Labioplasty: anatomy, etiology, and a new surgical approach

Algorithm for Trim and Wedge Labiaplasties

In the last decade labiaplasty procedures have been on the rise in the United States. The trim and the wedge are among the most commonly used techniques. The purpose of this paper is to provide a trim-wedge algorithm to guide the surgeon based on the qualities of the individual patient. The choice of technique should be based on the reasonable labiaplasty candidate's goals, her nicotine/cocaine usage, and the physical characteristics of her labia, including edge quality, texture, pigmentation, symmetry, morphology of protrusion, and labial length. By considering these individual patient factors, the trim-wedge algorithm may improve labiaplasty outcomes and increase patient satisfaction. Some surgeons perform only the wedge or only the trim, and no algorithm should alter that. After all, the best technique is always the one the surgeon performs comfortably and safely.

LEVEL OF EVIDENCE: 4

Women's aesthetic perceptions of the genitalia and their association with anatomical measurements

BACKGROUND

The purpose of this study is to determine women's perceptions of the vulva with the criteria defined in the literature for the ideal vulva and determine their relationship with anatomical measurements to determine the extent to which women's perceptions of normal align with our aesthetic standards of normality.

METHODS

First of all, a questionnaire was given to all participants. The items of the data collection form included personal information, obstetric and gynecological information, their perceptions of their external genitalia and any physical, sexual, psychological, and hygiene problems they experience. Then examination and measurements of the external genitalia were performed.

RESULTS

The majority of participants considered their genitalia normal (n = 101, 89.4%), while 12 participants (10.6%) considered them abnormal. Statistical analyses showed that women's perception of their genitalia as normal in appearance and size was associated with labia minora asymmetry (p = 0.023 and p = 0.006, respectively) and hyperpigmentation (p = 0.010 and p = 0.047, respectively) but not with labia minora measurements or protrusion (p > 0.05).

CONCLUSIONS

Although there is a tendency in the field of aesthetic surgery to define ideals and aesthetic standards for all parts of the body, our definitions of normality do not always coincide with those of the individual. The appearance of the genitalia is as personal as the face, and an individual's self-perception is more important than our ideal.

LEVEL IV

Evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Curvilinear Labiaplasty and Clitoral Hood Reduction Surgery

The two base techniques for labiaplasty surgery are the linear excision and the wedge excision. The modification of using radiofrequency in a curvilinear manner is exceptionally precise, safe, and can produce exceptionally beautiful results based on surgical skill and experience. We recommend using this curvilinear technique as the core skill to learn as a labial surgeon both for ease and safety. Presented are the steps to achieve safe and consistent results no matter the anatomy. The method to reduce the lateral clitoral hood to help balance the appearance of the vulvar structures is also presented.

The Butterfly Technique: A Retrospective Study for Labia Minora Reduction Using an Integrated Approach

In recent years, the demand for genital plastic procedures has increased. Of those, the reduction of the labia minora has become very popular. Several techniques are described, with all its advantages and disadvantages. The aim of this study is to introduce a novel approach combining de-epithelialization with wedge resection.

Methods

In this retrospective study, we included patients seen between September 2011 and April 2014 with hypertrophic labia minora. The surgical technique consisted in an integrated approach of de-epithelialization and wedge excision. Patients were examined for early and late postoperative complications. Furthermore, patient satisfaction was evaluated at the final follow-up.

Results

A total of 17 labioplasties (Franco type II-IV) in 10 patients with a mean age of 29 ± 12 years (range 20-62 y) were performed. Three patients experienced wound-healing problems, requiring surgical revision. After a median follow-up of 39 ± 6 months (range 28-48 mo), a high overall patient satisfaction has been achieved (8.6 ± 1.1). No dyspareunia, hypertrophic scarring, or micturition problems have been reported.

Conclusions

By using our integrated approach, hereby called the "butterfly technique," the neurovascular supply remains preserved, and an efficient volume reduction can be achieved with a concealed scar. Nevertheless, suture techniques and suture materials have to be tested to reduce the incidence of wound dehiscence rate.

