A Systematic Approach for Superb Labiaplasty Results: an invited article for Healio

Labiaplasty is one of the most popular aspects of my New York City plastic surgery private practice. While labiaplasty is a life-changing procedure with an extremely high degree of patient satisfaction, it is also a complex topic. This was an invited article for online physician magazine Healio.com about the ins and outs of labiaplasty. The intended audience is medically oriented, so some portions of this article are more technical. -Dr. Devgan

"Gray Line with Black, Blue & Yellow" by Georgia O'Keefe, 1923. Iconic female painter Georgia O'Keefe has a series of famous flower paintings that are thought to represent the female private parts and the power of femininity.

"Gray Line with Black, Blue & Yellow" by Georgia O'Keefe, 1923. Iconic female painter Georgia O'Keefe has a series of famous flower paintings that are thought to represent the female private parts and the power of femininity.

A Systematic Approach for Superb Labiaplasty Results

By Lara Devgan, MD, MPH

Labiaplasty, or cosmetic rejuvenation of the female genitalia, is the fastest growing plastic surgery procedure in America. The most recent set of statistics published by the Amercian Society of Plastic Surgeons reveals that the number of labiaplasties has nearly doubled over the past year, with a 44% increase as compared to the previous year. 

What is labiaplasty?

Labiaplasty is, in short, any plastic surgery procedure designed to improve the cosmetic appearance of the female private parts. Areas of concern include the labia minora, the labia majora, the clitoral hood, the perineum, the mons pubis, or any combination of the above.

The most common complaint for women in my practice is hypertrophy or excess tissue of the labia minora. This area can hang down and create uncomfortable and unsightly bulging in the genital region. Not only does this frequently make a woman feel self-conscious about her physical appearance, but it can also make exercise, sexual intercourse, or activities of daily living uncomfortable. In severe cases, women experience chafing, skin irritation, and rashes in the affected regions. Generally speaking, labia minora hypertrophy is something that a woman is born with, though it can certainly be exacerbated by hormonal changes or the trauma of childbirth. 

Another common concern is redundancy of tissue in the perineum. This is frequently related to injuries and tissue tears that occur during vaginal deliveries, including episiotomies.

As women age, they also experience atrophy of the labia majora. This creates a droopy or saggy appearance of the outer, more visible tissues of the female genitalia. Most women with atrophy of the labia majora are perimenopausal or postmenopausal, although it can also occur in women who have lost a significant amount of weight or who have poor tissue elasticity.

Mons pubis bulkiness is a less common complaint related to female genital rejuvenation. Puffiness in this an atomic region is generally associated with excess fat deposition in the area. It can also be seen in patients who have lost a significant amount of weight.

Prominence of the clitoral hood is a less common complaint related to cosmetic improvement of the female genitalia. Women who have clitoral hood hypertrophy have often been exposed to higher than typical amounts of testosterone or other male hormones, either during in utero growth, pubertal development, or later in life. 

How should a plastic surgeon analyze a labiaplasty patient?

A full history and physical examination are essential in evaluating a labiaplasty patient. This includes a detailed account of menarche, puberty, pregnancies, types of delivery, and menopause. It also includes a history of any exposure to hormones or hormonally mediated medications. 

Physical examination should include a systematic analysis of the labia majora, labia minora, clitoral hood, perineum, and mons pubis. It must also include an analysis of tissue type and quality. This includes assessing a patient's subcutaneous fat deposition as well as the elastic recoil of the skin and soft tissue. 

Preoperative photographs are important to document the patient's anatomical concerns. These are taken with the patient in both standing and frogleg positions. A gloved hand can be used to splay the tissues apart to document particular areas of concern, as needed.

What is the surgical approach to labiaplasty?

The surgical approach to labiaplasty is uniquely tailored to each individual patient depending on her anatomic concerns. 

Labia minora hypertrophy is addressed with labia minora reduction. Widely accepted techniques for labia minora reduction include wedge excision, straight-line edge excision, lazy S edge excision, and opposing W-plasties. 

The best technique for a given patient will depend on how prominent her labia minora tissues are, her degree of asymmetry, the pigmentary changes along her mucosal to skin border, and the desires of the patient and surgeon. In my practice, I frequently perform all of the above maneuvers, depending on the situation. It is important to seek a plastic surgeon with a high comfort level in each of these surgical approaches to ensure that you get the best technique for your concerns.

