mandibular bone, sensory deficit. Excluding asymmetry and over- or under-correction, the other symptoms dissipate within three to six months post-surgery. [ 7 ]  Individuals with abundant soft tissue or thick skin may consider an additional lifting procedure done simultaneously with the jaw reduction surgery, as there is a high possibility of sagging soft tissue. Age and skin elasticity level also determines whether a lifting procedure is required. [ 3 ]


Non-surgical techniques are essentially limited to cases in which the masseter is enlarged. While a masseter muscle can be large due to genetic reasons, it can commonly be an acquired trait. Like any muscle it increases in size with exercise. Behaviors such as repeated gum chewing, teeth clenching, or  bruxism  can contribute to enlargement of the muscle.


A convenient method to treat an enlarged muscle is through the use of  botox  injections. Botox is injected into the muscle, weakening it so it slowly becomes smaller through  atrophy  over several months. There is no down-time and improvement is gradual—individuals who interact with the patient may never know that a plastic surgical procedure was performed


The use of Botox for jaw reduction has been studied scientifically.  Improvement is generally not seen for at least 2–3 weeks. Peak improvement occurs at months 3 to 9 with good results still observable at one year in many patients. [ 8 ]


The procedure can result in temporary  paralysis  of the muscles that move the lips, a rare, but danger acknowledged complication.


Labiaplasty  (also known as  labioplasty ,  labia minora reduction , and  labial reduction ) is a  plastic surgery  procedure for creating or altering the  labia minora  (inner labia) and the  labia majora  (outer labia), the folds of skin of the human  vulva . It is a type of  vulvoplasty . There are two main categories of women seeking cosmetic genital surgery: those with conditions such as  intersex , and those with no underlying condition who experience physical discomfort or wish to alter the appearance of their vulvas because they believe they do not fall within a normal range. [ 1 ]


The size, colour, and shape of labia vary significantly, and may change as a result of childbirth, aging, and other events. [ 1 ]  Conditions addressed by labiaplasty include  congenital defects  and  abnormalities  such as  vaginal atresia  (absent vaginal passage),  Müllerian agenesis  (malformed uterus and fallopian tubes), intersex conditions (male and female sexual characteristics in a person); and tearing and stretching of the labia minora caused by childbirth, accident, and age. In a male-to-female  sexual reassignment   vaginoplasty  for the creation of a  neovagina , labiaplasty creates labia where once there were none.


A 2008 study reported that 32 percent of women who underwent the procedure did so to correct a functional impairment; 31 percent to correct a functional impairment and for aesthetic reasons; and 37 percent for aesthetic reasons alone. [ 2 ]  According to a 2011 review, overall patient satisfaction is in the 90–95 percent range. [ 3 ]  Risks include permanent scarring, infections, bleeding, irritation, and nerve damage leading to increased or decreased sensitivity. A change in requirements of publicly funded Australian plastic surgery requiring women to be told about natural variation in labias led to a 28% reduction in the number of surgeries performed. [ 4 ]  Unlike public hospitals, cosmetic surgeons in private practice are not required to follow these rules, and critics say that "unscrupulous" providers are charging to perform the procedure on women who would not want it if they had more information. [ 4 ]


Images of vulvae are absent from the popular media [ 5 ] [ 6 ]  and advertising [ 7 ] [ 8 ] : 19   and do not appear in some anatomy textbooks, [ 9 ]  while community opposition to  sex education [ 10 ] [ 11 ]  limits the access that young women have to information about natural variation in labias. [ 12 ]  Many women have limited knowledge of vulval anatomy, and are unable to say what a "normal" vulva looks like. [ 13 ] : 6    [ 14 ] [ 15 ] [ 16 ]  At the same time, many  pornographic  images of women's genitals are  digitally manipulated , changing the size and shape of the labia to fit with the censorship standards in different countries. [ 12 ] [ 17 ] [ 18 ] [ 19 ]  Medical researchers have raised concerns about the procedure and its increasing prevalence rates, with some speculating that exposure to pornography images on the Internet may lead to  body image  dissatisfaction in some women. [ 20 ]  Although it is also suggested that evidence for this is lacking, [ 20 ]  the  National Health Service  stated that some women bring along advert or pornographic images to illustrate their desired genital appearance. [ 21 ] [ 22 ]


The external  genitalia  of a woman are collectively known as the vulva. This comprises the labia majora (outer labia), the labia minora (inner labia), the  clitoris , the  urinary meatus , and the  vaginal opening . The labia majora extend from the  mons pubis  to the  perineum .


