Labiaplasty and Labia Minora Reduction 

Updated: Feb 25, 2022
Author: Rohit Seth, MD, PhD, MRCS(Edin); Chief Editor: Jorge I de la Torre, MD, FACS 

Overview

Background

Female genital cosmetic surgery (FGCS) is a growing field of plastic surgery that involves a variety of procedures designed to enhance or rejuvenate the female genitalia. This branch of cosmetic surgery includes monsplasty, vaginoplasty, hymenoplasty, labiaplasty, G-spot augmentation, clitoral hood reduction and/or lift, frenuloplasty, perineoplasty, fat injections, and combinations of these procedures.[1, 2, 3, 4]

Severe labia minora hypertrophy. The labia minora Severe labia minora hypertrophy. The labia minora extends 4 cm beyond the labia majora, which can cause pain with clothing and exercise.

A study carried out in 2015 by Oranges et al assessed labia minora excision techniques and identified eight labiaplasty techniques: edge resection, wedge resection, deepithelialization, W-plasty, laser labiaplasty, custom flask, fenestration, and composite reduction. Good outcomes resulted from all of these procedures, with findings of high patient satisfaction and low morbidity.[5]

There are several reasons why a patient may desire FGCS, including functional and aesthetic concerns.[6] Severe labia minora hypertrophy may cause pain when wearing underwear, riding a bicycle, exercising, or having sexual intercourse.[1] Patients have reported insecurities about appearance with a sexual partner or while wearing tight-fitting clothing, such as bathing suits.[7] In the same manner that children report being teased about physical features, numerous slang terms are associated with excess labial tissue; these are often psychologically damaging and increase social anxiety. Other common concerns are related to hygiene or infection.

In addition, there is a belief that trends in pubic hair grooming have led to increased visibility of and greater focus on the labia, while images of female genitalia have increased in the media and on the Internet, including video or photographic pornography.

Labia hypertrophy, anterior view. (Left) Heavy lab 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.

According to a 2000 study of 163 labia minora reductions, 87% of patients had labiaplasty surgery for aesthetic reasons, while 64% desired surgery because of discomfort in everyday clothing.[8] In the same study, 85% had bilateral labiaplasty, compared with 15% who had asymmetrical hypertrophy of the labia minora requiring a unilateral procedure.[8]

Labia minora reductions are more common than labia majora reductions or augmentations, although both are a growing field in plastic surgery.[2, 9] The goal of these procedures is to eliminate functional problems and to create labia that are aesthetically appealing. Labiaplasty surgeries can have substantial psychological benefits for patients who are self-conscious about the appearance of their genitalia. Patients with severe cases of labial hypertrophy frequently report decreased pain or discomfort with daily activity and sexual intercourse after the procedure.

History of the Procedure

Hypertrophy, or overgrowth, of the labia was historically viewed as an inconsequential variation of the normal labia. Over time, however, there has been increasing acknowledgement and understanding of the aesthetic and functional concerns of patients with large labia.[10]

The first description of aesthetic labiaplasty was published in 1983.[11] At that time, the only technique used to reduce the labia minora was the “trim method.”[12] In the 1990s, alternative labiaplasty techniques were developed,[12, 13] including the “wedge technique” described by Dr. Gary Alter in 1998.[12] Labiaplasty has been growing in popularity over the past several years. According to statistics from the American Society for Aesthetic Plastic Surgery (ASAPS), a 23% increase in labiaplasty was reported from 2015 to 2016 among ASAPS members.[14]

This underscores the progressive social acceptance of the procedure, as well as the need for safe and effective labiaplasty techniques. Current techniques for labiaplasty can be divided into the following:

  • Amputation techniques that involve a linear trimming of the labia minora
  • A wedge technique that excises tissue along the lower edge towards the labia majora crease
  • A central labial excision as a deepithelialization that preserves the natural free edge

Relevant Anatomy

The nerve sensation to the external genitalia arises from the pudendal nerve. The nerve traverses and subsequently splits at the superficial transverse perineal muscle into the superficial and deep perineal nerves. The superficial branch progresses to become the posterior labial nerve, and the deep branch becomes the dorsal nerve of the clitoris.

The anatomy of the clitoral hood has received a somewhat variable description in the literature. Anatomists refer to this as being the free edge of the prepuce. Many aesthetic surgeons, however, consider the clitoral hood to incorporate the skin superior to the free edge, extending to the anterior labial commissure and laterally including the prepuce. The frenulum inferiorly extends upwards to the clitoris and inferolaterally to the labia minora. This is an important landmark to mark out and identify, as clitoral hood deformity can result if it is not addressed adequately. The extent of the hood is variable in patients and will be determined by the overall size of the clitoris itself, the thickness being dependent on the underlying subcutaneous tissue.

Diagrams of vulvar and clitoral anatomy are shown below.

Anatomical diagram of the vulva. The typical exter 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.
A transverse section through the clitoral body. Th A transverse section through the clitoral body. The cross section is similar to that of the penis.

Problem

Labial hypertrophy is the increased growth of either the labia minora in relation to the labia majora or vice versa. Although labial hypertrophy is not yet strictly defined as a pathologic condition, patients who have aesthetic or functional concerns may benefit from labial reductions.[8]  A key consideration is determination of the nature of the patient's concerns. Is the concern related to the patient's own wish or that of a partner? How long has this been a concern for the patient? 