Excess tissue of the perineum as well as clitoral hood hypertrophy can both be addressed with conservative excision of redundant tissues. For clitoral hood hypertrophy, and excision of prominent tissue in the lateral clitoral hood region is planned. For perineal hypertrophy, excision of redundant tissue between the vagina and anus is planned, with care taken to avoid the muscle fibers that power the anal sphincter. 

Atrophy of the labia majora is best addressed with fat grafting or filler. A hyaluronic acid-based filler such as Juvederm, Restylane, or Voluma can be used to augment the labia majora in a minimally invasive manner. While filler has the advantage of no surgery and minimal downtime, it has the disadvantage of being a semipermanent solution that needs to be repeated every 4 to 6 months. 

Fat grafting is far more durable and is a preferred technique in the majority of patients. When fat grafting the labia majora, I harvest liposuctioned fat from the lower abdomen, spin it in a centrifuge to obtain the highest quality fat particles, and reinject it in a precise and controlled manner. 

The mons pubis can be addressed with either liposuction to debulk excess fatty tissue or a pexy procedure to resuspend a drooping mons pubis. The procedure of choice here is dependent on the plastic surgeon's analysis of the patient's anatomic issue.

Technical considerations 

Cosmetic surgery for female genital rejuvenation should only be performed by an experienced plastic surgeon who is comfortable with the anatomical areas in question.

In my practice, I find that accurate preoperative marking is essential. The should be done before injection of any local anesthetic agent, as local anesthesia will distort the patient's tissues and alter the planned incisions. 

Many of these procedures can be done with the patient wide-awake under local anesthesia only. However, I frequently use IV sedation performed by a board-certified anesthesiologist to increase patient peace of mind. The use of a pudendal nerve block is helpful ensuring the patient's intraoperative and postoperative comfort.

I routinely use a dose of preoperative antibiotics and frogleg positioning for these cases. Traction sutures, Colorado tip Bovie electrocautery, and meticulous hemostasis are also mainstays of my surgical approach for labiaplasty procedures.

For alterations of the genital mucosal tissue, I prefer to close in layers with 4-0 Vicryl and 5-0 chromic sutures. A gentle compressive dressing such as mesh panties with padding and an ice pack will limit postoperative inflammation and hasten recovery.

Pitfalls and complications

When done properly, the complication rate for labiaplasty procedures is extremely low.

A plastic surgeon must be mindful of pigmentary changes so as not to distort the "pink-white" or "pink-brown" junction between mucosa and skin. One must also take care to avoid vertically shortening the clitoral hood, as this can cause too much exposure of the clitoris and make sexual intercourse uncomfortable. 

Complications of labiaplasty include wound dehiscence, hematoma, discomfort with sexual intercourse or other activities, clitoral exposure, and scar tenderness. A patient who experiences any of these complications should be seen frequently in the postoperative period and referred to a more experienced plastic surgeon as needed.

Postoperative care and recovery

Many patients feel comfortable enough to return to work within 1 to 3 days after labiaplasty surgery. That being said, I recommend that all of my patients take one full week off of work commitments in the event that they are uncomfortable. 

Postoperative care includes pelvic elevation, frequent icing to minimize inflammation, use of bacitracin ointment and maxipads as needed, and avoidance of strenuous exercise or physical activity for 2 to 4 weeks.

Patients are permitted to shower the day following surgery, however the are advised not to soak in a bathtub or pool for at least 2 to 4 weeks. I also ask patients to refrain from sexual intercourse and use of tampons for one month.

Looking forward

Labiaplasty is expected to continue to rise in popularity as misconceptions about the procedure are cleared up and public awareness of the procedure grows. In the past several decades, there were certainly taboos associated with women thinking about or talking about rejuvenation of their private parts. However, as society becomes more progressive, feminism becomes more entrenched, and social standards become more accepting, increasing focus will be paid to this important area. 

Anatomy of the female genitalia, image credit Frank Netter, Netter's Anatomy

Anatomy of the female genitalia, image credit Frank Netter, Netter's Anatomy

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