Labiaplasty

Labiaplasty covers reduction procedures to both the labia minora and majora. The popularity of the labia minora procedure has increased dramatically once 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%. The motivations for this procedure can vary widely, including symptoms with clothing or intimacy, visibility of the vulva with today’s fashions, including exposure. Regardless of motivation, the primary indication continues to be driven by patient choice as Hamori in 2007 concluded that males do not really care about the visuals of the vulva. This procedure technically should not be expected to improve sexual function though it can certainly make one 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. In addition, there could be dryness, tightness, painful intercourse and persistent asymmetry. Overresection is the most problematic as reconstruction options are limited.  

This procedure requires a strict post-op protocol and a compliant patient as there should be no penetration activities for 6 weeks. The procedures are technically straightforward and can easily be done under local anesthesia in the complete privacy of your office where buffered Xylocaine with epinephrine is used and tolerated quite well. Others may prefer to do this in the operating room under anesthesia but all this does is increase the costs to the patient. Photographic documentation before and after is invaluable in helping patients appreciate what benefits have been achieved. In addition, 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 from surgeon to surgeon and on geography, ranging from $2000 to well over $6000.

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, if there is any excess that can be removed, a labiaplasty can be done. Ancillary procedures such as clitoral hood reduction need to be considered when planning a labiaplasty minora reduction as unaddressed hood redundancies can result in unsightly bumps and bulges. Labia majora reductions or filling can also be considered if the patient is bothered by her perceived deficiencies or excesses as well. There are two reliable methods for reducing labia minora, the trim (aka edge) method reported by Hodgkinson and the wedge method pioneered by Alter. Technique selection should be based on the anatomy, patient goals, and patient preferences. 

The trim technique involves excising excess labia along its edge maintaining at least a 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 are 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 I 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 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. And 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 or notching of the edge that would require a revision as well as inclusion cysts. Variations of wedges have been described where extensions of the resection is directed superior along the prepuce to address lateral hood redundancies at the same time.

Other variations of the above techniques as well as de-epithelialization and pedicle flap methods have been described but in my experience, fail 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 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. Patients are often 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 for that. Post-operative restrictions include no penetration sex for at least six weeks, avoidance of any pressures on the suture lines and of 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 always be considered once full healing has occurred with the prevailing opinions for complete healing being 6 months from surgery. Patient's opinions of the outcomes should be respected and if something is fixable, patients should be offered the opportunity to have a revision done, with my most common complaint being 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.