Labiaplasty and Labia Minora Reduction 

Updated: Jun 05, 2018
Author: Steven P Davison, DDS, MD; Chief Editor: Jorge I de la Torre, MD, FACS 



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.[3] 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, 4] 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.

Severe labia minora hypertrophy. The labia minora Severe labia minora hypertrophy. The labia minora extends 4 cm beyond the labia majora, which can cause pain with clothing and exercise.

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.[5]

The first publication to describe aesthetic labiaplasty was published in 1983.[6] During this time, the only technique used to reduce the labia minora was the “trim method.”[7] In the 1990s, alternative labiaplasty techniques developed,[7, 8] including the “wedge technique” described by Dr. Gary Alter in 1998.[7] 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.[9]

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.[10]

Significant hypertrophy of the labia can cause pain, irritation, and discomfort with clothing. The psychological problem of not feeling “normal” in comparison with the perceived ideal anatomy cannot be underestimated.[2]



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.[10] In the same study, 85% had bilateral labiaplasty, compared with 15% who had asymmetrical hypertrophy of the labia minora requiring a unilateral procedure.[10]

It is also purposed that increases in hair removal or changing hair patterns have affected the frequency of labiaplasty surgeries.[2, 4] 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.[11] 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.[11]


The exact cause of hypertrophy of the labia minora is unknown, and therefore a multifactorial etiology is purposed.[12] 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.[12]

Pregnancy and weight gain can increase the fat accumulation and ptosis of female genitalia, predominantly the labia majora.[1] 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.[5, 10, 13] In 1983, hypertrophy was defined as 5 cm; in current practice, labia minora longer than 3-4 cm are considered hypertrophic.[4]

In 2010, a new classification system was developed to measure labial hypertrophy as follows[13] :

  • 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[14] :

  • 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 majora

    Moderate labia hypertrophy. A moderate labia hyper Moderate 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.[15] Severe labia minora hypertrophy may cause pain when wearing underwear, riding a bicycle, exercising, or having sexual intercourse.[1] Patients have reported insecurities about appearances with a sexual partner or while wearing tight-fitting clothing, such as bathing suits.[13] 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.[11] These 2 situations in parallel have created a finite definition of “normal” genitalia, causing the number of women seeking labiaplasty surgery to increase.[2]

See the image below.

Labia hypertrophy, anterior view. (Left) Heavy lab Labia hypertrophy, anterior view. (Left) Heavy labia majora and a prominent clitoral hood, but no excess minora showing. (Right) Labia minora hypertrophy, with minimal majora showing.

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.[4] 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.

Increased labia majora due to ptosis, which can in Increased labia majora due to ptosis, which can interfere with daily activities such as exercise and increase insecurities when wearing tight clothing.

Relevant Anatomy

A diagram of vulvar anatomy is shown below.

Anatomical diagram of the vulva. The typical exter Anatomical diagram of the vulva. The typical external female genitalia include the labia majora, labia minora, clitoris, clitoral hood, mons pubis, labial commissure, urethra opening, and vaginal opening. Collectively, the external female genitalia are referred to as the vulva. Female genital plastic surgery can be performed on the labia minora, labia majora, mons pubis, vagina, and clitoral hood. The labia minora are 2 mucocutaneous folds that lie between the labia majora and surround the opening to the vagina and urethra. The labial folds extend from the rectum to the mons pubis. The labia minora extend anterior to the clitoral hood.



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.

Relative contraindications

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.[10] 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.



Laboratory Studies

Routine preoperative laboratory studies are necessary to evaluate patients for appropriate health status.

Imaging Studies

Routine imaging, such as a chest radiograph, is conducted when indicated for those patients receiving general anesthesia. Ultrasound examinations may be performed on patients with a Bartholin cyst or unilateral hypertrophy of the labia majora.

Diagnostic Procedures

Labia hypertrophy is a clinical diagnosis, and, as such, no diagnostic procedures are necessary. Patients with symptoms of infection, rash, or labial lesions require a gynecologic evaluation.

Histologic Findings

Surgical specimens are not typically sent for pathological study unless a mass or suspicious lesion is identified during surgery.



Medical Therapy

No medical management is available for labial hypertrophy.

Surgical Therapy

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.[12] 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.

Amputation technique

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 reduction surgeries and is often preferred when the labial hypertrophy is localized.[16] 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[13] ; others may consider this detrimental. The amputation technique is limited in that it greatly alters the natural appearance of the labia minora.[7] 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.