Significant hypertrophy of the labia can cause pain, irritation, and discomfort with clothing. Moreover, the psychological problem of not feeling “normal” in comparison with the perceived anatomic ideal must not be underestimated.[2]  It is quite important to ensure that the patient understands that although she may not feel normal, her anatomy is normal. Specifically, while the labia may be enlarged or asymmetrical, this does not make it abnormal, as there many variations in labial anatomy.

Epidemiology

Frequency

Labiaplasty surgeries are expected to continue rising in frequency as the techniques and procedures become more defined. Popularity of the procedure is also expected to grow as knowledge of the benefits increase. As previously stated, statistics from the ASAPS revealed a 23% increase in labiaplasty from 2015 to 2016 among the society's members.[14]

It is also proposed that increases in hair removal or changing hair patterns have affected the frequency of labiaplasty surgeries.[2, 9] A 2009 study analyzing the media’s influence on FGCS showed that 84% of younger women remove pubic hair, compared with only 36% of older women. Of all women who removed pubic hair, only 50% were happy with the appearance of their labia.[15]

Etiology

The exact cause of hypertrophy of the labia minora is unknown, but a multifactorial etiology is purposed.[16] Genetic factors and hormones can lead to hypertrophy of the labia early in life, while mechanical irritation from bicycling, sexual intercourse, genital piercing, horseback riding, and other factors can cause hypertrophy in later years.[16]  Infection is also associated with the condition.

Pregnancy and weight gain can increase the fat accumulation and ptosis of female genitalia, predominantly the labia majora.[1] Therefore, after childbirth or significant weight loss, a patient may desire to have the wrinkled appearance or increased size of her labia addressed. Also during pregnancy, pressure can increase and a feeling of heaviness ensue as a result of increased blood flow to the genital region.[17] On the other hand, a significant association between labial hypertrophy and multiparity has not been shown.[5]

In addition, weight loss and changes in the appearance of the labia majora can accentuate the size of the labia minora.

Pathophysiology

The medical community has not defined a singular grading system for hypertrophy of the labia. Past surgeons have defined hypertrophy of the labia minora as ranging from 3-5 cm.[10, 8, 7] In 1983, hypertrophy was defined as 5 cm, while in current practice, labia minora longer than 3-4 cm are considered hypertrophic.[9]

In 2013, Chang et al suggested the following simplified classification system to measure labial hypertrophy[7] :

  • Class 1 - Equal minora and majora
  • Class 2 - Minora extending beyond the majora
  • Class 3 - Hypertrophy involving the clitoral hood
  • Class 4 - Hypertrophy of the minora extending to the perineum

The following grading system, by Davison and West, to objectively measure labia minora hypertrophy has been used clinically[18] :

  • None - The labia minora extends no farther than the labia majora
  • Mild/moderate - The labia minora extends 1-4 cm beyond the labia major (see the image below)
  • Severe - The labia minora extends more than 4 cm beyond the labia majora
Moderate labia hypertrophy. A moderate labia hyper Moderate labia hypertrophy. A moderate labia hypertrophy before resection (left) and intraoperative results after resection (right).

Banwell classified labia minora morphologically as follows, "according to the distance from the most lateral prominence of the labium minus to the vaginal introitus"[19, 20] :

  • Type 1 - Upper third prominence
  • Type 2 - Middle third prominence
  • Type 3 - Lower third prominence 

According to the Motakef classification, labial protrusions are placed into class 1 (0 - 2 cm), class 2 (2-4 cm), or class 3 (>4 cm).[19, 20]

Presentation

There are several thoughts and opinions as to why the request for genital cosmetic surgery has seen a huge upward trend. Initially, many indicators pointed towards a desire for a standardized appearance that is essentially prepubescent and is sometimes referred to as the “Barbie" look. This gives the appearance of the vaginal opening being quite tight and the labia minora narrow.[21] In the author's practice, this has been far from the truth. The majority of patients that are consulted have felt that this was something that bothered them throughout puberty, with the problem having more to do with excess skin and less of the tucked-in look that the majority prefer. Almost every patient asks for a "normal-looking" labia. This is something very important to discuss. The author spends a considerable amount of time showing before and after pictures and highlighting the fact that there is no true “normal” labial appearance but that there is instead a great amount of variation.

The idea that genital appearance is culturally dependent and affected by the development of Internet pornography is also considered to be linked to patient requests for surgery. However, not one patient that the author has seen has wanted a labial procedure due to what the individual had viewed online. Nonetheless, in some cases, when the patient's partner has mentioned appearance, the comment is likely associated with perceptions that the partner formed from seeing pornographic images.

Indications

The primary indicators for labiaplasty are as follows:

  • Hypertrophy of the labia minora with aesthetic or functional impairment
  • Labial asymmetry

Patients who report functional and/or aesthetic concerns about hypertrophic labia may be considered candidates for surgery. However, individuals who focus on pain or sexual inadequacy as reasons for the procedure may need more preoperative assessment, including a psychological evaluation, prior to undergoing labiaplasty. For example, many patients have discomfort during intercourse due to the labial lips being caught, but other possible causes of dyspareunia need to be investigated as well. Moreover, concerns over sexual inadequacy may not be improved through surgery.

Patients who experience pain while exercising, especially with repeated trauma, may also be good candidates for the operation (see image below). The grading systems described in Pathophysiology should be used as a guide but not as an absolute indication for surgical candidacy.

Increased labia majora due to ptosis, which can in Increased labia majora due to ptosis, which can interfere with daily activities such as exercise and increase insecurities when wearing tight clothing.

Contraindications

Absolute contraindications

There are no absolute contraindications to labiaplasty. Any patient who is in good health and has symptomatic or aesthetic concerns should be properly evaluated. If the consulting surgeon believes that a surgical intervention can alleviate the symptom or improve the appearance, then an operation is reasonable.