The size, shape, and color of women's inner labia vary greatly. [ 23 ]  One is usually larger than the other. They may be hidden by the outer labia, or may be visible, and may become larger with sexual arousal, sometimes two to three times their usual diameter. [ 24 ]


The size of the labia can change because of childbirth.  Genital piercings  can increase labial size and asymmetry, because of the weight of the ornaments. In the course of treating identical twin sisters, S.P. Davison  et al  reported that the labia were the same size in each woman, which indicated  genetic determination . [ 25 ]  In or around 2004, researchers from the Department of Gynaeology, Elizabeth Garret Anderson Hospital, London, measured the labia of 50 women between the ages of 18 and 50, with a mean age of 35.6: [ 1 ]


compared to the surrounding skin ( n )


Labia reduction surgery is relatively contraindicated for the woman who have active gynecological disease, such as an infection or a  malignancy ; the woman who is a  tobacco smoker  and is unwilling to quit, either temporarily or permanently, in order to optimize her wound-healing capability; and the woman who is unrealistic in her aesthetic goals. The latter should either be counselled or excluded from labioplastic surgery. Davison  et al  write that it should not be performed when the patient is menstruating to reduce potential hormonal effects and the increased risk of infection. [ 25 ]


In  sexual reassignment  surgery, in the case of the male-to-female  transgender  patient, labiaplasty is usually the second stage of a two-stage vaginoplasty/ vulvoplasty  operation, where labiaplastic techniques are applied to create labia minora and a clitoral hood. In this procedure, the labiaplasty is usually performed some months after the first stage of vaginoplasty.


Labial reduction can be performed under  local anaesthesia ,  conscious sedation , or  general anaesthesia , either as a discrete, single surgery, or in conjunction with another,  gynecologic  or cosmetic, surgery procedure. [ 26 ]  The resection proper is facilitated with the administration of an anaesthetic solution (lidocaine + epinephrine in saline solution) that is infiltrated to the labia minora to achieve the tumescence (swelling) of the tissues and the constriction of the pertinent labial circulatory system, the hemostasis that limits bleeding. [ 25 ]


The original labiaplasty technique was simple resection of tissues at the free edge of the labia minora. One resection-technique variation features a clamp placed across the area of labial tissue to be resected, in order to establish hemostatis (stopped blood-flow), and the surgeon resects the tissues, and then sutures the cut labium minus or labia minora. This procedure is used by most surgeons because it is easiest to perform. The technical disadvantages of the labial-edge resection technique are the loss of the natural rugosity (wrinkles) of the labia minora free edges, thus, aesthetically, it produces an unnatural appearance to the vulva, and also presents a greater risk of damaging the pertinent nerve endings. Moreover, there also exists the possibility of everting (turning outwards) the inner lining of the labia, which then makes visible the normally hidden internal, pink labial tissues. The advantages of edge-resection include removal of the hyper-pigmented (darkened) irregular labial edges with a linear scar. Another disadvantage of the trim or "amputation" method, is that it is unable to excise redundant tissues of the clitoral hood, when present. [ 27 ] [ 28 ] [ 29 ] [ 30 ] [ 31 ] [ 32 ]  Complete amputation of the labia minora is more common with this technique, which often requires additional surgery to correct. In addition, the trim method does not address the clitoral hood. Clitoral hood deformities are common with this approach, again requiring additional corrective surgery. Some women complain of a "small penis" when the trim procedure is performed, owing to the un-addressed clitoral hood tissue and completely removed (amputated) labia minor. [ 33 ]  Most plastic surgeons do not perform this procedure, and instead favor the extended wedge approach, which is technically more demanding, but produces a more natural result and is able to create a natural and proportioned appearance to the vulva. [ 34 ]  Reconstructive procedures are often required after the trim (amputation) labiaplasty. [ 35 ]


Labial reduction by means of a central wedge-resection involves cutting and removing a partial-thickness wedge of tissue from the thickest portion of the labium minus. [ 28 ]  Unlike the edge-resection technique, the resection pattern of the central wedge technique preserves the natural rugosity ("wrinkled" edge) of the labia minora. If performed as a full-thickness resection, there exists the potential risk of damaging the pertinent labial nerves, which can result in painful  neuromas , and numbness. A partial thickness removal of mucosa and skin, leaving the submucosa intact, decreases the risk of this complication. F. Giraldo  et al.  procedurally refined the central wedge resection technique with an additional 90-degree  Z-plasty  technique, which produces a refined surgical scar that is less tethered, and diminishes the physical tensions exerted upon the surgical-incision wound, and, therefore, reduces the likelihood of a notched (scalloped-edge) scar. [ 28 ] [ 36 ]  The central wedge-resection technique is a demanding surgical procedure, and difficulty can arise with judging the correct amount of labial skin to resect, which might result in either undercorrection (persistent tissue-redundancy), or the overcorrection (excessive tension to the surgical wound), and an increased probability of  surgical-wound separation . The benefit of this technique is that an extended wedge can be brought upwards towards the prepuce to treat a prominent clitoral hood without a separate incision. [ 35 ]  This leads to a natural contour for the finished result, and avoids direct incisions near the highly-sensitive clitoris.


