Perineoplasty in Beverly Hills

What is a perineoplasty?

A perineoplasty (also called a perineorrhaphy, or a perineal repair) rebuilds the perineum, the wedge of skin and muscle between the vaginal opening and the anus, and with it the opening of the vagina. The perineal body is where the muscles that circle the vaginal opening meet in the midline, and it gives the entrance its support and tone. A vaginal delivery stretches it, a tear or an episiotomy cuts through it, and the repair done in the delivery room, on swollen tissue, can heal with the muscles no longer meeting, a shortened perineum, an opening that gapes at rest and a band of scar that catches during intercourse. That is what women mean by feeling loose since the baby, and because it is a structural change, exercise and creams do not reverse it. Dr. Cat performs the repair on its own, when the labia are fine and the opening is the complaint, or in the same surgery as a labiaplasty, when childbirth has changed both.

What a perineoplasty treats

• A perineum that healed short, thin or scarred after a tear or an episiotomy
• A vaginal opening that gapes at rest, lets air move in and out, or lets water in during a bath
• Less friction and sensation during intercourse since childbirth
• A scar band at the back of the opening that pulls, stings or catches
• Muscles of the perineal body that no longer meet in the midline

Not a vaginoplasty

A perineoplasty treats the opening and the perineum; it does not tighten the whole vaginal canal. A vaginoplasty is a deeper operation on the walls of the canal itself, and the two are sometimes planned together. Most women whose complaint began with childbirth have a stretched or scarred opening rather than a lax canal, and the examination tells the two apart. Neither operation treats pelvic organ prolapse or urine that leaks with a cough, which are pelvic floor conditions for a urogynecologist.

ThermiVa for mild laxity

Not every complaint of looseness needs an incision. ThermiVa is radiofrequency applied to the labia and the vaginal walls to build collagen and improve tone, with no downtime: a 30 to 45 minute session, three sessions spaced several weeks apart, and results that last several months to a year. Dr. Cat performs the treatments herself; our vaginal rejuvenation page describes what it does for mild laxity, dryness and mild stress incontinence. What radiofrequency cannot do is rebuild a perineal body that was torn or cut, close a gap between separated muscles or remove a scar; for that kind of structural change, surgery is the answer, and ThermiVa can follow once the repair has healed.

Who is a good candidate for a perineoplasty?

The right candidate has a perineum that changed structurally, most often after a vaginal delivery with a tear or an episiotomy, and symptoms the repair addresses. Some patients come in about the labia and learn at the examination that the perineum is part of the picture; our page on enlarged labia covers that side of it.

Candidacy is decided at the examination: if the change is in the structure of the perineum, a scar, a gap in the muscles or a shortened perineal body, a perineoplasty is the operation; if the tissue is intact and simply less toned, radiofrequency may be enough.

Perineoplasty alone or with a labiaplasty

A perineoplasty on its own suits the woman whose labia are in proportion and whose complaint is the opening or the scar. Added to a labiaplasty, it suits the woman childbirth changed at both ends: labia minora that stretched and darkened, and a perineum that scarred or gaped. The two are done in one surgery under one anesthesia with one recovery. A clitoral hood reduction, which reduces the excess skin over the clitoris, can be part of the same plan when the hood is full.

How Dr. Cat does it

Dr. Cat is a board-certified plastic surgeon who completed two surgical residencies, one in head and neck surgery, microvascular and facial reconstructive surgery, and advanced training in general plastic and reconstructive surgery, Harvard-educated and UCLA trained. She has performed more than 500 labiaplasties, authored the chapter on aesthetic surgery of the female genitalia in the International Textbook of Cosmetic Surgery, and approaches the perineum the way she approaches the labia: as one structure, where a repair at the back of the opening has to match the labia in front of it.

The repair, step by step

Through an incision at the back of the vaginal opening, the scar and the excess, thinned skin are removed. The separated muscles of the perineal body are found and brought back together in layers with dissolvable sutures, which rebuilds the perineum to its original height and restores the support behind the back wall of the vagina. The skin is then closed so that the opening is narrowed to a normal size and the perineum is smooth, with no scar band to catch. Nothing artificial is placed, and no sutures need removing.

Repaired to a normal size, not the smallest one

Her rule for the tightening itself is restraint. An opening rebuilt too tight makes intercourse painful and is harder to correct than one repaired to a normal size, so the aim is a normal, supported entrance, not the smallest one possible. The perineum is rebuilt to its own height, in proportion with the labia, so the result looks as if childbirth had never changed it.

Surgery day

The plan is agreed at the consultation, reviewed at your pre-op appointment and confirmed the morning of surgery with precise surgical markings. Surgery is under general anesthesia with a board-certified physician anesthesiologist in Dr. Cat's QUAD A accredited surgery center on Rodeo Drive, with a numbing solution applied to the area as well. Every step is hers, under 3.5X magnification operating lenses, closed in precise layers with dissolvable sutures; when a labiaplasty is part of the plan the labia are reduced in the same session and the transition between them and the perineum is shaped last. A perineoplasty on its own is shorter than a labiaplasty, which takes two and a half to four and a half hours. No aftercare-facility night is needed: you go home the same day with someone to drive you and stay the first night.