Not all physicians consider young age to be a contraindication for labia minora reduction. Some patients have been operated on during adolescence or even before (age 10 years).[9, 22, 23]  The author disagrees with surgery in these cases, however, because in many patients the labia can continue to develop beyond puberty into early adulthood. The author's own preference is to defer surgery until a minimum age of 18 years. This will ensure that the patient has completed development and can give consent for the procedure herself.

Surgery on a pregnant patient should also ideally be deferred, and patients should be educated with regard to the way in which the labial area will change during pregnancy. The labia can enlarge due to pregnancy-related hormones, and they can darken, stretch, and even tear during delivery. Therefore, it is more reasonable to suggest surgery following completion of the family.

Although menstruation is not a direct contraindication, surgery may be avoided while the patient is menstruating. The local anesthetic is generally more uncomfortable, and patients find the experience far more distressing, during this time. However, the author has carried out surgery in patients who have been menstruating and found no issues with wound dehiscence, wound infection, or heightened pain during the procedure.

It is important to distinguish elective female genital surgery, such as labiaplasty, from genital mutilation. Female genital mutilation (FGM) is practiced in a variety of cultures and involves young women and girls who have procedures performed on the vulva against their will. Whether or not a person agrees with the performance of labiaplasty is of the greatest importance in determining if a patient is seeking out and consenting to the procedure of her own volition. Surgery is never performed at the request or under the duress of an individual other than the patient. 

The World Health Organization (WHO) highlights these facts regarding FGM[24] :

  • In FGM, the external female genitalia is partially or totally removed or other injury is visited upon the female genital organs, for nonmedical reasons
  • No health benefits are derived for girls or women from FGM
  • FGM can cause severe bleeding and problems with urination, along with cysts, infections, and complications in childbirth, with increased risk for newborn deaths
  • More than 200 million girls and women alive today have undergone FGM in 30 countries in Africa, the Middle East, and Asia, where the practice is concentrated
  • Girls between infancy and age 15 years are the most frequent targets of FGM
  • FGM represents a human rights violation
  • WHO opposes FGM in all of its forms and opposes performance of FGM by healthcare providers (medicalization of FGM)
  • In 27 high-prevalence countries, the cost of treating the health complications of FGM comes to $1.4 billion (USD) annually

Relative contraindications

Minimal relative contraindications to labiaplasty exist. Patients with gynecologic disease are not good candidates for the surgery. As with most operations, patients who smoke increase their risk for poor healing, particularly raising the chance of wound dehiscence.[8] Other factors that contribute to increased risk of wound dehiscence, such as collagen disorders, should be considered when planning for labiaplasty. 

Patients need to be counseled with regard to body dysmorphia disorder (BDD), and most importantly, a patient must have realistic expectations prior to surgery and be advised appropriately. There is a general consensus that BDD should be considered a contraindication to cosmetic treatments. Clinicians should use a multidisciplinary approach in the management of patients seeking labiaplasty, including cooperation among specialists in psychiatry, cosmetic surgery, family practice, and other specialties. This will ensure the best outcome for the patient.

Patient Education

Patient education is one of the most important aspects of the surgical consultation. The author routinely gives out before-care and aftercare instructions to the patient, which highlight the procedure itself, as well as risks and complications and frequently asked questions. The information below is based on the author's personal information pack.

Why do patients request this procedure?

The vaginal opening is flanked by the labia majora (the outer labia) and the labia minora (the inner labia). In some individuals, the labia minora may hang down, or "stick out"; this can become bothersome during exercise or when using cosmetics or may lead to an increased frequency of infections and to issues with sexual intercourse. A labiaplasty helps to correct these issues by surgically reducing the labia minora so that they do not hang below the labia majora. This operation may be performed under local anesthesia, under local anesthetic with oral sedation, or with general anesthesia, while the minora are artistically trimmed and sutured. 

The author’s own practice primarily involves local anesthetic cases; he routinely performs labiaplasties alone or in combination with labia majora and clitoral hood reduction, with no detriment to patients' outcomes or results.

Am I an ideal candidate for a labiaplasty?

The ideal candidate for a labiaplasty is a female older than age 18 years with excess labia minora who seeks minora reduction due to physical or emotional complaints. The patient needs to be fully informed and of sound judgment prior to proceeding with this operation.

Frequently asked questions

These include the following:

