Vaginal Rejuvenation
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.
What is Vaginal Rejuvenation?
There was a 44% increase in labiaplasty procedures performed in the US between 2012 and 2013.
Labia minora reduction is the most commonly requested and performed procedure on the female external genitalia.
It is estimated that greater than 90% of female genital procedures performed involve alteration of the labia minora.
Although the labia minora are usually the focus of patients’ concerns, achieving a desirable cosmetic outcome often requires additional external genital alterations.
It is therefore essential that the entire anatomic region—labia minora, labia majora, clitoral hood, perineum, and mons pubis—be evaluated in the preoperative assessment of women seeking labiaplasties.
I offer what I have learned in performing over 600 labiaplasties.
Proper evaluation of the vulva requires examination of all the local anatomy
Female external genital cosmetic surgery procedures are viewed by many plastic surgeons and gynecologists as being technically simple operations. They often are.
Many women, however, present with anatomic challenges that make achieving good aesthetic outcomes difficult.
Labia majora redundancy, deflation and ptosis, vertical and/or horizontal clitoral hood excess, and redundant labial tissue posterior to the introitus (in addition to unlimited labia minora size, shape, and pigmentation variations) may be present and require attention.
Such women need more nuanced procedures to achieve aesthetically acceptable, natural-appearing outcomes. Simply reducing the labia minora in women with complex anatomic issues may result in unnatural-appearing genitalia and the perception of genital deformity as unintended consequences.
Prominent lateral clitoral hood folds or labial remnants between the introitus and anus (Figures 1 and 2), proportional to large labia minora before surgery, may appear more unnatural after a simple labia minora reduction, regardless of the labiaplasty technique employed. Patient dissatisfaction and an augmented sense of genital embarrassment may occur.
Greater than 90% satisfaction rates
Accurate evaluation of anatomic issues, surgical planning, and technical execution are essential in achieving optimal aesthetic outcomes.
For labia minora reduction, reported patient satisfaction rates are remarkably high (greater than 90%) in published surveys involving various techniques.
It therefore appears that, when competently performed, most labiaplasty techniques result in high patient satisfaction rates and low complication rates.
Labia Minora Alteration - Labiaplasty
As previously stated, reduction of the labia minora is by far the most commonly requested female external genital cosmetic procedure.
Those seeking surgery, in my experience, have labia minora that, albeit large, fall within the normal minora size range.
Female genital cosmetic surgery is overwhelmingly sought for aesthetic reasons.
Although minor functional complaints (ie, irritation) are common, significant issues are rare. This experience mirrors the published findings of Crouch et al. They report that all women in their study had “normal-sized” labia, with the majority of complaints being related to genital appearance or minor discomfort issues.
The main indication for labiaplasty, therefore, is overwhelmingly the same as for other aesthetic procedures: patient preference.
Anatomic considerations
Labia minora size and shape show almost unlimited variations. Surgical procedures must be tailored to individual anatomy and preference.
- Labia thickness, pigmentation, and pigment variation, if present, must be considered.
- Clitoral hood redundancy, in either a vertical (hood too long) or horizontal (redundant lateral folds) dimension, should be addressed if present.
- Significant pigmentation
- Prominent lateral clitoral hood folds and redundant labial tissue posterior to the introitus, when present, should be excised
Labiaplasty Techniques
Wedge excision techniques, first described and popularized by Alter preserve labia edges and edge pigmentation.
As previously stated, this is often desirable in those women with significant pigmentation variation from the free minora margins inward. Wedge excision, if overzealously performed, can cause constriction of the introitus/vagina. Incision line dehiscence, usually a consequence of excess tension, can be problematic. When it occurs, repair is required to avoid notching of the labium with persisting deformity. Wedge excision techniques also frequently require modification to adequately address clitoral hood issues or other anatomic variations.18
Edge excision, with its many variations, was the first popularly reported labiaplasty technique.
- Its major advantage is its technical simplicity and adaptability to virtually any labial size or shape.
