Female genital cosmetic surgery (FGCS) is a growing field of plastic surgery, which involves a variety of procedures designed to enhance or rejuvenate the female genitalia. Types of FGCS include monsplasty, vaginoplasty, hymenoplasty, labiaplasty, G-spot augmentation, clitoral unhooding, frenuloplasty, perineoplasty, fat injections, and combinations of these procedures. [1, 2] Surgery to the labium, known as labiaplasty, which is surgical modification of the labia minora or labia majora, is the focus of this article. Secondary procedures often associated with labiaplasty also are discussed.
Labia minora reductions are more common than labia majora reductions or augmentations, although both are a growing field in plastic surgery. Reasons for this increasing popularity include growing cultural acceptance, availability of Internet genital exposure, and hair removal procedures that expose tissue that previously went unnoticed. [2, 3] The goal of the procedure is to eliminate functional problems and create labia that are aesthetically appealing. Labiaplasty surgeries can have substantial psychological benefits for patients who are self-conscious about the appearance of their genitalia. Patients with severe cases frequently report decreased pain or discomfort with daily activity and sexual intercourse after the procedure.
History of the Procedure
Hypertrophy, or overgrowth, of the labia was historically viewed as an inconsequential variation of the normal labia. Over the past decade, there has been increasing acknowledgement and understanding of the aesthetic and functional concerns of patients with large labia. 
The first publication to describe aesthetic labiaplasty was published in 1983.  During this time, the only technique used to reduce the labia minora was the “trim method.”  In the 1990s, alternative labiaplasty techniques developed, [6, 7] including the “wedge technique” described by Dr. Gary Alter in 1998.  Labiaplasty has been growing in popularity over the past several years. According to the American Society of Aesthetic Plastic Surgeons statistics, a 44% increase in vaginal rejuvenation procedures from 2012 to 2013 was reported, making this one of the fastest growing cosmetic procedures. 
This underscores the progressive social acceptance of the procedure, as well as the need for safe and effective labiaplasty techniques. Current techniques for labiaplasty can be divided into the following 3 groups:
Amputation techniques that involve a linear trimming of the labia minora
A wedge technique that excises tissue along the lower edge towards the labia majora crease
A central labial excision as a deepithelialization that preserves the natural free edge
Labia hypertrophy is the increased growth of either the labia minora or labia majora in relationship to one another. Although labial hypertrophy is not strictly defined yet as a pathologic condition, patients who have aesthetic or functional concerns may benefit from labial reductions. 
Significant hypertrophy of the labia can cause pain, irritation, and discomfort with clothing. The psychological problem of not feeling “normal” in comparison to the perceived ideal anatomy cannot be underestimated. 
Labiaplasty surgeries are expected to continue increasing in frequency as the techniques and procedures become more defined. Popularity of the procedure is expected to increase as knowledge of the benefits increase.
According to a 2000 study of 163 labia minora reductions, 87% of patients had labiaplasty surgery for aesthetic reasons, while 64% desired surgery because of discomfort in everyday clothing.  In the same study, 85% had bilateral labiaplasty, compared with 15% who had asymmetric hypertrophy of the labia minora requiring a unilateral procedure. 
It is also purposed that increases in hair removal or changing hair patterns have affected the frequency of labiaplasty surgeries. [2, 3] A 2009 study analyzing the media’s influence on female genital cosmetic surgery (FGCS) showed 84% of younger women remove pubic hair, compared with only 36% of older women.  Of those women, only 50% were happy with the appearance of their labia.
Additionally, women reported being twice as likely to have cosmetic labia surgery if the cost of the procedure were lower. 
The exact cause of hypertrophy of the labia minora is unknown, and therefore a multifactorial etiology is purposed.  Genetic factors and hormones can lead to hypertrophy of the labia early in life. Mechanical irritation from bicycling, sexual intercourse, genital piercing, horseback riding, and other factors can cause hypertrophy later in life. 