Satisfaction Survey of Women After Cosmetic Genital Procedures: A Cross-Sectional Study From Saudi Arabia

Background

Female cosmetic genital surgery (FCGS) aims for better aesthetic genital appearance and improved functional aspects to enhance women's self-esteem and satisfaction.

Objectives

This study aims to assess the satisfaction of women who have undergone FCGS and its impact on their sexual, psychological, and aesthetic aspects.

Methods

An observational cross-sectional study was conducted in private clinics in Riyadh, Kingdom of Saudi Arabia, between March and June 2019, in women who underwent FCGS. Phone interviews were conducted in the Arabic language. The survey comprised 4 sections: demographics, motives for FCGS, quality-of-life questionnaires about genital appearance satisfaction, and sexual function.

Results

Out of the 196 women undergoing FCGS during the study period, 11.7% refused to participate, and 37.2% did not answer phone calls; 51% of the women participated in the study. The women's age ranged between 23 and 55 years; 64% underwent vaginoplasty, and 73% underwent other cosmetic procedures. Ninety-two percent of the women did not have any complications after these procedures.

Conclusions

In this group of women, FCGS was safe and effective, and the majority of participants reported overall satisfaction and improvement of sexual function, genital appearance, and self-esteem.

Level of Evidence 4

Anterior and Posterior Commissuroplasty: Taking Labiaplasty to the Next Level

As the popularity of female cosmetic genital surgery has grown, so has the number of publications detailing surgical techniques, particularly regarding labiaplasty. As a nascent surgical field, much room remains for finesse and exploration of new techniques to optimize outcomes and patient satisfaction. We present the techniques for anterior and posterior commissuroplasty the senior author (O.J.P.) has developed. Anterior commissuroplasty is efficacious in addressing a number of anatomic variations to achieve the appearance of a single midline cleft, which is commonly requested by patients. Posterior commissuroplasty was developed to address skin excess at the posterior fourchette that may develop as a result of labiaplasty. Either technique may be used in combination with labiaplasty or as a stand-alone procedure. These tools may be a useful addition to the repertoire of a surgeon practicing female genital surgery.

LEVEL OF EVIDENCE: 4

Audit of Female Genital Aesthetic Surgery: Changing Trends in India

Introduction

Female genital cosmetic surgery (FGCS) is undoubtedly a fast-growing speciality in the world with increasing demand for a variety of procedures to beautify the female genitals. In India, over the last few years, there has been a steady growth in the interest for these procedures.

Materials and Methods

A variety of FGCS procedures were performed on 76 patients from January 2012 to August 2016. The procedures performed were as follows: vaginal tightening, labia minoraplasty, labia majoraplasty, clitoral hood reduction, and hymenoplasty.

Discussion

Based on FSFI scores, labia minoraplasty was more valuable as a cosmetic procedure and vaginal tightening was associated with better sexual function after surgery.

Conclusion

FGCS is no doubt in its infancy in India. However, there is a steady rise in the awareness and demand for these procedures. A combination of procedures to improve individual components leads to improved aesthetic and functional aspects of female genitalia.

Female Cosmetic Genital Surgery: Delivering What Women Want

Female cosmetic genital surgery (FCGS) is the latest and fastest growing sub-specialty in the broad specialty of gynecology. It encompasses procedures designed to change aesthetic and/or functional aspects of women's genitalia. In case of FCGS, there is difficulty in separating purely aesthetic concerns from medical concerns, because there is much overlap. The initial controversies over FCGS have almost settled down in the light of the mounting scientific evidence suggesting that a number of procedures that currently exist are safe, effective, and capable of treating to a considerable extent the suite of conditions associated with course-of-life vulvo-vaginal changes. Also, the rapidly expanding demands that have arisen for FCGS procedures from women across the globe have made it imperative for the reconstructive pelvic surgeons to master the cosmetic genital procedures so as to deliver the women what they want, in the most scientific manner. The issue of asking for and provisioning of FCGS is essentially a matter of individual patient and physician decision-making.

Evaluation of Body Image and Sexual Satisfaction in Women Undergoing Female Genital Plastic/Cosmetic Surgery

BACKGROUND

Little prospective data exists regarding the procedures constituting female genital plastic/cosmetic surgery (FGPS).