  1. Will I have a scar? Any time an incision is placed, a scar will form. The incisions normally heal very well and are hidden. The scar will initially appear red and raised, but as it progresses through scar maturation, it will eventually become pale. This process takes around 6-9 months. The surgical technique used will also determine how visible the scar will be. 
  2. Is the surgery painful? This is a difficult question to answer. Pain symptoms are related to the area of surgery and also to the patient's own ability to address the pain. Some patients have a very high pain tolerance and do not find the surgery very uncomfortable. Others find the surgery quite painful. Painkillers should be given following the surgery and are advised for a minimum of 48 hours regularly postoperatively. Thereafter, continuation of painkillers depends on the patient's tolerance for pain.
  3. Will sutures need to be removed after surgery? Most surgeons use absorbable stitches. These will usually dissolve over the course of 1 week. Sutures usually do not need to be removed after the surgery.
  4. When can I resume intercourse/sexual activity? It is best to avoid sexual activity (intercourse/masturbation) for at least 4 weeks. This will give the area time to heal. Any aggressive manipulation/stimulation during this time can result in wounds breaking down and can possibly lead to infection.
  5. How long will I be swollen? Swelling will persist for 2 weeks or longer. This is because the region of surgery is such that the swelling is working against gravity. 
  6. How long will I be out of work? Individuals can normally return to work in 1-2 weeks. This depends on the type of work that the individual performs. Most desk-related jobs are easier to return to. 
  7. How long before I can exercise?  The author suggests avoiding strenuous exercise for the first 2 weeks, with no heavy lifting or bending. However, the author does suggest walking around; otherwise, there is a tendency not to move, and in the author's experience, the majority of patients who have had a difficult postoperative recovery have been those who did very little in the immediate postoperative period. Regular, short walks around the house are suggested. This will help to reduce the swelling and consequently decrease pain in the area. Following this, very light exercise can be performed from 2-4 weeks. After 4 weeks, patients can resume physical and sexual activity. By 6 weeks, most patients are back to their normal routine.
  8. When can I shower? The author asks patients to shower the next day. There are various regimens given; the author prefers that patients wash the surgical area but without the soap directly contacting the incision line. Cleaning the area reduces the chance of infection. It also removes the dried blood and generally helps patients to feel more comfortable. However, there most be no submersion in a bath or swimming for a minimum of 2 weeks, to allow the superficial wound to heal.
  9. When can I drive a car? This depends on a number of factors. If patients are taking strong painkillers, then it is suggested that they avoid driving until they have stopped the medication. Patients also need to be able to perform an emergency stop. This may be quite difficult during the first week following surgery. The author also highlights to patients that although they may feel well enough to drive, their car insurance may be nullified if they drive on the day of surgery, and so they should check to see what their insurance policy states.  
  10. Can I become pregnant afterwards? This surgery will not affect the ability to become pregnant.
  11. How long does the operation take? This varies from patient to patient. However, the operation normally takes 1 hour to complete, although this depends on whether the procedure is combined with labia majora and/or clitoral hood reduction.
  12. Does someone have to stay with me after surgery? The author always advises that patients have someone with them following the surgery to help them get home and also to have someone stay with them. Most patients tolerate the operation without any problems, but due to the location of the surgery, individuals can be quite uncomfortable and therefore may require help with everyday activities for the first week.
 

Presentation

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.

 

Workup

Laboratory Studies

Routine preoperative laboratory studies are necessary to evaluate patients for appropriate health status if the procedure is being performed under a general anesthetic. When local anesthetic is used, if the history does not dictate it, baseline blood tests are seldom required.

Imaging Studies

Routine imaging, such as a chest radiography, is conducted when indicated for those patients receiving general anesthesia. Ultrasonographic examinations may be performed on patients with a Bartholin cyst or unilateral hypertrophy of the labia majora.

However, the author carries out all the procedures under local anesthetic; therefore, a full workup is not required for the majority of patients.

Diagnostic Procedures

Labia hypertrophy is a clinical diagnosis, which means that no diagnostic procedures are necessary. Patients with symptoms of infection, rash, or labial lesions require a gynecologic evaluation.

Histologic Findings

Surgical specimens are not typically sent for pathologic study unless a mass or suspicious lesion is identified during surgery.

Other Tests

There are no routine tests for labial hypertrophy unless the need for testing is indicated by findings in the history or examination.

 

Treatment

Approach Considerations

The chosen approach is generally related to the skill set of the surgeon and to what will best suit the patient. The author does not use a specific technique but instead applies whichever procedure will best address the patient's primary concern. 

Medical Therapy

No medical management is available for labial hypertrophy. However, there are cases in which skin tightening of the labia can be achieved through radiofrequency or CO2 laser resurfacing techniques. These are beyond the scope of this topic but can give excellent results if used in combination with surgical procedures or as standalone therapies in cases where this treatment would suffice.

Surgical Therapy

Labiaplasty surgery can be successfully performed under local anesthesia, sedation, or general anesthesia. The author prefers to use local anesthesia for three main reasons. First, at critical points in the surgery, the awake patient can be involved in determining the amount of resection. This improves patient satisfaction and decreases the need for revisions. Second, local anesthesia reduces the need for someone to care for the patient after this sensitive procedure. Third, there is a significant cost reduction without anesthesia fees, making this price-point–sensitive procedure accessible to more individuals.

Surgical site preparation and draping are standard. Povidone-iodine solution (Betadine) is minimally reactive and very effective.

There are several methods of analgesia for labiaplasty. The author injects at the top of the hood initially and creates a small bleb. He then inserts a cannula from there, with extension along the length of the base of the labia to provide a regional block. Following this, a 30-gauge needle is used to inject into the labia/clitoral hood as required, after checking for any areas that are still sensate. The solution of local anesthetic consists of Xylocaine 2% 5 mL and Marcaine 0.5% 5 mL, with 1 mL of bicarbonate 8.4%. The author finds that this solution reduces the sting of the anesthetic. Usually, for labia majora reduction, the author uses around 2.5 mL of the above mixture per side. For the clitoral hood, 1- 1.5 mL per side is used, and for the labia, anywhere from 2-4 mL per side. The author found that the use of topical anesthetic did not make much difference with regard to pain.

Local anesthesia with lidocaine should also be used during general or sedation anesthesia for added vasoconstriction and postoperative pain control.

As postoperative bleeding is a risk, hand-held thermocautery or electrocautery coagulation is highly recommended to reduce bleeding risk from resected mucosal edges.

Postoperative pain occasionally requires moderate narcotics such as hydrocodone or acetaminophen with codeine. In the United Kingdom, paracetamol and codeine phosphate are suggested pain relief.