This unilateral hypertrophy of the left labia mino This unilateral hypertrophy of the left labia minora can be addressed with the labiaplasty amputation technique.
Diagram of amputation technique. Diagram of amputation technique.

Wedge technique

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.[17] 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.[13]

Wedge excision results. Before (left) and 3 months Wedge excision results. Before (left) and 3 months after (right) a wedge excision labiaplasty for moderate labia hypertrophy, allowing for preservation of the natural edge.

Central 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.[5] A second technique involves a full-thickness resection of a V-shaped wedge of excess labial tissue.[13, 4] This resection maintains the natural edge and minimizes the scar. The third approach is the 90° Z-plasty.[18] This wedge technique reduces tension on the suture line, further minimizing the scar.[17] The advantage of the central wedge is simplicity. The main drawback is limited allowance to aesthetically alter the labial appearance.

Central wedge technique. Central wedge technique.

Anterior wedge

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.[7] 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.

Anterior wedge technique with labial crease extens Anterior wedge technique with labial crease extension.
Anterior wedge technique. (Left) The dog ear is ex Anterior wedge technique. (Left) The dog ear is extended into the labial crease. (Center) The labia is approximated centrally. (Right) The dog ear is closed anteriorly.

Posterior wedge

This technique removes the posterior fornix labia, leaving an intact labial rim (see image below).[19] A drawback of the posterior wedge technique is the length of the flap and the distance the blood supply must travel.

Posterior wedge technique. Posterior wedge technique.

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.

Deepithelialization technique

This technique involves the deepithelialization of the center region of the labia while preserving the natural free edge of the labia minora.[8] 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.[5]

Benefits of using this technique include nerve, tissue, and lymphatic preservation.[5] There is minimal to no blood loss using this technique.[5] 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.

Deepithelialization technique. Deepithelialization technique.
Central deepithelialization technique. The pattern Central deepithelialization technique. The patterns drawn out on the mucosa and skin sides of the labia illustrate the central deepithelialization technique. The tristar excision as a deepithelialization maximizes nerve and vascular supply to the edge while minimizing dog-ears.

Laser labiaplasty

Laser techniques are very similar to deepithelializing methods, using a laser rather than a scalpel. Both erbium and carbon dioxide lasers can be used.[17] Proposed benefits of laser therapy are reduced blood loss and enhanced healing,[17] 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.[20]

Additional procedures

Clitoral unhooding

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.[21] 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.[7]

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.

Clitoral unhooding Y-to-V technique. Clitoral unhooding Y-to-V technique.

An alternative to the clitoral unhooding technique is the clitoral tightening.[12] 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.[12]

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.[12] 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.[22] 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.

Labia majora reduction technique with ellipse wedg Labia majora reduction technique with ellipse wedge.

G-spot alteration

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.[1] One injection, G-Shot, uses hyaluronic acid off-label to increase the presumed G-spot size up to 100%.[17] 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.[14] The procedure works well in combination with labiaplasty and/or abdominoplasty in patients who have experienced massive weight loss.

Authors’ technique

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.

Labiaplasty results. Before (left) and 1 year afte Labiaplasty results. Before (left) and 1 year after (right) a successful labiaplasty with wedge technique, labia majora reduction, clitoral unhooding, and posterior fornix release. If desired by the patient, the amputation technique can be used on the left labia minora to enhance the results and create color symmetry.

Preoperative Details

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.

Intraoperative Details

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.

Postoperative Details

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.[10] 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.

Smoking predisposes patients to dehiscence. This l Smoking predisposes patients to dehiscence. This labia minora reduction patient (left) was a smoker. She smoked during the 2 preoperative and postoperative weeks, causing dehiscence to the left labial crease (center). The dehiscence had no long-term complications on the result (right).

A study by Bucknor et al suggested that in patients who undergo labiaplasty, the likelihood of postoperative sequelae (ie, revisional surgery and complications) is greater in patients in whom sexual dysfunction is an indication for the procedure.[23]  

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.[24] A similar study in 2000 reported that 80% of the patients were satisfied with their results.[10] 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.[12]

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.[25]

A study by Surroca et al of 58 patients who underwent labia minora reduction (with 75.8% of cases being treated with wedge excision) found that surgical outcome satisfaction was higher in women with children than in those who were nulliparous.[26]

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.[2] 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.[2] Microethical issues include proper informed consent and knowledge of normal female genitalia anatomy.[2] 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.[2] 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.