Labiaplasty and Labia Minora Reduction Treatment & Management
- Author: Steven P Davison, DDS, MD; Chief Editor: Jorge I de la Torre, MD, FACS more...
No medical management is available for labial hypertrophy.
Labiaplasty surgery can be successfully performed under local anesthesia, sedation, or general anesthesia. The authors prefer to use local anesthesia for 3 main reasons. First, at critical points in the surgery, the awake patient can be involved in determining the amount of resection. This improves patient satisfaction and decreases the need for revisions. Second, local anesthesia allows the patient to escort herself to and from surgery, therefore eliminating the need for another person to care for them while undergoing this sensitive procedure. Third, there is a significant cost reduction without anesthesia fees, making this price-point-sensitive procedure accessible to more individuals.
Surgical site preparation and draping are standard. The authors have found povidone-iodine solution (Betadine) to be minimally reactive and very effective.
Local anesthesia starts with the application of a topical anesthetic such as BLT cream, which contains benzocaine (20%), lidocaine (6%), and tetracaine (4%). The thin mucosa of the labia allows rapid penetration of the topical anesthetic, making it more analogous to dental than dermal topical therapy. Then, 5-10 mL per side of 1% lidocaine with 1:100,000 epinephrine is injected with an ultrafine (31-gauge) needle, maintaining local anesthesia for up to 2 hours. Local anesthesia with lidocaine should also be used during general or sedation anesthesia for added vasoconstriction and postoperative pain control.
As postoperative bleeding is a risk, hand-held thermocautery or electrocautery coagulation is highly recommended to reduce bleeding risk from resected mucosal edges.
Postoperative pain occasionally requires moderate narcotics such as hydrocodone or acetaminophen with codeine.
The amputation technique (see images below) is also referred to as the trim/strip method, “clip and snip,” or linear labiaplasty. This technique is the simplest of the labia -eduction surgeries and is often preferred when the labial hypertrophy is localized. The excess skin on the labia minora is amputated and the new open edge is sutured closed. A proposed benefit of this technique is pinker labial edges that lie within the labia majora folds ; others may consider this detrimental. The amputation technique is limited in that it greatly alters the natural appearance of the labia minora. This technique presents a risk for nerve end interruption and results in the loss of the pigmented skin/mucosal margin and the natural edge of the labia minora.
The greatest evolution in labiaplasty involves the wedge technique (see image below). In this technique, a portion of the labial edge is excised and the “dog-ear” excision is carried into natural creases of the labial folds. The 3 types of wedges are anterior, central, and posterior. These techniques maintain the natural mucosa and skin edge, preserve tumescence and sensation, and maximize the aesthetic results. Common features are often deepithelialization of the wedge, leaving the submucosal lymphatics and nerves intact. A reported disadvantage of this technique is the potential damage to nerves along the edge of the removed wedge.
There are 3 described techniques for excising a central wedge (see image below). The first technique involves a deepithelialization of the central wedge and preserving the underlying submucosa. A second technique involves a full-thickness resection of a V-shaped wedge of excess labial tissue.[12, 3] This resection maintains the natural edge and minimizes the scar. The third approach is the 90° Z-plasty. This wedge technique reduces tension on the suture line, further minimizing the scar. The advantage of the central wedge is simplicity. The main drawback is limited allowance to aesthetically alter the labial appearance.
Labial hypertrophy may also be corrected using an anterior wedge excision (see images below). This technique resects anterior mucosa and skin. The dog-ear is extended into the labia minora and labia majora crease. This is well hidden and provides optimal aesthetic results. The amount of resection is variable; clinical judgment is needed to prevent excessive resection and narrowing of the labia. Additionally, the anterior wedge technique has the advantage of pulling down some of the excess clitoral hood into the labial crease.
This technique removes the posterior fornix labia, leaving an intact labial rim (see image below). A drawback of the posterior wedge technique is the length of the flap and the distance the blood supply must travel.
All of these techniques preserve the mucosal-to-skin presentation, between labia tissue and the surrounding skin. Each is adaptable to the amount of resection necessary, but limited in that the incision line is placed directly in the labia, as opposed to a labial fold. A mitigating benefit of these techniques is the incision is hard to see, even on the labial edge.
