63. Female Genital Aesthetic Surgery
Incidence of female genital aesthetic surgery has increased as the quest for the aesthetic “ideal” becomes more popular.
Fivefold increase in the number of patients seeking cosmetic surgery of the vaginal region. 1
Often, the balance of aesthetic beauty and functional optimization, particularly in terms of sexual intercourse, has played hand in hand.
Genital beauty is culturally defined and dependent. 2 (Table 63-1)
In Japan, the “winged butterfly” appearance of the small labia is popular.
In Western society, protruding inner labia are considered less desirable.
In part of Africa, in a ritual known as Kudenga, the inner labia are stretched from a young age in the belief it optimizes sexual intercourse.
Labiaplasty has become the cornerstone of this multiarea concern
Aesthetic and functional concerns drive this trend.
Reasons in Westernized women 3 :
Media
Internet
Brazilian waxing
Functional issues like rubbing and hygiene
Media influence may increase pressure for women to improve their appearance. 4
Small, hardly visible, symmetrical labia minora have become the norm, with commercial images being altered to reduce the size. 4 , 5
Growing habit of shaving the genital area, and even the availability of pornography, may influence this ideal image. 4
A series from Alter 6 revealed the following reasons for surgery:
85.5% aesthetic reasons, with some discomfort with clothing, exercise, or sexual intercourse
13.3% aesthetic reasons alone
1.2% medical reasons
Ideal aesthetic traits for each segment 2 , 7 :
Labia minora that is symmetrical and does not protrude past the labia majora on standing
Full labia majora that conceals the labia minora completely with minimal bulkiness in tight clothing
Inconspicuous clitoral hood
Mons fat pad that does not protrude in clothing
Labia Minora Enlargement
A series from Alter 6 revealed the following reasons for surgery:
Type | Measurement (cm) |
I | <2 |
II | 2-4 |
III | 4-6 |
IV | >6 |
Conditions and Causes
Enlargement or hypertrophy in both length and width 9 – 16 (Box 63-1)
Most feel that 5 cm in length, measured from the base of the minora to the labial edge, is the upper limit of normal. 4
Some have suggested that those seeking reduction have a mean labial width of 3.52 ± 0.71 cm8 , 9
Felicio classification 8 (see Table 63-2)
Box 63-1% Causes of Labia Minora Enlargement
Congenital
Most common
Acquired
Pregnancy, birth control pills, aging, exogenous hormones 7 , 11
Topical estrogen 12
Stretching or weight attachment of the labia 13
Dermatitis secondary to urinary incontinence 14
Vulvar lymphedema from infections with filarial sanguinous 14
Myelodysplastic disease 15
Repetitive stretching from pregnancy, sexual intercourse, chronic masturbation 16
Atrophy or hypoplasia
Issues driving correction
Aesthetic
Loss of self-esteem/social embarrassment
Functional
Interference with intercourse
Chronic local irritation
Hygiene problems
Almost 50% of patients seeking correction report difficulty performing adequate local hygiene 10
Discomfort during walking, cycling, sitting, wearing more formfitting pants
Clitoris and Clitoral Hood
Note:
Clitoral hood conditions may develop either separately or along with labia minora hypertrophy.
Excessive, unattractive skin from preputial fold hypertrophy
Can occur in the horizontal and vertical dimension
Parallel folds lateral to the clitoral hood
Drape-like folds that separate the anterior vulvar commissure on standing 1
May protrude to give the appearance of a small penis
Apparent hypertrophy of hood after aggressive edge trim labiaplasty 17
“Buries” the clitoris
Phimotic clitoral hood over the clitoris
Clitoral glans hypertrophy
Elongation or general size
Primary or secondary from hormonal changes
Genetic abnormalities such as disorders of sexual development
Clitoral hood varies greatly and is commonly asymmetrical. 19
Length of 2-6 cm measured from the midline of the anterior labial commissure to the distal clitoral prepuce
Smooth or with multiple folds
May have a parallel fold lateral to the main clitoral hood
Variable thickness depending on the amount of subcutaneous tissue (dartos fascia)
May protrude, if enlarged, to give the appearance of a small penis
Note:
This quite often becomes noticeable after a labiaplasty that does not address the clitoral hood concomitantly or after aggressive trimming of the labia minora. Hood redundancy is the most common reason patients seek revision surgery. 18
Labia Majora
Primary hypertrophy 2
Volume excess
Fatty infiltration of the labia majora and ptosis of the anterior labial commissure 20
Secondary hypertrophy
Volume loss, creating excess skin
Fat and skin excess
Creates overhang and droop, often with a central crease from the introitus
Protuberance
Creates two concerns:
Overly fatty, full labia majora
Fat deficient, stretched labia majora with skin excess
Issues driving correction
Same as those for labia minora reduction
Aesthetic concern
Functional concern
Discomfort, fitting of clothes, hygiene, secondary sexual dysfunction, chronic irritation
Weight-related issues are key concerns.