Amputation technique

The amputation technique (see images below) is also referred to as the trim/strip method, “clip and snip,” or linear labiaplasty. This modality is the simplest of the labial reduction surgeries and is often preferred when the hypertrophy is localized.[25] The excess skin on the labia minora is amputated, and the new, open edge is sutured closed. A proposed benefit of this technique is pinker labial edges that lie within the labia majora folds;[7]  some may consider this detrimental, however. The amputation technique is limited in that it greatly alters the natural appearance of the labia minora.[12] This surgery also presents a risk for nerve end interruption and results in the loss of the pigmented skin/mucosal margin and the natural edge of the labia minora.

This unilateral hypertrophy of the left labia mino This unilateral hypertrophy of the left labia minora can be addressed with the labiaplasty amputation technique.

The level of labial skin to be removed will determine the overall result. The removal of only the labial edge will produce a rim look, removal of most of the labia minora at or below the level of the labia majora will result in what is referred to as a hybrid look, and removal of almost all of the labia will result in a "Barbie" look.

In marking the area to be operated on, the author usually marks in accordance with the amount of tissue removal requested by the patient. A photograph is taken to highlight what will be removed, and this is shown to the patient to again confirm the amount of tissue that the patient would like to have resected. The author errs on the side of conservative markings to reduce the risk of overresection. The author also marks the medial labia minora tissue lower than the lateral, thereby enabling the scar to be hidden medially, once healed.

Labiaplasty resection markings. Labiaplasty resection markings.

Wedge technique

The greatest evolution in labiaplasty involves the wedge technique (see the image below). In this operation, a portion of the labial edge is excised, and the “dog-ear” excision is carried into natural creases of the labial folds. The three types of wedges are anterior, central, and posterior. These techniques maintain the natural mucosa and skin edge, preserve tumescence and sensation, and maximize the aesthetic results.[26] Common features are often deepithelialization of the wedge, leaving the submucosal lymphatics and nerves intact. A reported disadvantage of this technique is the potential damage to nerves along the edge of the removed wedge.[7, 27]

Wedge excision results. Before (left) and 3 months 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.

Central wedge

There are 3 described techniques for excising a central wedge (see image below). The first technique involves a deepithelialization of the central wedge and preserving the underlying submucosa.[10] A second technique involves a full-thickness resection of a V-shaped wedge of excess labial tissue.[7, 9] This resection maintains the natural edge and minimizes the scar. The third approach is the 90° Z-plasty.[28] This wedge technique reduces tension on the suture line, further minimizing the scar.[26] The advantage of the central wedge is simplicity. The main drawback is limited allowance to aesthetically alter the labial appearance.

Central wedge technique. Central wedge technique.

Anterior wedge

Labial hypertrophy may also be corrected using an anterior wedge excision (see images below). This technique resects anterior mucosa and skin. The dog-ear is extended into the labia minora and labia majora crease. This is well hidden and provides optimal aesthetic results.[12] The amount of resection is variable; clinical judgment is needed to prevent excessive resection and narrowing of the labia. Additionally, the anterior wedge technique has the advantage of pulling down some of the excess clitoral hood into the labial crease.

Anterior wedge technique with labial crease extens Anterior wedge technique with labial crease extension.
Anterior wedge technique. (Left) The dog ear is ex 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.

Posterior wedge

This technique removes the posterior fornix labia, leaving an intact labial rim (see image below).[29] A drawback of the posterior wedge technique is the length of the flap and the distance the blood supply must travel.

Posterior wedge technique. Posterior wedge technique.

All of these techniques preserve the mucosal-to-skin presentation, between labia tissue and the surrounding skin. Each is adaptable to the amount of resection necessary, but limited in that the incision line is placed directly in the labia, as opposed to a labial fold. A mitigating benefit of these techniques is the incision is hard to see, even on the labial edge.

Deepithelialization technique

This technique involves the deepithelialization of the center region of the labia while preserving the natural free edge of the labia minora.[13] The design of the deepithelialization as a tripoint allows anterior, posterior, and vertical reduction. The length of the wedge excised should not be longer than the length from the clitoral hood to the posterior side of the labia minora.[10]

Benefits of using this technique include nerve, tissue, and lymphatic preservation.[10] There is minimal to no blood loss using this technique.[10] Although the central wedge technique removes a central portion of the leading edge, the deepithelialization technique removes a portion of the central labia while preserving the leading edge. For this reason, this technique is limited in the amount of tissue that can be removed and there is a risk of recurrent hypertrophy with the deepithelialization technique.

See the images below.

Deepithelialization technique. Deepithelialization technique.
Central deepithelialization technique. The pattern 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.

Laser labiaplasty

Laser techniques are very similar to deepithelializing methods, using a laser rather than a scalpel. Both erbium and carbon dioxide lasers can be used.[26] Proposed benefits of laser therapy are reduced blood loss and enhanced healing,[26] although most of the benefit may be marketing. Limitations of this technique include higher risk for epidermal inclusion cysts.