OBJECTIVES

To evaluate whether the procedures of labiaplasty and vaginoperineoplasty improve genital self image, and evaluate effects on sexual satisfaction.

METHODS

Prospective cohort case-controlled study of 120 subjects evaluated at baseline, 6, 12, and 24 months postoperative, paired with a demographically similar control group. Interventions include labiaplasty, clitoral hood reduction, and/or aesthetic vaginal tightening, defined as perineoplasty + "vaginoplasty" (aka "vaginal rejuvenation."). Outcome measures include body image, genital self-image, sexual satisfaction, and body esteem.

RESULTS

As a group, study patients tested at baseline showing body dissatisfaction, negative genital self-image, and poorer indices of sexual satisfaction. Preoperative body image of study patients were in a range considered to be mild to moderately dysmorphic, but matched controls at one and two years; genital self-image scores at entry were considerably lower than controls, but by 2-year follow-up had surpassed control value at entry. Similarly, sexual satisfaction values, significantly lower at entry, equaled at one, and surpassed control values, at 2 years. Postoperatively, at all points in time, these differences in body image and genital self-image disappeared, and sexual satisfaction markedly improved. Overall body esteem did not differ between study and control groups, with the exception of the genital esteem quotient, which improved after surgery.

CONCLUSIONS

Women requesting and completing FGPS, when tested by validated instruments, at entry report sexual dissatisfaction and negative genital self-image. When tested at several points in time after surgery up to two years, these findings were no longer present. When performed by an experienced surgeon, FGPS appears to provide sexual and genital self-image improvement.

LEVEL OF EVIDENCE

2 Therapeutic.

Labia Minora, Labia Majora, and Clitoral Hood Alteration: Experience-Based Recommendations

Aesthetic alteration of the genitalia is increasingly sought by women unhappy with the size, shape, and appearance of their vulva. Although the labia minora are usually the focus of concern, the entire anatomic region--minora, labia majora, clitoral hood, perineum, and mons pubis--should be evaluated in a preoperative assessment of women seeking labiaplasty. Labiaplasty is associated with high patient satisfaction and low complication rates. The three basic labia minora reduction techniques--edge excision, wedge excision, and central deepithelialization--as well as their advantages and disadvantages are discussed to assist the surgeon in tailoring technique selection to individual genital anatomy and aesthetic desires. We present key points of the preoperative anatomic evaluation, technique selection, operative risks, perioperative care, and potential complications for labia minora, labia majora, and clitoral hood alterations, based on a large operative experience. Labiaplasty competency should be part of the skill set of all plastic surgeons.

Aesthetic Labia Minora Reduction with Combined Wedge-edge Resection: A Modified Approach of Labiaplasty

BACKGROUND

Nowadays, the demand for female genital rejuvenation procedures especially for labiaplasty is surging. Labia minora reduction has been the most practiced esthetic procedure for the female genitalia in China. Gynecological plastic surgeons have proposed several methods for labia reduction, but there is no consensus on which one is the best choice. Patients often receive re-operations for inadequate resection and asymmetry with existing methods. Here we present a modified method of labiaplasty combined wedge and edge resection and to discuss the appropriate indications of this method.

METHODS

From January 2009 to March 2014, we performed 524 labia esthetic surgeries. The methods we used mainly include simple edge resection, wedge resection, modified de-epithelialization, and the combined method discussed in this article. Forty-nine patients aged from 25 to 45 years were selected to receive combined wedge-edge labial resection and were retrospectively reviewed. Patients were required to come back for follow-up assessment at 1 and 6 months.

RESULTS

Twenty-one of forty-nine (42.9 %) patients underwent unilateral labial reduction. The average time for the procedures was 56 min. The mean follow-up was 4.5 months. All the surgeries were successfully performed and 47 patients experienced an uneventful postoperative period. A minor dehiscence occurred in two patients. One of the patients received a revision surgery correcting a postoperative asymmetry malformation. Finally, all the patients were satisfied with the esthetic appearance.

CONCLUSION

The combined wedge-edge reduction of the labia minora is a simple and safe method associated with high satisfaction and a low complication rate. Therefore, we propose this combined procedure for bi-dimensional and/or unilateral hypertrophied labia minora especially in those who require removal of the dark margin of the labia.