Weight gain and obesity with resultant fat and skin enlargement
Secondary to weight loss or time after pregnancy
Ptosis of mons from massive weight loss, creating majora laxity and skin excess
Mons Pubis
Lipodystrophy
Descent of tissue
Massive weight loss
Excess skin
Massive weight loss
Goals of Treatment
Varies across cultures, particularly in relation to the labia minora
Aesthetically desirable result, addressing any functional issues
Preserving sensory innervation and physiology is critical.
Labia Minora
Create an aesthetically pleasing labia minora while addressing functional concerns 4 , 6
Reduction of the hypertrophic labia minora
Thin and straight labia
Light colored, with optimal color and texture match of the labial edges
Nonredundant edges
Symmetry
Preservation of the introitus
Maintenance of neurovascular supply
Preservation of sensitivity to the labium and labial edge
Malinovsky et al 23 reported several different groups of nerve endings involved in sexual sensitivity with labial hypertrophy
Improve volume of the atrophic or hypoplastic labia minora 8
Aesthetic
Some point out a functional aspect
May provide greater comfort for some with sexual intercourse
May provide more shock absorption as well as aid in tightening of the vaginal space
Note:
This has been a topic of debate with some feeling that the minora are not perfectly symmetrical, citing a functional advantage of one labia being larger than the other as a sealing mechanism for protection against vaginitis (see below). 8
Clitoris and Clitoral Hood
Reduce excess skin
Release entrapment
Resuspend to the pubic symphysis
Labia Majora
Reduce excess skin redundancy and tissue descent
Reduce fat volume
Enhance contour
Augment atrophy
Mons Pubis
Lift and tighten
Decrease protuberance of excess fat
Lift descent
Contour excess or ptotic skin
Smooth transition from the lower abdomen to pubic area
Correct ptosis of the anterior labial commissure
Increase visibility of the genitalia
Decrease pressure on urinary bladder and sense of urinary urgency
Pertinent Anatomy
Clitoral Region
Clitoris, prepuce, frenulum, clitoral hood
Clitoris
Erectile organ typically 2 cm in length and <1 cm in diameter
Attached to the pubic symphysis by the suspensory ligament of the clitoris
Consists of a root, body, and glans
Body
Composed of two corpora cavernosa and two crura which diverge inferiorly and laterally to attach bilaterally to the ischium
Corpora cavernosa enclosed within the fibroelastic tunica albuginea
Glans
Most highly innervated organ of the area
Covered by thinly cornified stratified squamous epithelium devoid of sebaceous, apocrine, or sweat glands
The subcutaneous tissue (dartos fascia) of the hood is superficial to the deeper Buck fascia.
Dorsal neurovascular bundle travels at the 11 o’clock and 1 o’clock positions at the junction of the glans and body.
Travels within the deep Buck fascia directly on the tunica albuginea
Prepuce
Covers the glans
Formed from folds of the labia minora that pass dorsal (anterior) to the glans
Frenulum
Extends from ventral (posterior or deeper) glans bilaterally
Meets with an extension of the hood to form the labia minora
Clitoral Hood
Appearance varies and is frequently asymmetrical 19
Length 2-6 cm
Smooth or corrugated
Parallel folds
Variable thickness
Protrusive if hood is thickened or clitoris enlarged
Labia Minora
Other names include nymphae or labium minus pudenda.
Two longitudinal, hairless cutaneous folds
Varying in size and devoid of fat
Internally situated between the labia majora
Paired folds surrounding the vestibule of the vagina
Skin is smooth, pigmented, and mildly rugose at the edges.
The dermis has a comparatively thick connective tissue component.
Composed mainly of elastic fibers and small blood vessels, making up erectile tissue
The dermis is similar in thickness to eyelid dermis. This varies patient to patient. Some patients have very thick dermis of the labia minora. 16
Core of spongy connective tissue
Contain erectile tissue and many small blood vessels and sensory nerve endings
Contribute significantly to engorgement and thickening during sexual stimulation
Inner surfaces of each labium have numerous sebaceous and eccrine glands, along with sensory nerve endings.
Pink color of mucus membranes
The posterior ends may be joined across the midline by a fold of skin (frenulum labiorum pudendi, fourchette, or posterior commissure of the labia minora).