- Overzealous resection
- labial amputation: a disastrous outcome.
- Excision of the minora edges can result in unnatural-appearing labia in women with significant pigmentation variation.
- tender scars or scar contractures.
- Edge scalloping may also occur
Central deepithelialization or excision procedures are, in my opinion and practice, less commonly utilized than either edge excision or wedge resection techniques.19
- The major advantage, as with wedge resection, is the preservation, when desired, of the minora edge.
- The procedures have several shortcomings. They result in multiple incision lines (medial and lateral surfaces of the labia) and prolonged postoperative minora edema. Inclusion cyst formation, as a consequence on incomplete deepithelialization, can occur. Central deepithelialization can increase labia minora thickness, which, in my experience, is usually undesirable. Furthermore, it is difficult to make the minora as small as is possible with the other, aforementioned labiaplasty techniques.
Clitoral Hood Alteration
Clitoral hood redundancy, when present, may be in the horizontal or vertical planes, or both.
Horizontal excess, in the form of extra hood folds parallel and lateral to the central portion of the clitoral hood, is most commonly observed
Clitoral hood folds may be unilateral or bilateral, and result in a widened appearance. Multiple and/or asymmetric folds may be present. Vertical excess manifests as a ptotic, elongated clitoral hood.
When present, clitoral hood redundancy should be dealt with during labiaplasty.
Not doing so may yield unnatural-appearing genitalia.
In my experience, failure to address clitoral hood folds and redundant labial tissue posterior to the introitus are the most common motivators for labiaplasty revision.
Horizontal redundancy is treated by vertically-oriented excision of lateral clitoral hood folds. Excision is generally oriented parallel to the sulcus between the clitoral hood and the labia majora
Vertical hood excess is addressed by transverse excision of a portion of the hood, usually as an inverted V wedge, across its full width. Excision is usually done cephalic to the free margin of the hood
In case of very elongated hoods, significantly overhanging the clitoral glans, the hood may be conservatively shortened by excision at the free margin itself.
In no circumstance, in my opinion, should the clitoral glans be exposed (if covered) or further exposed (if partially covered). Doing either will result in an unpredictable, and perhaps undesirable, effect on clitoral sensation. In all cases, excision must be superficial.
Labia Majora Alteration
Puffy Labia Majora
Labia majora alteration is sought by women bothered by puffy, prominent majora at one extreme, and deflated, sagging majora at the other (Figure 8). Fatty fullness without skin redundancy may occasionally be effectively treated by liposuction. Improvement is usually modest. Small diameter cannulas (<3 mm) should be used, and superficial plane maintained. Prolonged postoperative edema is common.
Flat Deflated Labia Majora
Women with flat majora, or deflated majora with minimal skin excess, may seek augmentation. It is easily achieved utilizing standard autologous fat grafting techniques. Usually several grafting sessions are necessary to achieve the desired result. In general, no more than 20 cc of fat should be injected into each labium at one sitting.4 One must use caution in augmenting majora with significant skin redundancy, as an unacceptable degree of bulging and labial prominence may result.
Ptotic Labia Majora
Ptotic, deflated labia majora, in my opinion, are best treated by reduction rather than augmentation. Surgical excision of redundant majora, in my experience, yields consistently excellent results and high patient satisfaction. Although others suggest that excision should be from the central portion of the majora20 or laterally at the vulva-thigh crease,5 I disagree. I see no benefit in placing the resulting excision scar in the thigh crease or on the labia majora itself. I always resect the medial segment of the majora. The medial incision is in the sulcus between the minora and majora, with the lateral incision in the majora. Incisions are made along the full anterior-posterior length of the majora. Cresenteric excision of the redundant width of the majora is performed. The resulting scar, located within the interlabial sulcus, is virtually imperceptible.4,21 The extent of resection should be conservative to avoid pulling the introitus/vaginal orifice open. It is therefore determined with the patient supine in maximum frog leg position. Pinching of redundant majora, without tension on the introitus, is done. The lateral incision line is then marked. In my experience, up to 50% of the horizontal width of the majora may be safely excised in women with marked majora ptosis or redundancy (Figures 9 and 10). Resection should always be in a superficial plane: skin and subcutaneous tissue only. The labia majora are very vascular. Absolute hemostasis prior to closure is essential to avoid hematoma formation.