Aesthetic surgery of female external genitalia

Aesthetic surgery of the external genitalia in women encompasses many procedures and may address the labia minora, clitoral hood, labia majora, mons pubis, or vaginal opening. During the initial evaluation, the surgeon should consider all aspects of the external genitalia to develop an appropriate surgical plan. It may be necessary to perform 2 or more procedures during the same surgical session to achieve the desired aesthetic result. In this continuing medical education (CME) article, we review the literature and summarize the available cosmetic techniques for female external genitalia. Resection of the labia minora has been described in several peer-reviewed reports. We also discuss the procedures and modifications to direct resection, wedge resection, and deepithelialization of the labia minora. Aesthetic surgery of the clitoral hood may involve straight-line resection, extended wedge resection, or inverted V hoodoplasty. The mons pubis may be treated with mons pubis pexy, wedge resection, or lipomodeling. The labia majora can be managed with direct resection or lipomodeling, and hymenoplasty may be performed to correct a wide vaginal opening.

Postoperative clitoral hood deformity after labiaplasty

Aesthetics of the female genitalia have come under increasing scrutiny with the popularity of Brazilian waxing trends and media promotion of sheer fashions. Women seek to have a clean and youthful appearance of the vaginal region, with minimal if any labial minora show beyond the labia majora. Labiaplasty by edge resection of the redundant labia minora tends to be the preferred method of treating labia minora hypertrophy by most gynecologists and plastic surgeons. This technique is effective in removing the excess circumferential rim of the labia minora, thus decreasing bulk and protrusion from the introitus. However, in select patients with redundant clitoral hood tissue, edge trim techniques may result in an imbalanced postoperative result where the hood actually looks larger. These patients complain of a prominence of the clitoral hood not present prior to their labiaplasty. In this case report, the author describes 2 cases of excess clitoral hood prominence after free-edge resection labiaplasty. Both patients were unhappy with the result of their labiaplasties and sought surgical correction. Presentation, anatomical findings, options for treatment, and avoidance of such deformity are discussed.

Female genital cosmetic surgery: a review of techniques and outcomes

The aesthetic and functional procedures that comprise female genital cosmetic surgery (FGCS) include traditional vaginal prolapse procedures as well as cosmetic vulvar and labial procedures. The line between cosmetic and medically indicated surgical procedures is blurred, and today many operations are performed for both purposes. The contributions of gynecologists and reconstructive pelvic surgeons are crucial in this debate. Aesthetic vaginal surgeons may unintentionally blur legitimate female pelvic floor disorders with other aesthetic conditions. In the absence of quality outcome data, the value of FGCS in improving sexual function remains uncertain. Women seeking FGCS need to be educated about the range and variation of labia widths and genital appearance, and should be evaluated for true pelvic support disorders such as pelvic organ prolapse and stress urinary incontinence. Women seeking FGCS should also be screened for psychological conditions and should act autonomously without coercion from partners or surgeons with proprietary conflicts of interest.

Refreshing labioplasty techniques for plastic surgeons

BACKGROUND

Patient requests for plastic surgery of the female genitalia have become more common. There are several technical options to manage hypertrophic labia minora, including direct excision, wedge resection, and deepithelialization. Labia majora hypertrophy and hypoplasia can also be managed surgically. The aim of this study was to summarize labioplasty techniques to date, and describe the senior author's technique for labia minora and majora labioplasty.

METHODS

Seventy-four patients underwent direct labia minora excision with or without clitoral hood molding and management of labia majora by the senior author from January 2009 to August 2011.

RESULTS

The average follow-up time was 6 months. The range of the patients' ages was wide with an average age of 35 years. One patient had an infection and one had wound dehiscence. Six patients had palpable fatty cysts in the labia majora after fat injections; the cysts of five of these patients reabsorbed before 6 months. In one patient a palpable mass persisted 8 months after surgery; however, it was not visible or painful and the patient was satisfied with the result. No cases of scar contracture, painful scar, or discomfort because of labial edge distortion were noted. The satisfaction rate was close to 100 %.

CONCLUSION

The direct excision of the excess labia minora is a good technique and does not produce scar-associated problems.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article.