This technique involves the deepithelialization of the center region of the labia while preserving the natural free edge of the labia minora. The design of the deepithelialization as a tripoint allows anterior, posterior, and vertical reduction. The length of the wedge excised should not be longer than the length from the clitoral hood to the posterior side of the labia minora.
Benefits of using this technique include nerve, tissue, and lymphatic preservation. There is minimal to no blood loss using this technique. Although the central wedge technique removes a central portion of the leading edge, the deepithelialization technique removes a portion of the central labia while preserving the leading edge. For this reason, this technique is limited in the amount of tissue that can be removed and there is a risk of recurrent hypertrophy with the deepithelialization technique.
See the images below.
Laser techniques are very similar to deepithelializing methods, using a laser rather than a scalpel. Both erbium and carbon dioxide lasers can be used. Proposed benefits of laser therapy are reduced blood loss and enhanced healing, although most of the benefit may be marketing. Limitations of this technique include higher risk for epidermal inclusion cysts.
Custom flask technique
A newer technique, custom flask labiaplasty, involves a flask-shaped incision. The technique allows precise, customized reduction of the labia minora and is designed to avoid interruption of vascularity and nerve innervation. A study by Gonzalez et al of 27 patients who underwent the procedure reported that 25 (92.6%) were satisfied with the surgical results; one (3.7%) minor postoperative complication occurred.
Composite reductions of the labia are often performed to ensure a balanced and symmetrical result. In this composite reduction, a labiaplasty is combined with clitoral unhooding. Clitoral unhooding reduces the amount or thickness of epithelial tissue surrounding the clitoris. From an anterior view, this can be aesthetically displeasing. The balance in technique is unhooding the clitoris without an unhooded clitoris. Excessive exposure leads to hypersensitivity, as well as the appearance of the microphallus.
The classic clitoral un-hooding is a modified Y-to-V technique. The clitoral hood is incised and the excess tissue on either side of the Y can be amputated, as depicted below.
An alternative to the clitoral unhooding technique is the clitoral tightening. In conjunction with a central wedge, wings of the anterior labia are advanced posterior and the clitoris is tightened posteriorly into the cleft.
Complications of the composite labial reductions are minimal and similar to those of any labiaplasty technique. In a 2013 study, 35% of patients who underwent the composite procedure experienced increased sexual excitability and no patients experienced prolonged pain.
Labia majora reduction
The problems of the labia majora are 2-fold: (1) atrophy of the fat and (2) excess skin. The solutions are fat grafting and surgical resection, respectively. If a patient has atrophy of fat in the labia majora, the author recommends injection of 10-15 mL of fat into each side of the labia majora, of which approximately 40-60% survives. The most common technique the authors use for a surgical resection of excess labia majora skin is an elliptical wedge on the inner edge of the labia, as shown below. This is designed to place the final closure into the labial crease.
Both fat grafting and fillers, such as Radiesse, can be applied to the anterior vaginal wall to enhance the perceived G-spot. Injections of fillers and/or collagen to the G-spot enhance the size, which should, in turn, increase sexual pleasure. One injection, G-Shot, uses hyaluronic acid off-label to increase the presumed G-spot size up to 100%. These injections can lead to bleeding, infection, urinary complications, and lack of sensitivity in the G-spot.
The mons has also been an increasing region of focus in female genital cosmetic surgery (FGCS). Using a wedge excision method, wide mons are reduced. The procedure works well in combination with labiaplasty and/or abdominoplasty in patients who have experienced massive weight loss.
The authors’ technique reflects their overall cosmetic surgery philosophy, which is to tailor the operation to the problem or concern. They believe that no one technique is ideal for all patients. Therefore, specific techniques or combinations of techniques should be used on patients after their particular hypertrophic labia minora have been examined. We predominantly use a progressive anterior wedge excision. The closure line is situated at the anterior to mid third of the labia minora. The excess is removed from the central third. The dog-ear or scar excess is extended into the anterior labial crease. A clitoral unhooding is also performed as needed as a V-to-Y excision is used. Any excess tissue remaining on the transition from the clitoral hood to the labia minora is amputated.
For a patient who desires to keep the natural looking edge of the labia minor without a visible scar, the deepithelialization technique is recommended. The deepithelialization technique in combination with clamp resection should be used for patients with considerable excess skin.