Labial reduction by means of the de-epithelialization of the tissues involves cutting the  epithelium  of a central area on the medial and lateral aspects of each labium minus (small lip), either with a scalpel or with a  medical laser . This labiaplasty technique reduces the vertical excess tissue, whilst preserving the natural rugosity (corrugated free-edge) of the labia minora, and thus preserves the sensory and erectile characteristics of the labia. Yet, the technical disadvantage of de-epithelialization is that the width of the individual labium might increase if a large area of labial tissue must be de-epithelialized to achieve the labial reduction. [ 37 ]


Labial reduction occasionally includes the resection of the  clitoral hood  when the thickness of its skin interferes with the woman's  sexual response  or is aesthetically displeasing. [ 33 ] [ 34 ]


The surgical unhooding of the clitoris involves a V–to–Y advancement of the soft tissues, which is achieved by  suturing  the clitoral hood to the pubic bone in the midline (to avoid the  pudendal nerves ); thus, uncovering the clitoris further tightens the labia minora. [ 35 ]


Labial reduction by means of  laser  resection of the labia minora involves the de-epithelialization of the labia. The technical disadvantage of laser labiaplasty is that the removal of excess labial  epidermis  risks causing the occurrence of  epidermal inclusion cysts . [ 38 ]


Labial reduction by de-epithelialization cuts and removes the unwanted tissue and preserves the natural rugosity (wrinkled free-edge) of the  labia minora , and preserves the capabilities for  tumescence  and  sensation . Yet, when the patient presents with much labial tissue, a combination procedure of de-epithelialization and clamp-resection is usually more effective for achieving the aesthetic outcome established by the patient and her surgeon. In the case of a woman with labial webbing (redundant folding) between the labia minora and the labia majora, the de-epithelialization labiaplasty includes an additional resection technique – such as the five-flap Z-plasty ("jumping man plasty") – to establish a regular and symmetric shape for the reduced labia minora. [ 25 ]


Post-operative pain is minimal, and the woman is usually able to leave hospital the same day. No vaginal packing is required, although she might choose to wear a sanitary pad for comfort. The physician informs the woman that the reduced labia are often very swollen during the early post-operative period, because of the  edema  caused by the anaesthetic solution injected to swell the tissues.


She is also instructed on the proper cleansing of the surgical wound site, and the application of a topical antibiotic ointment to the reduced labia, a regimen observed two to three times daily for several days after surgery. [ 25 ]


The woman's initial, post-labiaplasty follow up appointment with the surgeon is recommended within the week after surgery. She is advised to return to the surgeon's consultation room should she develop  hematoma , an accumulation of blood outside the pertinent ( venous  and  arterial ) vascular system. Depending on her progress, the woman can resume physically unstrenuous work three to four days after surgery. To allow the wounds to heal, she is instructed not to use tampons, not to wear tight clothes (e.g. thong underwear), and to abstain from sexual intercourse for four weeks after surgery. [ 25 ]


Medical complications to a labiaplasty procedure are uncommon, yet occasional complications – bleeding,  infection ,  labial asymmetry , poor wound-healing, undercorrection, overcorrection – do occur, and might require a revision surgery. An over-aggressive resection might damage the nerves, causing painful  neuromas . Performing a flap-technique labiaplasty occasionally presents a greater risk for  necrosis  of the labia minora tissues. [ 25 ]


Labiaplasty is a controversial subject. Critics argue that a woman's decision to undergo the procedure stems from an unhealthy self-image induced by their comparison of themselves to the prepubescent-like images of women they see in commercials or pornography. [ 39 ]


In Australia, the  Royal Australian College of General Practitioners  has issued guidelines on referring patients with dissatisfaction with their genitals to specialists. [ 13 ]  A change in requirements of publicly funded Australian  plastic surgery  requiring women to be told about natural variation in labias led to a 28% reduction in the numbers of surgeries performed. [ 4 ]  Unlike public hospitals, cosmetic surgeons in private practise are not required to follow these rules, and critics say that "unscrupulous" providers are charging to perform the procedure on women who would not undergo it if they had more information. [ 4 ]


