Introduction
Identity and self esteem are intimately related to the self perceived appearance of ones genitalia. Female genital aesthetics is a product of cultural norms and a woman’s perceived concept of beauty. Modern trends have moved towards a lack of pubic hair, making subtle labial irregularities more conspicuous. Additionally, the free accessibility of pornographic photos or videos has made many women feel their genitalia is inadequate compared to new societal norms. These women often tend to avoid situations where they might feel vulnerable, including wearing tight pants or swimsuits, group showers, or sexual intimacy. Patient awareness has led to a significant demand for genital aesthetic surgery, and it is no surprise that according to the American Society of Aesthetic Plastic Surgeons 2017 Statistics, labiaplasty is up 217.2% from 2012 to 2017 [https://www.surgery.org/sites/default/files/ASAPS-Stats2017.pdf]. Female aesthetic genital surgery can greatly enhance the confidence of a perceived or real genital deformity and labial reduction and clitoral hood surgery can give a natural appearance with an extremely high satisfaction rate exceeding 90%. Although there is no standard genital aesthetic ideal, basic guidelines for genital aesthetics include 1) symmetrical labia minora that do not protrude past the labia majora, especially when standing; (2) a clitoral hood that is reasonably short and non-protuberant without extra folds; (3) full labia majora without redundant skin but not overly fatty which can cause an unsightly bulge in clothes, and (4) a mons pubis that has mild fullness but does not protrude in clothes.
Additionally, women with enlarged labia minora or majora or clitoral hood complain of irritation and discomfort with exercise, sexual intercourse and wearing tight clothing. Massively enlarged labia can interfere with sexual intercourse, hygiene and self-catheterization.
Anatomy and Physiology
A thorough understanding of the anatomy is paramount to avoid clitoral injury and to prevent sensation deficits. Normal labia minora anatomy encompasses a broad range of sizes, thickness, and color. The glans clitoris sits directly under the prepuce.The frenula are folds of skin extending from the glans clitoris and merge with the extension of the clitoral hood to form the labia minora. The external blood supply to the female genitalia consist of branches from the external superficial pudendal artery, the internal pudendal artery, and contributions from the internal circumflex artery. The external superficial pudendal artery anastomoses with the posterior labial artery, in the labium majora. This initial anastamosis gives off multiple branches to the labia minora
Indications
Overwhelmingly, labia minora enlargement is congenital, although women do claim to have enlargement after childbirth, hormone therapy and with age. Labia minora reduction is indicated in women as young as 12 years old, where enlargement can affect self esteem, cause discomfort or social stigmata. Women perceive an ideal labia minora as light in color, thin, straight and symmetrical.
Felicio et al. defined degrees of labial hypertrophy from type I (< 2cm) through type VI (> 6cm), but since rarely a medically necessary procedure, when excess can be removed, a labiaplasty can be perfomed. Ancillary procedures such as clitoral hood reduction need to be considered when planning a labia minora reduction as unaddressed hood redundancies can result in unsightly bumps and bulges. There are two reliable methods for reducing labia minora: (1) the trim method, also known as the edge method, reported by Hodgkinson, and (2) the wedge method pioneered by Alter. Technique selection should be based on the anatomy, patient goals, and patient preferences.
Contraindications
Contraindications include patients with body dysmorphic disorder and those expecting this procedure to enhance their sexual lives and improve the ability to achieve orgasm.
Equipment
Equipment needed for this procedure include a basic surgical tray with ruler, marking pen, fine serrated scissors, and fast absorbing sutures such as Monocryl, Chromic, or Vicryl. Dorsal lithotomy position will be necessary and 0.25% Marcaine for local long-lasting anesthesia
Personnel
A scrub technician or surgical assist should be available during the procedure.
Preparation
Preoperatively, the woman should be examined in the lithotomy position. With the use of a mirror to visualize her genitalia, she should indicate her concerns to the surgeon. This ensures the surgeon and patient are in agreement as to the aesthetic goals. Photographs should be taken with the patient in lithotomy and in a standing position with legs slightly abducted to shoulder width to adequately visualize labial protrusion. Pre-operative antibiotics are given within 30 minutes of incision. This procedure can be performed in the office with conscious sedation and local anesthetics or as an outpatient surgery
Technique
There are two primary ways to reduce the labia minora: the wedge excision or the trim technique.
Asymmetric or protuberant labia minora can be corrected by excising or trimming the excess areas with a knife, scissor or laser and over-sewing for closure. It is imperative to leave a 1cm cuff of minora to retain a functional “seal” to the entroitus. This technique is best for marked redundancies, excessive thicknesses, and where the patient is accepting of a potential change in the color of the minora edge. Although advantages of this technique are the short operative time and the creation of light-colored labial edges (advantage to some), the disadvantages are more numerous and include placement of a longitudinal scar line along the labial edge that is often irregular and scalloped. This can result in a higher incidence of discomfort. Additional disadvantages area relatively high incidence of asymmetry and over-resection– which is very difficult to impossible to correct. It can be difficult to maintain the normal transition between the frenulum of the clitoris, the clitoral hood, and the labium with the trim technique -often resulting in aesthetically unpleasing 'dog-ears' superiorly and inferiorly.
The wedge technique, championed by Dr. Gary Alter, preserves the natural edge of the labia, resecting only a wedge or ‘V’ of the most protuberant minora, preserving the natural labial edge. The only disadvantages are a longer operative time, required surgical expertise, and occasional persistence of darker labial edge pigment.
Other variations of the above techniques as well as de-epithelialization and pedicled flap methods have been described but have failed to produce consistent and desired outcomes.