The deep planes are closed with 4.0 or 5.0 Monocryl sutures and the labial edge is approximated with a 5.0 Vicryl Rapide. Any skin closure is performed with a 5.0 Vicryl Rapide subcuticular or a 5.0 fast-absorbing suture. Regardless of the technique used to reduce the labia minora, it is recommended that any long-acting sutures are used in a buried interrupted or running suture. Running sutures externally can lead to aesthetically poor results on the free edge of the labia minora, while the buried running suture can create a smooth free edge. This scalloped look to the free edge is hard to correct. See the image below.
All patients are seen preoperatively to evaluate the best approach for labia minora reduction. Patients are evaluated while standing and marked in the lithotomy position. The presence of pubic hair is irrelevant for the procedure. The patient should not shave immediately prior to the operation to avoid increased infection risks.
Although the procedure can be conducted under local, sedation, or general anesthesia, the authors prefer to use local anesthesia if possible. Topical cream is applied 30 minutes prior to the start of the procedure. The authors use 10-20 mL total of 1% lidocaine with 1:100,000 epinephrine as the local anesthetic. The procedure is conducted with the patient in the lithotomy position.
All labiaplasty procedures are same-day surgeries. Under local anesthesia, the patient may not require a responsible adult following the procedure. This allows her the option to maintain utmost privacy for this sensitive procedure. Topical antibiotic ointment is applied to the incision immediately following surgery and applied 3 times a day for the first 5 postoperative days. If bleeding occurs, the patient should apply pressure for 10 minutes with a sanitary pad. The patient may choose to use a sanitary pad at all times in her undergarments until the incisions have healed. The patient may begin taking a bath 48 hours after the procedure.
Patients are seen postoperatively at 1 week and 1 month following their procedure. The patient may return to normal work and exercise in 3-4 days. However, it is recommended that the patient avoid the use of tampons or tight underwear and clothing for 4 weeks. Similarly, the patient should avoid sexual intercourse for 4 weeks.
Complications are uncommon for the labiaplasty procedure. Wound dehiscence and bleeding are early complications that have been documented. Smoking predisposes patients to dehiscence or wound breakdown (see the image below). The most common complication is patient dissatisfaction with the final results. Communication regarding the patient’s expectations is critical. In the authors’ practice, the frequency of revisions has reduced after the transition to using local anesthesia, which allows active patient involvement in determining the final resection.
Outcome and Prognosis
In the authors’ experience, patients are generally well satisfied with their results after having a labiaplasty. According to a study of female genital plastic surgery including labiaplasty and vaginoplasty patients, 91.6% of women who underwent surgery reported an increase in sexual function following the procedure. A similar study in 2000 reported that 80% of the patients were satisfied with their results. Additionally, a study of labial reductions in 2012 reported 92.3% of women had functional problems corrected, while 89.7% of patients were relieved of psychological distress.
A retrospective study by Lista et al of 113 patients who underwent labia minora reduction reported the edge excision technique to have a low complication rate and satisfactory aesthetic results. Transient symptoms, such as swelling, bruising, and pain, were reported by 15 patients (13.3%), and bleeding occurred in one patient (0.9%). Four patients underwent revision surgery, for further tissue excision.
One of the problems with evaluating patient satisfaction with labiaplasty is the limited long-term follow-up. Patients rarely return for evaluation after their 1-month check-up, despite being advised to make and attend follow-up appointments.
Future and Controversies
Cosmetic alterations or rejuvenation of female genitalia is a growing topic in plastic surgery literature and practice. Plastic surgery literature identifies changing hair patterns and media exposure as additional factors contributing to the growth in female genital cosmetic surgery (FGCS)trends. As the awareness and desire for rejuvenated genitalia increases, so will of the frequency of procedures.
Much of the discussion surrounding FGCS involves the ethical concerns. Some of the macroethical issues include social pressures, limited economics, and defining necessary procedures. Microethical issues include proper informed consent and knowledge of normal female genitalia anatomy. Finally, although labiaplasties are not mutilation surgeries, they have been correlated with female genital mutilation. Unlike genital mutilation, labiaplasties are not intended to decrease natural sexual function, nor do they restrict any basic human rights. Again, labiaplasty is separate from genital mutilation because this elective FGCS is an operation of choice and not an operation intended to decrease sexual function against the patient’s will.
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