Increasing numbers of women in Western countries are also using  Brazilian waxing  to remove pubic hair, and choosing to wear tight-fitting swimwear and clothing. [ 13 ] [ 40 ]  This has led to increased numbers of women complaining of pain and discomfort from chafing of the  labia minora , as well as cosmetic concerns around how the appearance of genitals. [ 13 ] [ 41 ] [ 42 ]  In many countries, media regulation classifies "hardcore" and "softcore" pornography – demanding that magazines with "hardcore" pornography be wrapped in black plastic and sold only to people over 18 who show photo ID. [ 17 ] [ 43 ]  Sales of magazines in black plastic tend to be low, and thus many magazine publishers choose to comply with the "softcore" standards. [ 17 ]  In Australian magazines, images of vulvas that do not look like "a single crease" are digitally modified to comply with the censorship standard. [ 17 ]  An Australian pornographic actress says that images of her own genitals sold to pornographic magazines in different countries are  digitally manipulated  to change the size and shape of the labia according to censorship standards in different countries. [ 12 ] [ 18 ] [ 19 ]  Community opposition to  sex education [ 10 ] [ 11 ]  limits the access that young women have to information about natural variation in labias. [ 12 ]


Linda Cardozo , a gynaecologist at  King's College Hospital , London, told the newspaper that women were placing themselves at risk in an industry that is largely unregulated.  Nina Hartley  says that "she’s seen every type of vulva in her three decades working in the industry. When young women start out in porn, producers don’t send them off for a routine labiaplasty." [ 44 ]


Although  female genital mutilation  – the practice of cutting off a woman's labia and sometimes clitoris, and in some cases creating a seal across her entire vulva – is illegal across the Western world, Simone Davis, a professor and gender theorist at Mount Holyoke College in Massachusetts, argues that "when you really look carefully at the language used in some of those laws, they would also make illegal the labiaplasties that are being done by plastic surgeons in the U.S." [ 45 ]  The  World Health Organization  (WHO) defines female genital mutilation as "all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons." [ 46 ]  The WHO writes that the term is not generally applied to elective procedures such as labiaplasty. [ 47 ]


The  American College of Obstetricians and Gynecologists  (ACOG) published an opinion in the September 2007 issue of  Obstetrics & Gynecology  that several "vaginal rejuvenation" procedures were not medically indicated, and that there was no documentation of their safety and effectiveness. ACOG argued that it was deceptive to give the impression that the procedures were accepted and routine surgical practices. It recommended that women seeking such surgeries must be given the available surgical-safety statistics, and warned of the potential risks of infection, altered sensation caused by damaged nerves,  dyspareunia  (painful sexual intercourse),  tissue adhesions , and painful scarring. [ 48 ]


In the UK, Lih Mei Liao and Sarah M. Creighton of the University College London Institute for Women's Health wrote in the  British Medical Journal  in 2007 that "the few reports that exist on patients' satisfaction with labial reductions are generally positive, but assessments are short-term and lack methodological rigour." They wrote that the increased demand for cosmetic genitoplasty (labiaplasty) may reflect a "narrow social definition of normal." The  National Health Service  performed double the number of genitoplasty procedures in the year 2006 than in the 2001–2005 period. The authors noted that "the patients consistently wanted their vulvas to be flat, with no protrusion beyond the labia majora ... some women brought along images to illustrate the desired appearance, usually from adverts or pornography that may have been digitally altered." [ 21 ] [ 22 ]  The Royal Australian and New Zealand College of Obstetricians and Gynæcologists published the same concern about the exploitation of psychologically insecure women. [ 45 ]


The International Society for the Study of Women's Sexual Medicine produced a report in 2007 concluding that "vulvar plastic surgery may be warranted only after counseling if it is still the patient's preference, provided that it is conducted in a safe manner and not solely for the purpose of performing surgery". [ 49 ]


Notes


Further reading


Media related to  Labiaplasty  at Wikimedia Commons


Laser hair removal  is the process of  hair removal  by means of exposure to pulses of  laser  light that destroy the  hair follicle . It had been performed experimentally for about twenty years before becoming commercially available in 1995–1996. [ 1 ]  One of the first published articles describing laser hair removal was authored by the group at  Massachusetts General Hospital  in 1998. [ 2 ] [ 3 ]  Laser hair removal is widely practiced in clinics, and even in homes using devices designed and priced for consumer self-treatment. Many reviews of laser hair removal methods, safety, and efficacy have been published in the dermatology literature. [ 4 ]


R. Rox Anderson  and Melanie Grossman [ 5 ]  discovered that it was possible to selectively target a specific  chromophore  with a laser to partially damage basal stem cells inside the hair follicles. This method proved to be successful, and was first applied in 1996. In 1997, the  United States Food and Drug Administration  approved this tactic of hair removal. As this technology continued to be researched, laser hair removal became more effective and efficient; thus, it is now a common method in removing hair for long periods of time.