Preparing for surgery

After the consultation, Dr. Cat's team gives you the pre-operative instructions: clearance and lab tests, at least two months without smoking or vaping, the medications to stop before and after surgery, a Hibiclens wash the night before, nothing to eat or drink from the night before, no makeup, skincare or jewelry on the day, and a ride home with someone who stays the first night.

Perineoplasty recovery timeline

Recovery from a perineoplasty is a little longer than from a labiaplasty, because muscle has been repaired and the repair sits where you sit, walk and use the bathroom. Here is what most patients can expect; Dr. Cat gives you written instructions and sees you through it.

• The night of surgeryYou go home a few hours after waking, with someone to drive you and stay the night. Expect swelling and soreness at the perineum rather than sharp pain; most patients manage with Tylenol and ice. Walk a little that evening.
• Days one to threeSitting down, standing up and bowel movements are the moments you notice the repair. A stool softener and a high-fiber diet start on day one, because straining pulls on the repair. Rinse with lukewarm water after using the bathroom and pat dry; warm sitz baths from the second or third day soothe the area.
• One weekSwelling is settling and most patients are back at desk work. Short, frequent walks; no lifting and no exercise; loose cotton underwear rather than jeans, thongs or leggings.
• Weeks two to fourThe dissolvable sutures begin to come away on their own. Light spotting, itching as the nerves wake up and a feeling of tightness at the opening are normal. No exercise, heavy lifting, swimming, hot tubs or tampons.
• Four weeksExercise resumes, starting with the activities that put no pressure on the perineum, once Dr. Cat has checked the repair.
• Six weeksNothing goes into the vagina, no intercourse, tampons or menstrual cups, for about six weeks, the interval a muscle repair at the opening needs to gain its strength. Dr. Cat examines the repair and clears you; the first times are gentle and with lubricant.
• Three to six monthsThe scar softens and flattens, the tightness at the opening settles into a normal, supported feel, and the final result shows. Pelvic floor exercises then strengthen the muscles that were repaired and help the result last.

Perineoplasty results, and how long they last

The result is a perineum rebuilt to its height, an opening narrowed to a normal size and supported from behind, and no scar band to catch. Women describe the change as friction and sensation returned during intercourse, the end of air trapping and of water entering in the bath, comfort where the scar used to pull, and an appearance that matches the rest of the vulva. The repair is of your own tissue: the muscles stay together and the removed scar does not return. What can change it is another vaginal delivery, which is why the operation waits for the last planned pregnancy, and the ordinary loss of tissue tone with the years, which pelvic floor exercises and ThermiVa maintenance help with.

Perineoplasty before and after photos

Perineoplasty results are photographed with the labia work they are most often part of, and the gallery has no separate perineoplasty category. Our labiaplasty before and after photos show the vulva as a whole: in the after photos, look at the lowest point of the opening, where the perineum should stand at its full height with the entrance closed at rest. At the consultation Dr. Cat shows you perineoplasty cases matched to your anatomy.

Risks and safety

A perineoplasty is a modest operation in a demanding location: the perineum is moist, it moves with every step, and it sits between the vagina and the anus. Here is what can happen, what Dr. Cat does to prevent it, and when to call us.

How much does a perineoplasty cost in Beverly Hills?

A perineoplasty on its own is about $10,000 to $15,000 with Dr. Cat, quoted in writing at your consultation. Added to a labiaplasty it is about $3,500, because the anesthesia, the facility and the recovery are already part of the plan; a labiaplasty itself is about $24,000 to $27,000. Every quote is itemized: the surgeon's fee, the board-certified physician anesthesiologist, the accredited facility and your follow-up visits.

The price reflects one surgeon who performs every step herself, a physician anesthesiologist for the whole case and an accredited facility. A cheap repair of the perineum is a poor bargain: an opening rebuilt too tight, or a scar that separated and healed wide, is corrected through scar tissue at a cost above the original surgery done well. Our labiaplasty cost guide explains what a quote is made of.

Consultation fee, insurance and financing

A consultation with Dr. Cat is $500, or $1,500 for a revision consultation, and the full amount is credited toward your surgery. The practice partners with Cherry, its primary financing partner, and also accepts CareCredit and Alphaeon Credit; see financing and payment plans. A perineoplasty done for appearance, comfort or sexual function is cosmetic, and insurers do not cover it; a repair of a documented childbirth injury with symptoms is sometimes reviewed by an insurer. Dr. Cat's office does not bill insurance, but can provide the paperwork if your plan makes an exception.

Your consultation with Dr. Cat

It starts with a free 15-minute discovery call with our Patient Concierge, who books your consultation. The consultation is private and conducted by Dr. Cat herself, in person on Rodeo Drive or, for out-of-town patients, by private video consultation through OnPatient, the HIPAA-secure patient portal, with the examination in person before surgery. She starts by asking what specifically bothers you and what you want to achieve, then examines the perineum and the opening: the height and thickness of the perineal body, the scar, whether the muscles meet in the midline or leave a gap, how wide the opening sits at rest, and the labia beside it. She tells you whether what you have is a structural change that surgery repairs or a laxity that radiofrequency can improve, and whether the labia belong in the plan, and you leave with an itemized written quote.