History
Patient history can be related to the psychological impact that the appearance of the labia has had on the individual's life. Many patients have had concerns with this area since the time of puberty. There is some evidence that the Internet has played a part in stirring feelings of anatomic inadequacy. However, in the author's practice, many patients are not looking for the ideal genital appearance and are more concerned with the extent to which the excess tissue hangs lower than the outer labial lips.
BDD is an important aspect of assessment during the consultation for any number of cosmetic procedures. It is something that is essential to pick up on; otherwise, the unwary surgeon will be left with an unhappy patient, an inability to achieve the desired results, and an overriding feeling of potential conflict at each encounter.
The factors to keep in mind with respect to patients with BDD is a preoccupation for more than an hour a day and an inability for patients to distract themselves from potential or perceived flaws in the area in question. It is necessary to consider whether the patient is manifesting obsessive-compulsive–type behavior rather than BDD. Another red flag to note during the consultation is a lack of listening to and acknowledgement of what is being said. Many patients will listen but then revert back to their initial concern. If they highlight that this is affecting their everyday life and that they cannot function appropriately due to the problem, this should trigger alarm bells that other concerns are more imperative to discuss than contemplation of the surgical procedure. The concern may be over one specific area in question or a whole host of areas.
Patient history may also reflect nonaesthetic concerns, such as discomfort during exercise or intercourse, catching of the labia on certain clothing, and the occurrence of frequent infections, such as urinary tract infections and thrush.
Patients who are multiparous, athletes, premenopausal, or postmenopausal should be questioned about symptoms of vaginal looseness and stress urinary incontinence.
Physical Examination
The physical examination is a very sensitive topic and can be quite embarrassing for the patient. Many individuals become quite emotional in association with the exam, as this may well be the first time that they are showing the labial area to someone else. A chaperone must be present to help provide support for the patient and for the protection of the clinician/surgeon conducting the examination.
The examination involves assessing the overall appearance of the area and highlighting any obvious asymmetry and any abnormalities seen. The author commonly uses a mirror to engage the patient in the examination. In this way, the physician can highlight each of the labial parts to the patient and have the individual help to identify what she perceives to be the problem or concern.
The clitoral hood and labia majora should also be examined and discussed. An excessive clitoral hood that is not addressed during the surgery can result in a less-than-optimum postoperative result and subsequent surgery to manage the issue.
On assessing the clitoris, documentation should include whether sensation is felt, whether the clitoris is very sensitive, whether sensitivity is localized to the clitoris or extends to the frenulum or surrounding hood, and which area of the clitoris is most sensitive. In addition, the patient should be advised that although the ability to orgasm is seldom affected, the location of greatest sensitivity may change. This is mainly related to initial swelling and stretch of the area and to the subsequent positional change that may result from a clitoral hood reduction.
The labia majora should be examined as well, to determine whether any treatment is required here. Management includes excision and lifting of the labia majora, using hyaluronic acid/fat to fill the area and make it more voluminous, and employing resurfacing techniques to aid in the rejuvenation of the labia majora skin. This last can be carried out using various nonsurgical procedures, such as CO2 laser or radiofrequency treatments.
A routine vaginal examination with speculum is carried out to ensure that no other issues exist and to provide the clinician with a complete baseline preoperative assessment. This will also be useful in patients who are concerned with a feeling of looseness within the vagina. In addition, the patient should be examined for stress urinary incontinence.
Photographs are essential and should be taken before and after surgery, as well as at each follow-up appointment.
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Severe labia minora hypertrophy. The labia minora extends 4 cm beyond the labia majora, which can cause pain with clothing and exercise.
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Moderate labia hypertrophy. A moderate labia hypertrophy before resection (left) and intraoperative results after resection (right).
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Labia hypertrophy, anterior view. (Left) Heavy labia majora and a prominent clitoral hood, but no excess minora showing. (Right) Labia minora hypertrophy, with minimal majora showing.
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Increased labia majora due to ptosis, which can interfere with daily activities such as exercise and increase insecurities when wearing tight clothing.
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Anatomical diagram of the vulva. The typical external female genitalia include the labia majora, labia minora, clitoris, clitoral hood, mons pubis, labial commissure, urethra opening, and vaginal opening. Collectively, the external female genitalia are referred to as the vulva. Female genital plastic surgery can be performed on the labia minora, labia majora, mons pubis, vagina, and clitoral hood. The labia minora are 2 mucocutaneous folds that lie between the labia majora and surround the opening to the vagina and urethra. The labial folds extend from the rectum to the mons pubis. The labia minora extend anterior to the clitoral hood.
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This unilateral hypertrophy of the left labia minora can be addressed with the labiaplasty amputation technique.
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Diagram of amputation technique.
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Wedge excision results. Before (left) and 3 months after (right) a wedge excision labiaplasty for moderate labia hypertrophy, allowing for preservation of the natural edge.
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Central wedge technique.
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Anterior wedge technique with labial crease extension.
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Anterior wedge technique. (Left) The dog ear is extended into the labial crease. (Center) The labia is approximated centrally. (Right) The dog ear is closed anteriorly.
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Posterior wedge technique.
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Deepithelialization technique.
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Central deepithelialization technique. The patterns drawn out on the mucosa and skin sides of the labia illustrate the central deepithelialization technique. The tristar excision as a deepithelialization maximizes nerve and vascular supply to the edge while minimizing dog-ears.
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Clitoral unhooding Y-to-V technique.
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Labia majora reduction technique with ellipse wedge.
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Labiaplasty results. Before (left) and 1 year after (right) a successful labiaplasty with wedge technique, labia majora reduction, clitoral unhooding, and posterior fornix release. If desired by the patient, the amputation technique can be used on the left labia minora to enhance the results and create color symmetry.
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Smoking predisposes patients to dehiscence. This labia minora reduction patient (left) was a smoker. She smoked during the 2 preoperative and postoperative weeks, causing dehiscence to the left labial crease (center). The dehiscence had no long-term complications on the result (right).
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A transverse section through the clitoral body. The cross section is similar to that of the penis.
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Labiaplasty resection markings.
Tables
| Complication | Association |
|---|---|
| Wound dehiscence | The highest percentage of wound dehiscence was seen in inferior wedge resection with a superior pedicle flap reconstruction. |
| Hematoma | This was most commonly associated with Z-plasty. |
| Postoperative bleeding | This was not associated with any specific techniques per se. Hematomas were more commonly associated with Z-plasties |
| Urinary retention | This was mainly associated with general anesthetic cases and not specifically related to the technique used. However, careful infiltration of the local anesthetic is required, as there can be some blockage of the surrounding nerves, which can lead to a degree of urinary retention |
