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Stony Brook, NY

Labiaplasty

One of the concerns that some of my patients have regards their genitalia, specifically the size of the labia minora. There are two sets of female genital “lips”. The outer lips. or labia majora are thick skin folds that comprise the outer border of the female genitalia. They are of variable length, but even when on the longer side, they still only measure no more than 2 cm or so. The labia majora are thick, and as such, are not very movable. The inner lips, or labia minora, are much thinner than the outer lips. They lie on either side of the border of the vaginal opening. The outer layer of the labia minora is comprised of skin. The inner layer is comprised of vaginal mucosa transitioning to skin as you move away from the vaginal opening towards the thigh. The intervening tissue between these layers is only a couple of millimeters thick. The length of the labia minora, from vaginal opening towards the thigh is very variable. Sometimes the length can be up to 4 or 5 centimeters (about 2 inches), occasionally even longer.

Figure 1: Diagram of the external anatomy of the vulva demonstrating the relationship between the labia major and labia minor, the clitoris and its “hood” and the vaginal orifice (opening).

In most women, when standing, the labia minora are either flush (even) with the labia majora or even receded back behind the labia majora and not visible from view. When the labia minora are lengthened, they protrude past the labia majora and sometimes hang downward. For women, a lengthened labia minora is frequently a cause of concern. For some women, the appearance of the lengthened labia is a concern for aesthetic reasons. Back in 1995, the first labiaplasty I performed was on a woman who was a nudist and was concerned about the appearance of her genitalia. The other concerns are more functional. For some women, a lengthened labia gets pulled into the vagina during intercourse and this causes discomfort. There may also be discomfort during sports and irritation in certain clothing. Whether for aesthetic concerns or functional issues, a labiaplasty is an easy to perform procedure that will address both of these problems.

How is labiaplasty performed?

Prior to going to the operating room, the patient is marked with a gentian violet surgical skin marker while she observes using a large hand held mirror. This allows her to give me input upon exactly how much tissue she desires to remove, rather than me try to venture a guess. Every woman has a personal preference and this preference is variable. There is no right or wrong here. It’s whatever the woman is comfortable with. Labiaplasty is best performed under general anesthesia, although it could be performed under local anesthesia. My personal opinion is that a woman would be far more comfortable having the surgery performed while asleep than being subjected to local anesthesia being injected into such a sensitive area. After the excess tissue is removed, the skin is closed with an absorbable suture, so no suture removal is required. After surgery, the patient applies bacitracin ointment a few times a day to the area to prevent infection and scabbing. The labia minora are fairly swollen for several days, but this resolves over the next few weeks. There is no other dressing required, other than a thick pad such as a maxi pad or combine dressing for the first few days. There is no problem with toileting. Sexual intercourse can be resumed in about six weeks when the wounds are healed and not tender. It is also recommended that you abstain from motorcycle, horseback and bicycle riding for the same period of time.

There are several ways to perform a labiaplasty. The first is simply trimming the external excess labial skin (external trimming technique), however, there are more sophisticated techniques such as the central wedge resection or “V” resection and the custom flask labiaplasty techniques .

The "External trimming"resection technique

Figure 2: The resection of excess skin is marked along the labia.

Figure 3: The excess labial skin has been removed and the raw tissue edge along the labial edge is sutured. The final result is shown.

Probably the most commonly performed, if not the easiest technique is to simply trim the excess labial skin. (external trimming technique) The advantage to this procedure is that it is simple to understand and technically easy to perform. It will not address excess clitoral hood skin. One disadvantage to this method is that the normal outer border of labial skin is removed and a new edge of skin is created as the two layers of labial skin (the inside and outside) heal together. Sometimes, there can be an irregular, almost “sawtooth” contour to the edge of the skin as it heals. This can happen when there is a lot of swelling after the surgery and the sutures placed into the edges of the skin cut into the skin edge as the swelling progresses. I have seen this happen on one occasion however it was successfully corrected by surgical revision. The other disadvantage is that this procedure does not do a very good job of holding the edge of the labia minora within the confines of the labia majora. As stated earlier, it is desirable to have the labia minora set back so as not to protrude any further than the outer edge of the labia majora. Although the external trimming technique will reduce the size of the labia in the front to back dimension, it does not reduce the height of the labia. This vertical laxity will result in the labia minora protruding forward in some cases, despite the fact that it was trimmed horizontally, or "front to back". Ideally, the labia minora needs to be under some degree of tension to prevent such "bowstringing" forward. Think of the labia minora as you would a violin string - if the string is under proper tension, it stays close to the fingerboard of the violin, but if the strings are loose, they will bow forward. The other two techniques do a much better job of holding the labia minora back, at least in my opinion. Lastly but infrequently, the outer edge of the labia minora can be a source of some discomfort to the patient, although I have not personally heard this particular complaint from my patients. Despite the disadvantages stated, I have seen a high degree of patient satisfaction in my patients using this technique. For most patients, I prefer the other two procedures.