Custom flask technique

A newer technique, custom flask labiaplasty, involves a flask-shaped incision. The technique allows precise, customized reduction of the labia minora and is designed to avoid interruption of vascularity and nerve innervation. A study by Gonzalez et al of 27 patients who underwent the procedure reported that 25 (92.6%) were satisfied with the surgical results; one (3.7%) minor postoperative complication occurred.[30]

Additional procedures

Clitoral unhooding/clitoral hood reduction/clitoral hood lift

Composite reductions of the labia are often performed to ensure a balanced and symmetrical result. In this composite reduction, a labiaplasty is combined with clitoral unhooding. Clitoral hood reduction reduces the amount or thickness of epithelial tissue surrounding the clitoris.[31] From an anterior view, this can be aesthetically displeasing to the patient. Thus, there is a need to exercise balance in the technique. Excessive exposure leads to hypersensitivity, as well as the appearance of microphallus.[12]

Indications for a clitoral hood reduction are reduction or devolumization/debulking of the redundant prepuce, with some patients finding that the extent to which the clitoral hood covers the clitoris reduces the ability of the area to be stimulated effectively. A clitoral hood lift and reduction can be incorporated in this instance. However, care must be taken not to give too much exposure to the clitoris, as this can result in the area becoming desensitized (similar to foreskin removal during a circumcision). This can lead to distress in patients; the ability to orgasm via the clitoris will remain, but superficial feeling may be lessened.

Contraindications to surgery are unrealistic expectations by the patient and psychosexual conditions, as well as concurrent infections, inflammatory diseases, coagulopathy, and smoking.

Since all of these procedures—unhooding, reduction, and lift—are restricted to the clitoral hood, risk for clitoral denervation is very unlikely for any of them. However, since the incision for a clitoral hood lift is along the horizontal/transverse aspect of the hood, there theoretically may be an increased risk for dorsal clitoral nerve disruption if the incision is placed too deep. The dorsal nerve sits below the hood, underneath the fascia; therefore, when dissecting this area, the clinician should take care to remain at the correct level.

The classic clitoral unhooding is a modified Y-to-V technique. The clitoral hood is incised, and the excess tissue on either side of the Y can be amputated, as depicted below.

Clitoral unhooding Y-to-V technique. Clitoral unhooding Y-to-V technique.

An alternative to the clitoral unhooding technique is the clitoral tightening.[16] In conjunction with a central wedge, wings of the anterior labia are advanced posterior and the clitoris is tightened posteriorly into the cleft.

Alter first described the technique of a combined labial wedge resection with the addition of a lateral "V" excision curving up along the lateral clitoral hood to eliminate the dog-ear. This could also allow for excision of excess clitoral hood skin laterally.[32]

Complications of composite labial reductions are minimal and similar to those of any labiaplasty technique, with few complications having been published regarding clitoral hood procedures. In a series of 407 clitoral hood reductions in patients undergoing combined procedures, Alter noted only one dog-ear formation and four stitch granulomas.[32]  In a 2013 study, 35% of patients who underwent the composite procedure experienced increased sexual excitability, and no patients experienced prolonged pain.[16]

Hamori discussed the option of using a V-to-Y advancement flap residual hood if excessive hoodectomy is carried out.[33]

It is important to discuss the overall benefits of clitoral hood reduction with patients to understand their reasoning behind requesting the procedure and whether they will be satisfied following the operation. Benson highlighted which patients are likely to be satisfied or dissatisfied following the procedure.[34] ​ There are several important aspects to consider. Patients who desire orgasm in the missionary position, have unresolved emotional issues, have a low sex drive, are seeking multi-orgasmic ability, and are looking for body modifications are generally those who will not be satisfied with the results. Anorgasmic patients, orgasmic patients with weak or slow orgasm, and patients who are orgasmic but need manual, oral, or mechanical stimulation or different positions tend to be more satisfied.

The clitoral hood reduction or lift will not mean patients will definitely orgasm more. However, easier access to the area, with less overlying tissue and a more positive feeling within the patient, as well as greater inner confidence, will aid these patients in achieving a more fulfilling experience.

Labia majora reduction

The problems of the labia majora are 2-fold: (1) atrophy of the fat and (2) excess skin. The solutions are fat grafting and surgical resection, respectively.[16] If a patient has atrophy of fat in the labia majora, injection of 10-15 mL of fat into each side of the labia majora, of which approximately 40-60% survives, can be recommended.[35] One technique for surgical resection of excess labia majora skin is an elliptical wedge on the inner edge of the labia, as shown below. This is designed to place the final closure into the labial crease.

Labia majora reduction technique with ellipse wedg Labia majora reduction technique with ellipse wedge.

G-spot alteration

Both fat grafting and fillers, such as Radiesse, have been applied to the anterior vaginal wall to enhance the perceived G-spot. Injections of fillers and/or collagen to the G-spot enhance the size, which has been purported to increase sexual pleasure.[1] One injection, G-Shot, uses hyaluronic acid off-label to increase the presumed G-spot size up to 100%.[26] There is, however, no consensus on the efficacy criteria for G-spot injections, which can lead to bleeding, infection, urinary complications, hypersensitivity reactions, and lack of sensitivity in the G-spot.

Monsplasty

The mons has also been an increasing region of focus in female genital cosmetic surgery (FGCS). Using a wedge excision method, wide mons are reduced.[18] The procedure works well in combination with labiaplasty and/or abdominoplasty in patients who have experienced massive weight loss.

Author’s technique

The author's technique reflects his overall cosmetic surgery philosophy, which is to tailor the operation to the problem or concern. He believes that no one technique is ideal for all patients. The author predominantly uses a curvilinear incision and bases the scar in such a way that the outer labial incision is higher than the inner incision. This allows the scar to be hidden internally. The author also frequently uses a progressive anterior wedge excision. The incision is made with a monopolar cautery using a Colorado needle. The setting is dependent on the cautery machine used but should allow for adequate cutting and coagulation. A bloodless incision line is created and aids better closure. This method minimizes blood loss as well.