LABIA ALTERATION: PERIOPERATIVE CONSIDERATIONS
Although many recommend general anesthesia. I perform virtually all labiaplasty procedures, including combined majora and minora reductions, using local anesthesia, with mild oral sedation (10-20 mg of diazepam).
- Topical anesthetic ointment or cream is applied at the same time oral sedation is administered.
- Approximately half of women undergoing minora procedures will not experience injection pain if 45 minutes elapse between topical anesthetic application and injection.
- One dose of a cephalosporin oral antibiotic (or clindamycin for Beta-lactam allergic patients) is taken 2 hours preoperatively.
- In combined labiaplasty procedures, the majora should be done first. For labia minora edge excision techniques, use of a traction suture placed in the most prominent portion of the labium is helpful. Clitoral hood folds, if present, should be excised first, followed by minora excision.
- Labia majora excision defects are also closed in two layers: 4.0 Monocryl interrupted sutures for the deep dermis and 5.0 Prolene (Ethicon, Somerville NJ) continuous sutures for skin. The skin sutures are removed 1 week after surgery.
Aftercare is similar for both labia majora and minora procedures
Aftercare is similar for both labia majora and minora procedures:
- minimal ambulation, ice compacts, and narcotic analgesia for the first 2 days
- topical antibiotic ointment application and sanitary pads as dressing for 1 week.
- Daily tepid showers are permitted. Routine follow-up visits occur at 1 week, 2 weeks, 4 weeks, and 12 weeks.
- Vicryl Rapide sutures, if still present, are removed at 2 weeks.
- Vaginal penetration is not permitted for 4 weeks.
Complications
Labiaplasty procedures have low complication rates. Most complications are minor and self-limited.
- Hematoma and wound dehiscence are most commonly reported
- In a recent study of 113 women undergoing labiaplasty, only one (0.8%) experienced a complication (bleeding)
- Self-limited postoperative edema, bruising, and/or pain, resolving within 2 weeks of surgery, were reported in 13.3% of patients in that study.
- wound dehiscence rarely requires repair after labial edge excision, but usually must be corrected after wedge resection to avoid minora notch deformity.
- Underreduction of the minora, or
- postoperative labial asymmetry, may also occur.
- Lista et al2 reported a 3.5% revision rate for persisting labial excess. Unaddressed clitoral hood redundancy and labial remnants posterior to the introitus, as indicated earlier, may also motivate revision requests.
- Prolonged edema and inclusion cyst formation, as previously indicated, can complicate central deepithelialization technique procedures.
- Overzealous resection with partial or complete amputation of the labium, although rare, is perhaps the most dreaded complication observed.
- Labial edge scalloping, usually minor, can occur after edge excision techniques.
- Scar contractures, although reported, are very rare.
- Persisting postoperative dyspareunia is extremely rare.
Advantages and Disadvantages
Labia Minora Reduction Techniques: Advantages and Disadvantages
| Reduction Technique | Advantages | Disadvantages |
|---|---|---|
| Edge Excision |
|
|
| Wedge Excision |
|
|
| Central Excision/ Deepithelialization |
|
|
References
Ready For a Vaginal Rejuvenation? Contact Us Today!
For those wondering whether Vaginal Rejuvenation might be the best cosmetic solution for you, we invite you to simply come in for a complimentary consultation with Dr. Chang or one of the cosmetic laser and injection nurses to explore whether you would make a good candidate. To find out more about Vaginal Rejuvenation, contact us online or at 703-729-5553 to arrange an appointment. Dr. Phillip Chang is a board-certified plastic surgeon in Northern Virginia near Leesburg, Virginia and an expert in a wide variety of cosmetic treatments.
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