Continuing Education Activity

Labia minora reduction is indicated for any patient wishing to reduce the size of their labia minora. This can be for cosmetic reasons or due to physical discomfort associated with a protuberant labia minora during intercourse or during daily life while wearing certain undergarments. Traditionally, two surgical techniques, the trim technique and the wedge technique are performed to reduce labial excess. This activity reviews the evaluation and management of patients undergoing labia reduction, reviews the surgical techniques involved, and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance patient outcomes.

Objectives:

• Outline the indications for surgical reduction of the labia minora.
• Review the contraindications to a surgical reduction of the labia minora.
• Summarize the various surgical techniques for labia reduction.
• Describe the importance of collaboration and coordination amongst the interprofessional team to facilitate safe labia minora reduction and minimize complications to improve patient outcomes.

Introduction

Identity and self-esteem can be intimately related to the self-perceived appearance of one's genitalia, particularly when one begins a relationship with a new partner. Female genital aesthetics is a product of cultural norms and a woman's perceived concept of beauty. Both exist within the context of a woman's society and her perceived societal norms. Modern trends have moved towards a lack of pubic hair, making subtle labial irregularities more conspicuous and potentially rendering one more self-conscious in this area. Additionally, the free accessibility of pornographic photos or videos, and the normalization of open sexual imagery and discussion over sexual practices and preferences in many societies in recent years, have made many women feel their genitalia could be inadequate compared to these perceived societal norms. These women 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 significant demand for genital aesthetic surgery, and according to the American Society of Aesthetic Plastic Surgeons 2017 Statistics, request for labiaplasty has increased by 217.2% from 2012 to 2017. Female aesthetic genital surgery can significantly enhance the confidence of a perceived or actual 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 globalized, standard genital aesthetic ideal and there are variables according to cultural and geographic preferences, 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.[1]

Additionally, women with enlarged labia minora, majora, or with significant clitoral hooding can complain of irritation and discomfort with exercise, sexual intercourse, and the wearing of 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 prevent postoperative sensation deficits. Normal labia minora anatomy encompasses a broad range of sizes, thicknesses, and colors. 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 consists 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 anastomosis gives off multiple branches to the labia minora.

Indications

Overwhelmingly, labia minora enlargement is congenital, although women claim to have enlargement after childbirth, hormone therapy, and increasing age.[2][3][4] Labia minora reduction is indicated in women as young as 12 years old if significantly symptomatic, where enlargement can affect self-esteem, cause discomfort, or social stigmata. The vast majority of labial reduction is performed for aesthetic reasons in sexually mature women. Women often 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). Since labial hypertrophy has rarely been considered a medically necessary procedure, this scale is often relegated to research purposes. Functionally, if excess labial tissue can be removed without injuring crucial structures, a labiaplasty can be performed, and this can also be tailored to the patient's aesthetic wishes. Ancillary procedures such as clitoral hood reduction must 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 anatomy, patient goals, and patient preferences.[5][6][7][8]

Contraindications

Contraindications include patients with body dysmorphic disorder and those expecting this procedure to enhance their sexual lives and improve their ability to achieve orgasm.

Equipment

Equipment needed for this procedure includes a basic surgical tray with a ruler, marking pen, finely serrated scissors, and absorbable sutures such as Monocryl, Chromic, or Vicryl. Dorsal lithotomy position will be necessary and 0.25% Marcaine for long-lasting local anesthesia.

Personnel

A scrub technician or surgical assistant should be available during the procedure. A co-surgeon is not necessary, though they may be present to facilitate fine retraction or for educational purposes.

Preparation

Preoperatively, the woman should be examined in the lithotomy position. Using a mirror to visualize her genitalia, she should indicate her concerns to the surgeon. This ensures the surgeon and patient agree on 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 visualize labial protrusion adequately. Pre-operative antibiotics are given within 30 minutes of the incision. This procedure can be performed in the office with conscious sedation and local anesthetics or as an outpatient surgery under monitored anesthesia care or general endotracheal anesthesia. As with any gynecologic or genital procedure, it is often prudent to have an assistant/witness present in the room for any intimate examination. Ideally, this person will be of the same assigned and chosen gender as the patient for the medico-legal safety of all involved.

Technique or Treatment

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, scissors, or a laser and over-sewing for closure.[9][4][10] It is imperative to leave a 1cm cuff of labia minora to retain a functional "seal" to the introitus. This technique is best for marked redundancies, excessive thicknesses, and where the patient is accepting of a potential change in the color of the visible labia minora edge. Although the advantages of this technique are the short operative time and the creation of light-colored labial edges (an advantage to some, but caution must be exercised in darker-skinned individuals), the disadvantages are more numerous. They include the placement of a longitudinal scar line along the labial edge that is often irregular and scalloped and may have decreased sensation along this scar. This can result in a higher incidence of discomfort. Additional disadvantages are a relatively high incidence of asymmetry and over-resection– which is very difficult or even 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 labia minora, preserving the natural labial edge. The only disadvantages are a longer operative time, the required surgical expertise, and the occasional persistence of darker labial edge pigment.[11][12]

 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, or a real-time camera, 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 maximal labial 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 ensured 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 labia is re-approximated in two layers using a 5.0 Monocryl or Vicryl on a small TF needle. The internal and external subcutaneous 'dog ears' are excised if present. 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 could 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 introital tightening procedure is performed during 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, allowing for introital adjustments during the closure.

 Patients are seen at three weeks post-op to remove any retained sutures and to evaluate healing. Itching can be intense as sutures dissolve, and patients should be educated beforehand. Post-operative restrictions include no vaginal penetration for six 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 to 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, patients should be offered the opportunity for a revision. A common complaint is of persistent, albeit less, asymmetry of the labia.

Complications

Although most patients heal exceptionally well, the most common complications are a slight separation of the labial edge closure or a small fistula, occurring in less than 2% of cases. These can typically be repaired under local anesthesia within 4 to 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 their obstetrician, gynecologist, or primary care provider for advice. These patients should be referred to a surgeon who specializes in labiaplasty. Educating the patient that labiaplasty is generally an elective procedure done primarily for cosmetic reasons is essential. The procedure is relatively simple but also associated with a number of serious complications.

These procedures require an interprofessional healthcare team approach. This team can include the woman's family clinician, the specialty surgeon, the nursing staff, and a pharmacist. Nurses will play a crucial role in helping prepare the patient for the procedure, assisting during the operation, and providing post-procedural care, monitoring, and patient education. Pharmacists can assist with appropriate post-operative pain medication recommendations. Of course, the surgeon will determine the overall direction of care, but this should be done with open communication with the patient's other clinicians. All team members should reach out and communicate any concerns they may encounter during the case. The interprofessional paradigm will lead to better patient outcomes and greater patient satisfaction. [Level 5]