The use of lasers in incision has been documented as well in several articles and can also provide a bloodless incision line. The closure line is situated at the anterior to mid-third of the labia minora, with the excess removed from the central third. The dog-ear, or scar excess, is extended into the anterior labial crease. Determination as to whether a clitoral hood reduction, a hood lift, or a combination of the two is performed is based on the patient's overall anatomy.

For a patient who desires a natural-looking edge on the labia minor without a visible scar, the deepithelialization technique is recommended. This procedure should be used in combination with clamp resection in patients with considerable excess skin.

Many surgeons use Monocryl sutures to close the deeper planes. This is a good choice and provides strength to the wound. The deep planes are closed with 4/0 or 5/0 Monocryl sutures, and the labial edge is approximated with a 5/0 Vicryl Rapide. Any skin closure is performed with a 5/0 Vicryl Rapide subcuticular or a 5/0 fast-absorbing suture. In some patients, the author has noted discomfort with the knots in Monocryl sutures; to ensure little discomfort, these do need to be placed deep. The other option is to use a 3/0 or 4/0 Vicryl suture. The author has found that this also gives a strong closure and that there is very little difference in dehiscence rates when compared with the Monocryl cohort. The author leaves the Vicryl knots on the outside. These cause very little discomfort and the patients are advised that these will come away of their own accord in around 2 weeks. If, however, at 2 weeks they are causing an issue and the wound is otherwise closed with no healing issues, the knots can be cut away.

Regardless of the technique used to reduce the labia minora, it is recommended that a strong, deep suture be placed in 3 points: superior, inferior, and in the middle of the wound. The author then uses a subcuticular 4/0 running suture to close the wound. Running sutures used externally can lead to aesthetically poor results on the free edge of the labia minora, but when buried, they can create a smooth, free edge. A scalloped look to the free edge is hard to correct. (See the images below.)

Labiaplasty results. Before (left) and 1 year afte 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.

Preoperative Details

All patients are seen preoperatively to evaluate the best approach for labia minora reduction. Patients are evaluated while standing and marked in the lithotomy position. The presence of pubic hair is irrelevant for the procedure. The patient should not shave immediately prior to the operation, to avoid increased infection risks. A loading dose of antibiotics is administered to the patient prior to incision (co-amoxiclav 1250 mg PO).

The author reviewed his cohort of patients with respect to preoperative and postoperative antibiotic use and found no difference in infection rates when antibiotics were given only post surgically. Although in selected patients, preoperative antibiotics are given, the author’s preference is now to give postoperative antibiotics alone (co-amoxiclav 625 mg tid for 1 week). Patients are also advised of the possibility of developing thrush following antibiotic use. This was found more commonly in patients who had previous episodes of antibiotic-associated thrush. Ascertaining this preoperatively will prepare the patient and surgeon, and antifungal treatment can be instituted earlier, as the clinical need dictates.

Postoperative Details

All labiaplasty procedures are same-day surgeries. The author gives a week-long course of oral antibiotics (co-amoxiclav 625 mg tid). Topical dressing (Jelonet, a Vaseline-based dressing) and gauze is placed on the area. Compression underwear is then given to the patient, with instructions to use it for a minimum of 4 weeks. This will help to reduce the swelling and keep the area adequately compressed. The patient is advised to wear tight pants (no G-strings or thongs) for a minimum of 4 weeks. If bleeding occurs, the patient should apply pressure for 10 minutes with a sanitary pad. The use of cold compresses will also help with overall reduction in bleeding, The patient may choose to use a sanitary pad at all times in her undergarments until the incisions have healed. The patient may shower the next day but is advised against lying in a bath and submerging the area, until the wounds have healed (usually 2 wk). The same advice applies to swimming.

Follow-up

Many surgeons have their own postoperative review protocols. It is recommended that the patient take at least 2 weeks off from work if she is engaged in manual labor or something other than a desk job. On return to work, she will require amended duties, which will be dependent on her level of function. If the patient has a desk job, she can return after 3-4 days, although a week is preferable. Gentle mobilization is suggested for the first 2 weeks, and the patient can start jogging at 2-4 weeks. Exercise that includes weights begins at 4 weeks (at 50% of the patient’s normal lifting weight), with the aim being to return to a normal workout routine by 6 weeks. The patient should not engage in intercourse or masturbation for a minimum of 4 weeks, with no heavy lifting during this time either.

Complications

Complications are uncommon for labiaplasty procedures, being seen in less than 1% of cases. Wound dehiscence and bleeding are early complications that have been documented.[8] Smoking predisposes patients to dehiscence or wound breakdown (see the image below). The most common complication is patient dissatisfaction with the final results. Communication regarding the patient’s expectations is critical. The frequency of revisions may be reducible by using local anesthesia, which allows active patient involvement in determining the final resection.

Smoking predisposes patients to dehiscence. This l 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).

A study by Bucknor et al suggested that in patients who undergo labiaplasty, the likelihood of postoperative sequelae (ie, revisional surgery and complications) is greater in patients in whom sexual dysfunction is an indication for the procedure.[36]  

As with most surgical procedures, the general and specific complications should be discussed.

