Labiaplasty and Labia Minora Reduction 

Labial hypertrophy is the disproportionate size of the labia minora relative to the labia majora. Labiaplasty, also known as labia reduction, labia rejuvenation, or vaginal lip reduction, is a procedure designed to improve the appearance of the external female genitalia. The goal is to obtain a more aesthetic appearance of the genitalia without adding unsightly scars or distorting normal anatomy.

Hodgkinson was one of the first to publish a description of the aesthetic vaginal labiaplasty in 1983.^[1] Alter subsequently presented innovations to the procedure in 1998 and 2005.^{[2, 3]} In 2000, Rouzier and colleagues presented their experience with a large series of patients.^[4] The same year, Choi presented an updated technique aimed at minimizing some of the more common complications.^[5] Modifications to the labiaplasty technique have also been described by Munhoz,^[6] Maas,^[7] and Giraldo.^[8]

Labial hypertrophy is the disproportionate size of the labia minora relative to the labia majora. Labiaplasty is a procedure designed to address labial hypertrophy. The goal is to obtain a more aesthetic appearance of the genitalia without adding unsightly scars or distorting normal anatomy.

Frequency

The prevalence of labial hypertrophy is difficult to estimate, but the annual frequency of labiaplasty procedures appears to be increasing along with the number of physicians who offer this service. This is an evolving field in plastic and gynecologic surgery. As the procedures available become more refined, with ever-improving functional and aesthetic results, the procedure is expected to gain in popularity.

The etiology of labia minora hypertrophy is varied and can be multifactorial. Some women are born with protruding labia minora. In other women, hypertrophy of the labia minora is observed later in life and has been attributed to factors such as mechanical irritation by intercourse or masturbation, childbirth, lymphatic stasis, and chronic irritation and inflammation from dermatitis or urinary incontinence. Childbirth by the vaginal route causes some women to develop hypertrophy, in some cases, due to hematoma formation at the time of birth. The recent popularity of genital piercing may lead to asymmetry when heavy hardware is placed. The author’s experience with treating identical twins with the same degree of labial hypertrophy supports the possible role of genetics in the size of labia.

No universally accepted definition for labial hypertrophy exists. Furthermore, the appearance of female genitalia is subject to considerable anatomic variance, just as women's perceptions of what is normal may vary.

No universally accepted definition or grading system exists for hypertrophy of the labia minora. Some surgeons measure the size of the labia horizontally from the midline. Others measure between the base and the free edge. In the past, surgeons have used numbers ranging from 3-5 cm to define labia minora hypertrophy. These numbers are used by some physicians as minimal measurements to proceed with surgery.

The authors have proposed the following grading system as a simple and reproducible means to objectively measure labia minor hypertrophy:

• None: The labia minora are concealed within or extend to the free edge of labia majora.
• Mild/Moderate: The labia minora extend 1-3 cm beyond the free edge of the labia majora.
• Severe: The labia minora extend >3 cm beyond the free edge of the labia majora.

Patients seeking labiaplasty often present with reports of difficulty with hygiene (toilet paper sticking), discomfort with tight clothing, pain with bicycle riding and similar sports, labia catching in zippers, or painful intercourse due to hypertrophy of the labia minora.^[9] Perhaps the most common is the perception that the labia minora are too visible. Many women report that the labia minora protrude beyond the labia majora while in the standing position, leading to self-consciousness and difficulty with intimacy. An example of a patient presenting for evaluation can be found below.

Another common report is asymmetry of the labia minora. Women often present to the clinic with one lip of the labia minora larger than the other. For these women, treatment may be limited to the one side; in such cases, the goal of reduction is to match the smaller side as closely as possible.^[10]

Labiaplasty can be safely performed any time after sexual maturity, although the author prefers a minimum patient age of 18 years. This procedure can be performed before or after pregnancy. Surgery should be performed when the patient is not actively menstruating to reduce potential hormonal effects on anatomy and increased risk of postoperative infection.

Patients who report nonpleasing aesthetic appearance, hygiene problems, chronic irritation, painful intercourse, and trouble with tight clothing are all considered candidates for surgery. Although the authors' grading system is a useful tool to quantify labial hypertrophy, no particular size or grade is used as an indication for surgery.

The external female genitalia, depicted below, are referred to collectively as the vulva. This comprises the labia majora, labia minora, clitoris, and the openings of the urethra and vagina.

The labia majora, the larger outer lips, extend from the mons pubis to the rectum. Just inside the labia majora are the smaller lips, the labia minora. In some women, they are hidden by the labia majora. In others, they are thicker and more prominent, and can extend well past the labia majora. Such an extension may be considered for reduction.

The labia minora consist of 2 folds of connective tissue that contain little or no adipose tissue. Anteriorly and superiorly, the labia minora divide into 2 parts. One part passes over the clitoris to form the prepuce. The other joins beneath the clitoris and forms the frenulum. The labia minora join the labia majora in their posterior extent and may be united by a transverse fold known as the frenulum of the labia or the fourchette. The skin and mucosa of the labia minora are rich in sebaceous glands.

The labia minora are rich in nerve endings and are usually sensitive to touch. These skin folds have a core of erectile connective tissue analogous to the male corpus spongiosum and are covered by stratified squamous epithelium. During sexual arousal, they swell and moisten with extracellular fluid. During urination, the labia minora function to direct the urine stream.

Absolute contraindications

No absolute contraindications to labia reduction surgery exist.

Relative contraindications

Labia reduction surgery is relatively contraindicated in patients who have active gynecological disease, such as infection or malignancy. Patients who are current smokers and are unwilling to quit temporarily or permanently to optimize wound healing may be excluded. Perhaps most importantly, patients with unrealistic goals or expectations should be appropriately counseled or excluded from surgery. In the author’s practice, the minimum age requirement for the surgery is 18 years, at which age the patient can give her own consent.