Labiaplasty covers reduction procedures to both the labia minora and majora. The popularity of the labia minora procedure has increased dramatically since women realized that redundancies and excesses in their vulva could be managed surgically and produce aesthetically pleasing results. Satisfaction has been reported to exceed 90%. Patient motivation for this procedure can vary widely, including symptoms with clothing or intimacy, including visibility or irritation of the vulva with today's fashions. Regardless of motivation, the primary indication continues to be driven by patient choice as Hamori in 2007 concluded that males predominantly are unconcerned about the appearance of the vulva. This procedure technically should not be expected to improve sexual function, although it can make a woman more confident during intimacy. It does bring potential risks and complications including scarring and irregular edges, hematoma, bleeding, over-resection or amputation, wound separation, shortened introitus, and even discomfort. Also, there could be subsequent dryness, tightness, painful intercourse, and persistent asymmetry. Overresection is the most problematic as reconstruction options are limited.
Normal labia minora anatomy encompasses a broad range of sizes, thickness, and color. Felicio in 2007 defined degrees of labial hypertrophy from type I (< 2cm) through type 6 (> 6cm), but since this is rarely a medically necessary procedure, when excess can be removed, a labiaplasty can be done. Ancillary procedures such as clitoral hood reduction need to be considered when planning a labioplasty minora reduction as unaddressed hood redundancies can result in unsightly bumps and bulges. Labia majora reductions or filling also can be considered if the patient is bothered by her perceived deficiencies or excesses as well. 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 the anatomy, patient goals, and patient preferences.
This procedure has no clear indications for it is primarily a personal decision made by a patient who is not pleased with the appearances of her vulva. Prospective patients may complain of pinching from clothing or intimacy, unintentional exposure, or hygiene issues due to the redundancies of skin and tissue. Most patients are simply variations of what is considered normal, but extreme situations are quite obvious, and insurance companies have authorized this procedure, though it more the exception than the rule.
Contraindications would include patients with body dysmorphic disorder and those expecting this procedure to enhance their sexual lives and improve the ability to achieve orgasm.
Equipment needed for this procedure include a cautery, basic surgical tray with ruler and marking pen, serrated scissors, fast absorbing sutures such as Monocrol, Chromic, or Vicryl Rapide (5-0), the ability to position the patient in stirrups (dorsal lithotomy position), and buffered lidocaine with epinephrine as well as bupivacaine to provide long-acting anesthesia at the completion of the procedure. Pre- and post-op photos should be obtained to allow for comparisons when healed, and protrusion should be taken with feet apart at a uniform distance (such as the width of a clipboard) in a standing position.
This procedure requires a strict post-op protocol and a compliant patient as there should be no penetration activities for six weeks. The procedures are technically straightforward and can easily be done under local anesthesia in the complete privacy of the office where buffered lidocaine with epinephrine is used and tolerated quite well. Others may prefer to do this in the operating room under anesthesia, but this is unnecessary and increases the costs to the patient. Photographic documentation before and after is invaluable in helping patients appreciate what benefits have been achieved. Also, if protrusion is one of the complaints, standing photos with feet uniformly apart should be done both before and after the procedure as well. Costs range widely based on the surgeon and geographically but range from $2000 to well over $6000.
An assistant should be available to open any extra supplies or instruments needed during the procedure.
The consent is reviewed, signed, witnessed, and a copy provided to the patient. Photos are taken in both the standing and dorsal lithotomy position. Oral sedation is provided after the agreement to the determined plan. Oral antibiotics also are given and time is allowed for the sedation to take effect. In a dorsal lithotomy position, her vulva and surrounding areas are prepped with a povidone-iodine cleansing agent. Next, a grounding pad is applied to her tummy or thigh, and the patient is draped.
There are two primary ways to reduce the labia minora: the wedge excision or the trim technique.
The trim technique involves excising excess labia along its edge, preserving at least one cm of minora from the interlabial sulcus to avoid amputation and preserve theoretical functions of the labia for 'sealing' the introitus. Excessive removal with this technique will produce an amputation outcome that is difficult to impossible to reconstruct. This technique is best for marked redundancies, excessive thicknesses, and where the patient is accepting of a potential change in the color of the minora edge. This procedure is simpler, can be used in any situation, and wound issues usually resolve on their own. The downside includes poor scarring on the wound edge, scalloping, prominent dog ears near the clitoral hood, and over-resection. Using a w-plasty or zig-zag along the edge can help avoid the scalloping and other potential scar issues and is routine when surgeons employ this technique. Attention must be given toward meticulous excision and closure of the superior and inferior ends of the incisions to prevent dog ears.
The wedge technique, championed by Gary Alter, MD, preserves the natural edge of the labia, resecting a wedge of minora where the redundancies are removed within the wedge. It requires meticulous, layered suturing, realignment of the edge, and avoidance of over-resection that would result in constriction of the introitus. Wedges can be multiple on one side if the conditions merit using more than one. In unique situations, wedges can be combined with trim techniques in attempts to achieve the best outcome possible from one procedure. Healing can be compromised by wound separation resulting in holes in the labia or notching of the edge that would require a revision. Cysts can form in the scar. Variations of wedges have been described where extensions of the resection are directed superiorly along the prepuce to address lateral hood redundancies at the same time.
Other variations of the above techniques as well as de-epithelialization and pedicled flap methods have been described but have failed to produce the consistent and desired outcomes that the trim or wedge methods produce. It is recommended that neophytes start with conservative resections to avoid the dreaded amputation or shortened introitus outcome that seems so common with surgeons thinking of this as a simple procedure.
Sutures used are quick dissolving types, such as Vicryl Rapide, Monocryl, or Chromic, and they are allowed to dissolve over the ensuing weeks. There is a preference for a running vertical mattress closure to oppose the edges and contibute to hemostasis in the deeper tissues. With wedge procedures, the closure is in layers with interrupted, buried 5-0 Vicryl. Patients often are seen at 3 weeks post-op to remove any retained sutures and to evaluate the healing. Itching can be intense as sutures dissolve, and patients should be prepared. Post-operative restrictions include no penetration sex for at least 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 tolerant of the impressive swelling that can follow as it may take weeks for resolution. Revisions can be considered once full healing has occurred with the prevailing opinions for complete healing is 6 months from surgery. Patient opinions of the outcomes should be respected and if something is fixable, patients should be offered the opportunity to have a revision done. A quite common complaint is of persistent, albeit less, asymmetry of the labia.
This procedure is a very gratifying one to perform as it produces dramatic results that are easy to appreciate and reproduce. Patients feel much better about themselves and are more confident with intimacy and activities. Realself.com's rating of this procedure as of June 2017 reveals a 95% satisfaction rate, and there are very few procedures with that satisfaction rating.
Complications include scarring and irregular edges, hematoma, bleeding, over-resection or amputation, wound separation, shortened introitus, and even discomfort. In addition, there could be dryness, tightness, painful intercourse. and persistent asymmetry.
Labiaplasty can make a marked improvement in the aesthetics of the vulva and increase a woman's confidence during intimacy. The satisfaction rate on www.realself.com exceeds 90%, but excessive resections can lead to disastrous results that may not be fixable. It requires excellent judgment on the part of the surgeon and full communication between the patient and surgeon to provide the best outcomes possible.