General complications

Infection

Antibiotic loading dose prior to surgery and a prophylactic course for 1 week help to prevent this

Bleeding

This can be avoided with meticulous cautery and by ensuring that patients avoid the use of any blood thinning and herbal supplementation. Inquire about the use of garlic/turmeric and other herbal supplements that thin the blood and can cause bleeding intraoperative or postoperatively

Bruising

The area will bruise; arnica cream is useful for reducing the bruising, but AVOID arnica tablets. Although arnica tablets are widely prescribed to reduce bruising, the author routinely advises against their administration prior to surgery, having noted far greater bruising with their use. This may be related to the systemic effect of arnica in breaking down clots formed in the tiny capillaries

Swelling

The area will swell, and this should be highlighted to the patient; the author shows patients before and after pictures. It is useful to have patient pictures at 1 and 2 weeks to show how the area changes in the immediate postoperative period

Numbness

With the use of local anesthetic, the area will be numb until the effects wear off. It is very rare to get lasting nerve damage following labiaplasty. There may be some numbness or altered sensation that persists around the area of the scar, but for most patients, this is not a major concern

Wound dehiscence

This is more commonly seen with surgical techniques that put tension on the scar or form T-junctions on closure, and dehiscence can be observed following infection. With the majority of patients, if the wound breaks down in a small area, this can be left to heal on its own or with the use of appropriate dressings. Once all is healed, a secondary revision of the resulting scar can be performed if the scar is noticeable and causing a problem

Abnormal scarring

The scarring in this area tends not to be obvious. Hypertrophic and keloid scarring is not commonly seen, but if it does arise, it should be treated accordingly

Specific complications

Asymmetry

It is important to note any asymmetry before the surgery, as this may be something that is not possible to rectify with the subsequent operation. If this is not highlighted beforehand and photographs are not been taken, it can be very difficult for the surgeon to defend the postsurgical presence of asymmetry. However, for most patients, tissue removal should result in an appearance that is as close to symmetrical as possible. The author does not guarantee 100% symmetry to patients, and they need to be advised that the body will not heal symmetrically, so that one side may initially be much more swollen that the other. The swelling can take a few weeks to resolve, and the overall result will not be evident for at least 6 months.

The author does not suggest any revision surgery before 6 months, at which point the healing has had time to settle. Some patients may push for a quicker resolution if they are not happy with the result or see an issue. The concern should not be disregarded but should be addressed at the correct time.

Too much labia removed

The most common complication is overresection. Chronic dryness, scarring at or near the vaginal opening, and pain with intercourse can result from an aggressive reduction. To treat overresection, it is essential to allow the area to fully heal. Rushing in too early to perform a reconstruction usually results in a less favorable outcome. The author advises all patients that they will be seeing close to the final result by 6 months. By this time, there will be very little additional change in the tissue. This is the best time to carry out any revision work that is required. For overresected areas, options such as V-to-Y advancement flaps and clitoral hood flaps are commonly used.

Too little labia removed

Sometimes patients feel that not enough labia has been removed. Again, this should be addressed, and if there is an obvious discrepancy between the amount that has been removed and what was intended for removal, then revision can carried out. In the majority of patients, any revision will be done at 6 months, to ensure that the wound has completely healed and will not change any further; there is less chance at this stage of wound dehiscence due to operating on inflamed and swollen tissue.

Abnormal labial scarring/pigmentation

If too much labial tissue has been removed or the scar has been placed incorrectly, then the labia minora's appearance will be affected. Also, in darker-skinned patients, the scar can be paler and obvious. The inner portion of the labia minora is pink compared with the outer portion, and care should be taken to ensure that this anatomic appearance is not disrupted.

Hooded appearance

This is more likely if the clitoral hood is not addressed at the same time and may warrant a subsequent procedure to reduce the hooded effect.

Most commonly occurring complications

In the aforementioned review of 38 published studies, by Oranges et al, patient satisfaction rates with labiaplasty exceeded 90%. The complication rates were reported at around 7%, with the most common complications noted in the table below.[5]

Most commonly occurring complications in labiaplasty [5] (Open Table in a new window)

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

The Oranges study found no complications to be serious, and all resolved easily either through a watch-and-wait policy or via secondary revision. Revision surgery was most commonly needed in patients secondary to wound-healing complications or postoperative bleeding. Further resections were most frequently performed if the first operation did not lead to the desired labial length.[5]

Outcome and Prognosis

In the author's experience, patients are generally well satisfied with the results after having a labiaplasty. According to a study of female genital plastic surgery patients, including those who had labiaplasty or vaginoplasty, 91.6% reported an increase in sexual function following the procedure.[37] A similar study in 2000 reported that 80% of patients were satisfied with their results.[8] Additionally, a study of labial reductions in 2012 reported that 92.3% of women had functional problems corrected, while 89.7% of patients were relieved of psychological distress.[16]

A retrospective study by Lista et al of 113 patients who underwent labia minora reduction reported that the edge excision technique had a low complication rate and satisfactory aesthetic results. Transient symptoms, such as swelling, bruising, and pain, were reported by 15 patients (13.3%), and bleeding occurred in one patient (0.9%). Four patients underwent revision surgery, for further tissue excision.[38]

A study by Surroca et al of 58 patients who underwent labia minora reduction (with 75.8% of cases being treated with wedge excision) found that surgical outcome satisfaction was higher in women with children than in those who were nulliparous.[39]

One of the problems with evaluating patient satisfaction with labiaplasty is the limited long-term follow-up. Patients rarely return for evaluation after their 1-month check-up, despite being advised to make and attend follow-up appointments. 

Future and Controversies

Much of the discussion surrounding FGCS involves ethical concerns. Some of the macroethical issues include social pressures, economic limitations, and the definition of necessary procedures.[2] Microethical issues include proper informed consent and knowledge of normal female genitalia anatomy.[2] In addition, although labiaplasties are not mutilation surgeries, they have been correlated with female genital mutilation. Unlike genital mutilation, however, labiaplasty is performed by choice, is not intended to decrease natural sexual function, and does they restrict any basic human rights.[2]