Figure 4: Labia minora showing excess tissue both horizontally and vertically. If the vertical excess is not addressed, the labia will often extend outside the confines of the labia majora, despite a reduction in horizontal excess.

The “Central Wedge” resection, devised by my colleague Gary Alter, M.D., is a bit more difficult to understand conceptually, however, it is really not that complicated. In this technique, a wedge of excess labial skin is removed, but the pattern of excision is a little different on the inside aspect of the labia as compared to the outside of the labia. On the inside, it is more of a “V turned sideways” pattern, and on the outside, it is more of an “V durned upside down” pattern. There are several distinct advantages to this technique. First, the natural edge of the labia is preserved throughout. The second is that the apex of the outside “V” (the top of the excision) can be taken all the way up to the level of the top of the clitoral hood so as to remove excess clitoral hood skin when it exists on the outside of the hood, which is very common. (Excess inner clitoral hood skin is less common and can be addressed by simple excision of that skin separately). If you simply trim the excess labial skin along its perimeter (the first techique) and there exists excess lateral hood skin, this lateral hood skin will not be able to be addressed and will look like a strange blob of wrinkled skin next to the clitoris. Using the Central Wedge technique, this excess clitoral hood skin can be seamlessly incorporated into the outside labial skin excision and the results will look absolutely beautiful! If the clitoral hood needs to be elevated as well, a separate set of incisions is usually required (discussed below).

The disadvantages of the Central Wedge technique are relatively minor: there is a more distinct transition of pigmentation between the upper and lower portions of the labia at the suture line, but this tends to lessen with time. Also, if there is a breakdown in the suture line, there can be a small hole within the scar, almost as if there was a small piercing placed there. This is uncommon and is easily repaired if required. The main advantage of the Central Wedge technique is the quality of the aesthetic result as well as the ability to obtain a natural looking result without excess labial skin which could be a source of cosmetic concern, or pulled inside the vagina during intercourse or irritated by clothing. This technique is now my preferred technique in most cases and even in revision cases.

The “Central Wedge” resection technique

(Preferred in most cases)

Figure 5: The incisions are somewhat different on the inner and outer aspects of the labia. In this figure, on the inner aspect of the labia, the “central wedge” or “V” is shown with the apex of the “V” pointing into the vagina (but not entering it). The mucosa, but not the tissue between the inner and outer layer of the labia is removed as shown.

Figure 6: The incision on the outer layer of the labia is shown. If there is excess lateral clitoral hooding, resection of this excess hood skin can be incorporated into the design of the resection of skin. Again, only the skin, and not the tissue between the inner and outer layer of the labia is removed as shown.

Figure 7: The resection of excess skin is complete. Now the incisions in the labia must be closed.

Figure 8: First, the tissue between the inner and outer layers of the labia is closed, followed by the inner and outer layers of the labia. Two differrent suture techniques are used to secure the repair and prevent wound separation. The final result is shown.

The “Custom Flask” resection technique

Figure 9: The incisions are marked for the Custom Flask labiaplasty. The pattern of skin to be removed resembles that of a laboratory flask, hence its name.

Figure 10: Final closure. The upper and lower outer limbs are brought together, and the two are then attached to the outer edge of the vaginal opening.

The Custom Flask Resection, recently described by another colleague, Federico Gonzalez, M.D., will pretty much yield a nice result on any case that the Central Wedge technique will be applicable. One disadvantage is that the Custom Flask resection will not by itself address excess clitoral hood skin and a separate set of incisions needs to be made for removal of excess clitoral hood skin and clitoral hood elevation (if needed). This is a very simple procedure and I would not consider this a decision factor against the Custom Flask labiaplasty. This will be discussed a little later on.

What I love about the Custom Flask labiaplasty is that it is (in my opinion) the procedure of choice when a patient presents with a substantial amount of labia minora skin AND a narrow vaginal introitus (opening) as in a woman who is a still a virgin. The problem in this case with a Central Wedge resection is that a large sidewards "V" of labia minora tissue needs to be removed but that will require the vertex (lower point) of the "V" to be well into the vaginal canal, which can result in significant narrowing of the vagina, making intercourse problematic. The Custom Flask resection does not require any incision to be made into the vaginal introitus itself, yields a nice reduction of tissue, keeps the labia minora under proper tension so as to hold the edge of it within the confines of the labia majora and is simple to perform. A clitoral hood reduction/elevation can easily be performed concurrently.

Patient Satisfaction

In my experience, patient satisfaction with labiaplasty has been very high using either the Central Wedge or the Custom Flask labiaplasty techniques. Both of these procedures offer greater flexibility to sculpt the labia and address clitoral hooding which the external trimming technique does not permit. Furthermore, both techniques leave the natural labial edge on the outer border of the labia whereas the external trimming technique leaves scar tissue along the outer edge of the labia. Complications are very rare, and have been limited to small areas of wound separation that healed spontaneously with no special care other than application of bacitracin ointment.

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