Pregnancy and weight gain can increase the fat accumulation and ptosis of female genitalia, predominantly the labia majora.  Therefore, after childbirth or significant weight loss, a patient may desire to have the wrinkled appearance or increased size of her labia addressed. Weight loss and changes in the appearance of the labia majora can all also accentuate the size of the labia minora.
The medical community has not defined a singular grading system for hypertrophy of the labia. Past surgeons have defined hypertrophy of the labia minora ranging from 3-5 cm. [4, 9, 12] In 1983, hypertrophy was defined as 5 cm; in current practice, labia minora longer than 3-4 cm are considered hypertrophic. 
In 2010, a new classification system was developed to measure labial hypertrophy as follows  :
Class 1 - Equal minora and majora
Class 2 - Minora extending beyond the majora
Class 3 - Hypertrophy involving the clitoral hood
Class 4 - Hypertrophy of the minora extending to the perineum
The following grading system by Davison and West to objectively measure labia minora hypertrophy has been used clinically  :
None – The labia minora extends no farther than the labia majora
Mild/moderate (see the image below) – The labia minora extends 1-4 cm beyond the labia major
Severe – The labia minora extends greater than 4 cm beyond the labia majoraModerate labia hypertrophy. A moderate labia hypertrophy before resection (left) and intraoperative results after resection (right).
There are several reasons a patient may desire female genital cosmetic surgery (FGCS), including functional and aesthetic concerns. Severe labia minora hypertrophy may cause pain when wearing underwear, riding a bicycle, exercising, or having sexual intercourse.  Patients have reported insecurities about appearances with a sexual partner or while wearing tight-fitting clothing, such as bathing suits.  In the same manner that children report being teased about physical features, numerous slang terms are associated with excess labial tissue and are often psychologically damaging and increase social anxiety.
Recent trends in pubic hair grooming have led to increased visibility of and increase focus on the labia. Additionally, images of female genitalia have increased in the media and on the Internet, including video or photographic pornography. In fact 78% of patients learned about labial reductions from the media.  These 2 situations in parallel have created a finite definition of “normal” genitalia, causing the number of women seeking labiaplasty surgery to increase. 
See the image below.
Labiaplasty surgery should not be considered until after the patient has reached sexual maturity. Some physicians advocate for surgery on patients as young as 15 years.  The authors defer surgery until age 18 years, so that patients may give consent for the procedure themselves. Surgery on a pregnant patient should be deferred. Timing of surgery away from menstruation for patient comfort is advised.
Patient who report functional and/or aesthetic concerns about their hypertrophic labia may be considered candidates for surgery. Candidates who focus on pain or sexual inadequacy as reasons for surgery many need more preoperative assessments, including a psychological evaluation, prior to conducting surgery. Pain while exercising, especially with repeated trauma, may indicate a good candidate for surgery (see image below). The grading systems described in Pathophysiology should be used as a guide, but not an absolute indication for surgical candidacy.
A diagram of vulvar anatomy is shown below.
There are no absolute contraindications to labiaplasty surgery. Any patient who is in good health and has symptomatic or aesthetic concerns should be properly evaluated. If the consulting surgeon believes a surgical intervention can alleviate the symptom or improve the appearance, then an operation is reasonable.
It is important to distinguish elective female genital surgery, such as labiaplasty, from genital mutilation. Genital mutilation is practiced in a variety of cultures and involves young women and girls having procedures performed on the vulva against their will. Whether or not a person agrees with labiaplasty surgery is of greatest importance to recognize and determine if a patient seeks out and consents to the procedure on her own volition. Surgery is never performed at the request or under the duress of an individual other than the patient.
Minimal relative contraindications exist. Patients with gynecological disease are not good candidates for labiaplasty surgery. As with most surgeries, patients who smoke increase their risk for poor healing, particularly wound dehiscence.  Other factors that contribute to increased risk of wound dehiscence, such as collagen disorders, should be considered when planning for labiaplasty surgeries. Most importantly, a patient must have realistic expectations prior to surgery and should be counseled appropriately.
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