Labiaplasty and Labia Minora Reduction Treatment & Management

Labial hypertrophy is not managed medically.

Labiaplasty can be performed safely with local anesthesia, conscious sedation, or traditional general anesthesia. It may be performed as a single procedure or in conjunction with other cosmetic or gynecological procedures. The author prefers the use of 1% lidocaine with 1:100,000 epinephrine. This helps to thicken the tissues, facilitating the tissue resection. It is also helpful for hemostasis.

As with all paired structures in the human body, the labia minora are rarely perfectly symmetrical. Although size discrepancy is usually subtle, patients often present with one lip considerably larger than the other. For those patients in which only one side is considered large, surgery is only performed on one side. In those patients in which both sides are considered too large, but one is larger than the other, greater resection is performed on the larger side with the goal of obtaining a reduced and symmetric result. Unilateral or bilateral webbing between the labia majora and minora may exist and can be addressed at the same time.

The evolution of surgical treatment is discussed below.

Amputation technique

The original technique for labiaplasty involves simple amputation of that portion of the labia that is determined to be excessive. This the most simple approach, and it is still commonly used.^{[1, 2, 3, 4]} In this technique, a clamp is placed across the area to be resected and left in place for several minutes to establish hemostasis. The tissues are then amputated and closed. The main drawback of this technique is the loss of the natural corrugated free edge of the labia, which results in an unnatural appearance.^{[2, 3, 4, 5, 6, 7]} This technique is also more likely to damage nerve endings than other techniques. Furthermore, this technique may result in everting the inner lining such that the pink-colored labial tissue, which is normally not seen, becomes visible.

Central wedge resection

First described by Dr. Alter,^[2] this technique involves a full-thickness resection of a wedge of tissue from within the borders of the labial tissue. This resection pattern is advantageous over the amputation technique because it preserves the natural free edge of the labia. However, because it is a full-thickness resection, the procedure does have the potential to cause nerve damage, which can result in painful neuromas or numbness. Giraldo and colleagues refined this technique with the addition of a Z-plasty.^[8]

De-epithelialization technique

This technique was described in 2000 by Dr. Choi.^[5] It involves de-epithelializing a central area on the medial and lateral sides of each lip of the labia minora. The removal of the epithelium may be done with either a scalpel or laser. This technique reduces the vertical excess while allowing preservation of the natural free edge. This important modification of Dr. Alter’s original procedure helps preserve the sensory and erectile characteristics of the labia. The drawback of this technique is that the width of the labia may increase if a large area needs to be deepithelialized.

Laser labiaplasty

Laser techniques have received a great deal of attention in the last several years. This technique is essentially the same as the de-epithelialization technique described above, with the exception that the excess skin epidermis is removed with a laser instead of a scalpel. The drawback is the occurrence of epidermal inclusion cysts in many patients.

Labiaplasty with clitoris unhooding

Some women have thickened skin over the clitoris, which may interfere with stimulation and decrease sensitivity. A surgical procedure to correct this, known as unhooding of the clitoris, involves a V-to-Y advancement of the soft tissues with suturing of the hood of the clitoris to the pubic bone in the midline (to avoid the pudendal nerves). This has the effect of further tightening the labia minora.

Authors’ technique

The authors believe that no one approach is ideal and that the procedure should be tailored for the individual patient. In most cases, the authors rely on the de-epithelialization technique to accomplish a safe reduction that preserves the natural free edge of the labia minora, as well as sensation and tumescence. However, when the excess of tissue is significant, a combination of de-epithelialization with clamp resection may be required to achieve the preoperative goal established by the surgeon and patient. For women with webbing of the labia or redundant folding, the procedure is supplemented with additional techniques, such as the jumping man or 5-flap Z-plasty, to establish a more regular and symmetric shape. An example of a patient the authors have treated can be found below.

In the author’s experience, the technique for closure can influence the aesthetic outcome. Other surgeons have used a running absorbable suture. In the author’s experience, this has often resulted in scalloping along the scar line. The author subsequently switched to using a running buried suture, which has resulted in a closure with a more natural appearance.

Evaluation should be made preoperatively with the patient in the standing position. The surgeon must understand the goals of the patient. Markings can then be made in the operating room with the patient in the lithotomy position. The markings are made prior to injection of local anesthesia to ensure accurate planning of tissue resection. The patient may be instructed to take antibiotics and/or antiinflammatory medication orally beginning the night prior to surgery; if not, intravenous antibiotics are given at the commencement of the procedure.

For optimal exposure, the patient should be placed in the lithotomy position. The labia minora should be infiltrated using 1% lidocaine with 1:100,000 epinephrine, and efforts should be made to preserve the markings. Prior to commencing surgery, the patient is given intravenous antibiotics.

Postoperative care and pain is minimal, allowing patients to go home the day of surgery. After cleansing the surgical site, topical antibiotic ointment is applied to the labia. This is done 3 times daily for 48 hours and then discontinued. No vaginal packing is needed, although patients may find wearing a sanitary pad comforting. Patients are encouraged to take sitz baths to optimize hygiene. Patients in the author’s practice receive a 5-day course of oral antibiotics. The patient should be made aware that the labia are often quite swollen in the early postoperative period from infusion of local anesthetic and from edema.

Patients return the next day and, again, 1 week later for a follow-up visits. If patients note severe pain or swelling, they are advised to return to the clinic for examination for the development of a hematoma.

After labiaplasty, patients can return to work or normal activity in about 3-4 days. Patients should avoid the use of tampons, tight clothing such as thong underwear, and sexual intercourse for 4 weeks to allow adequate healing of incisions. The excellent blood supply to the labia ensures rapid wound healing.

Complications with the procedure are not common. Those that are observed are similar to complications seen in other common surgeries and include bleeding, infection, asymmetry, poor wound healing, under or overcorrection, and the need for revision surgery. Aggressive resection may cause nerve damage with subsequent formation of painful neuromas. When one of the flap techniques is used, a higher incidence of tissue necrosis has been reported. As previously mentioned, failure to use a buried suture can result in scalloping along the free border of the labia minora.

Authors who have presented their experience with labiaplasty report that patients are generally well satisfied with the procedure and have few complications. A study reported in 2000 showed a greater than 90% satisfaction rate in more than 150 patients who underwent labiaplasty.^[4] In the author’s practice to date, all patients have reported total satisfaction. Many authors report that the reduced genitalia greatly enhance self-esteem.^{[1, 2, 4, 5, 6, 7, 8, 11]} Furthermore, patients report improved hygiene, improved sexual intercourse, and reduction or elimination of chronic irritation.^{[4, 5, 6, 11, 12]}

Female genital cutting (FGC) refers to amputation of any part of the female genitalia for cultural rather than medical reasons. Opponents of these practices use the terms female genital mutilation or female circumcision. It is important to distinguish between these cultural practices and labiaplasty, which is a surgical procedure that a woman seeks to improve a perceived functional or cosmetic problem. Labiaplasty is not mutilation surgery and should not be confused with mutilation surgery.