Preoperatively, the woman is examined in the lithotomy position with the head elevated. While using a mirror to visualize her genitalia, the surgeon and patient can discuss the desired areas of correction and the surgical markings for excision. Given the degree of labia minora length, thickness and shape, the surgical markings will vary depending on each patient’s specific anatomy. The clitoral hood is evaluated to determine protrusion, symmetry, location of problematic darkened skin, the presence of extra folds, and the amount of clitoral glans size and exposure. Next, the surgeon should evaluate the posterior introitus for a high posterior lip or gaping due to a previous episiotomy. A large wedge or ‘V’ shaped marking is made at the area of most protrusion and darkening. Excellent symmetry can usually be achieved even in asymmetric patients.
In the operating room, the patient will again be in the lithotomy position and general or regional anesthesia can be used. The upper labial incision of the wedge is usually placed at or just posterior to the convergence of the glans frenulum and clitoral hood. The degree of labium excised should achieve a straight, non-redundant labium that is approximated under no tension. Care should be taken to ensure that you do not over-resect and cause an overly tight introitus, which is usually insured by placing two fingerbreadths in the vagina. The medial ‘V’ extends internally to terminate distal to the hymeneal ring. The lateral ‘V’ is curved anterior in a hockey-stick design to eliminate a ‘dog-ear’ and to excise a redundant lateral clitoral hood or lateral hood folds. Thus, the medial and lateral V’s are asymmetrical. On rare occasions, another unilateral or bilateral posterior ‘V’ is necessary to achieve symmetry or adequate reduction.
After marking, lidocaine with epinephrine and/or marcaine can be injected. In the operating room, the patient will again be in the lithotomy position and general or regional anesthesia can be used. The upper labial incision of the wedge is usually placed at or just posterior to the convergence of the glans frenulum and clitoral hood. The degree of labium excised should achieve a straight, non-redundant labium that is approximated under no tension. Care should be taken to ensure that you do not over-resect and cause an overly tight introitus, which is usually insured by placing two fingerbreadths in the vagina. The medial ‘V’ extends internally to terminate distal to the hymeneal ring. The lateral ‘V’ is curved anterior in a hockey-stick design to eliminate a ‘dog-ear’ and to excise a redundant lateral clitoral hood or lateral hood folds. Thus, the medial and lateral V’s are asymmetrical. On rare occasions, another unilateral or bilateral posterior ‘V’ is necessary to achieve symmetry or adequate reduction.
The subcutaneous tissue of the anterior and posterior labium is re-approximated in two layers using a 5.0 Monocrylor Vicrylon a TF needle. The internal and external subcutaneous ‘dog-ears’ are excised. The labial edges and medial and lateral closures are re-approximated with interrupted, horizontal mattress 5-0 Monocryl on a TF needle. The lateral clitoral hood is closed with running subcutaneous 5-0 Monocryl and a running subcuticular 5-0 Monocryl. There should only be one small transverse incision line on the leading edge of the labium. Although not always achievable, the labia should protrude only slightly past the introitus.
If the clitoral hood has extra vertical medial folds or medial hypertrophic skin, these can be excised with vertical ellipses. In this case, the lateral ‘V’ labial excision can stop at the lateral labium. If the patient were to have redundant horizontal folds, you can perform vertical transverse ellipses to excise. Keep in mind that this can result in overexposure of the glans clitoris that can cause hypersensitivity or an unacceptable aesthetic appearance so conservative excision is advised.
If the introitus is too tight or if there is a high riding posterior lip, a midline incision can be made at the 6 o’clock position with aesthetic closure of the resulting dog-ears. If a perineoplasty, posterior vaginal repair, or entroital tightening procedure is performed at the same operation of a large labial reduction, care must be betaken to ensure that the introitus is not overly tight. This is prevented by delaying the perineal and vaginal repair distal to the hymeneal ring until the labia reduction is complete, which then can allow for introital adjustments during the closure.
Patients are seen at 3 weeks post-op to remove any retained sutures and to evaluate the healing. Itching can be intense as sutures dissolve, and patients should be educated beforehand. Post-operative restrictions include no vaginal penetration for 6 weeks, avoidance of any pressures on the suture lines, and refraining from any activities that could lead to tension on the incisions. Patients must be aware, and tolerant, of the significant swelling that can follow as it may take weeks for resolve. Revisions can be considered once full healing has occurred, typically no sooner than six months from surgery. Patient opinions of the outcome should be respected and if something is fixable, should be offered the opportunity for a revision. A common complaint is of persistent, albeit less, asymmetry of the labia.
Complications
Although the majority of patients heal extremely well,the most common complications are a slight separation of the labial edge closure or a small fistula, occurring inless than 2% of cases. These can typically be repaired under local anesthesia in 4-6 months from surgery. Major dehiscence is rare if performed as stated. Chronic scar discomfort or interference with intercourse are very rare and can be corrected. Occasionally, the labia or scars may stretch back over time, but this can be easily revised. If the labia still protrude too far after maximal ‘V’ excision, then medial and lateral elliptical excisions can be performed later, but this is rarely necessary.
Clinical Significance
Labiaplasty can make a marked improvement in the aesthetics of the vulva and increase a woman's confidence during intimacy;but excessive resections can lead to disastrous results that may not be correctable. It requires excellent judgment on the part of the surgeon and full communication between the patient and surgeon to provide the best outcomes possible
Enhancing Healthcare Team Outcomes
A significant number of women are seeking labiaplasty. Often, they first present to the nurse practitioner, obstetrician, gynecologist or the primary care provider for advice. These patients should be referred to a surgeon who specializes in labiaplasty. It is important to educate the patient that labiaplasty is generallyan elective procedure done primarily for cosmetic reasons. The procedure is relatively simple but also associated with a number of serious complications.