Anteriorly
Each labium divides into upper (anterior or dorsal) and lower (posterior or ventral) parts
Upper part passes above the clitoris to meet the contralateral side.
Creates an overhang known as the preputium clitoridis (prepuce)
Often asymmetrical
Lower part passes below the clitoris to meet the contralateral side, forming the frenulum of the clitoris.
Notable sensibility
Labia Majora
Prominent folds of skin surrounding the pudendal cleft
Each contains:
Loose subcutaneous tissue with smooth muscle
The termination of the round ligament of the uterus
Membranous fat, which is continuous with the superficial perineal fascia
Externally, covered with pigmented skin (variable), sebaceous glands, crisp pubic hair
Internally, pink and hairless
Mons Pubis
Rounded, fatty prominence anterior to the pubic symphysis, pubic tubercle, and superior pubic rami
Mass of fatty subcutaneous tissue
Typically increases at puberty, decreases at menopause
Surface continuous with the anterior abdominal wall
Vestibule
Space between the labia minora containing openings of the urethra, vagina, and ducts of the greater and lesser vestibular glands
Urethral orifice is located 2-3 cm posterior to the glans of the clitoris.
Bulbs of the vestibule
Paired masses of elongated erectile tissue (~3 cm in length) along the sides of the vaginal orifice
Covered by the bulbospongiosus muscles
Homologous to the bulb of the penis and corpus spongiosum
Vestibular glands
Greater vestibular glands are partially overlapped posteriorly by the vestibular bulbs.
Open in the vestibule on either side of the vaginal orifice
Secrete mucus during sexual intercourse
Lesser vestibular glands
Open into the spaces between the urethra and vaginal orifice
Secrete mucus into the vestibule to moisten the labia
Superficial perineal muscles
Superficial transverse perineal
Ischiocavernosus
Attaches to the ischial ramus and partly surrounds the crus of the clitoris
Contraction during arousal creates blood flow to the corpora cavernosa and compression of deep dorsal veins, contributing to clitoral engorgement (erection). 26
Bulbospongiosus
Arises from perineal body to pass around the vagina
Inserts into the clitoris
Covers the bulb of the vestibule and the greater vestibular glands
Weak constrictor of the vagina when acting together
Sensory Innervation
Anterior labial nerves
Ilioinguinal nerve
Genital branch of the genitofemoral nerve
Perineal branch of the posterior cutaneous nerve of the thigh
Posterior labial nerves
Run posterior to anterior toward the mons
Pudendal nerve
Perineal branches
Posterior labial branches
Terminal branches of the posterior cutaneous nerve of the thigh
Autonomic innervation from the pelvic and hypogastric plexus
Increases vaginal secretion
Erection of the clitoris
Engorgement of erectile tissue in the bulbs of the vestibule
Malinovsky et al 23 demonstrated multiple different groups of sensory nerve endings in hypertrophy of the labia minora involved in sexual sensitivity.
Vascular Supply
Extensive collaterals
External superficial pudendal artery branches
External superficial pudendal artery anastomosis with the posterior labial artery (branch of the internal pudendal artery)
Supplies much of the labia majora
This arch gives rise to multiple arches supplying labia minora
Internal pudendal artery branches
Perineal, posterior labial, dorsal clitoral arteries
Internal circumflex artery
Preoperative Evaluation
A thorough discussion regarding patient’s aesthetic and functional goals is essential.
Examine in both standing and lithotomy positions.
Evaluate area as a unit comprising the mons, pubic area, labia minora and majora, clitoral hood and clitoris, introitus.
Note:
Patients should use a mirror while pointing out areas of concern in each position. Surgeons can identify areas of resection or proposed lift.
Labia Minora
Protrusion
Length (base to most projecting point)
Length in anteroposterior direction
Thickness
Symmetry
Skin quality
Skin color
Relationship of the introitus
High posterior lip
Opened introitus from previous episiotomy
Labia Majora
Excess of loose skin
Excess or lack of fat
Projection in the anteroposterior direction
Anterior labial commissure in relation to the pubic symphysis
This is a guide point, particularly in procedures with a planned pubic lift
Must evaluate alongside mons pubis descent and pubic lipodystrophy
Note:
Evaluating the labia majora with the legs abducted and adducted is critical. The relationship to the inner thighs is noted here. This helps to prevent possible overresection of the labia majora and secondary tethering of skin, a complication that can lead to vaginal splaying.
Clitoris and Clitoral Hood
Evaluate patients while they are in standing and lithotomy position.
Note protrusion, symmetry, hyperkeratotic or darkened skin, extra folds (horizontal and vertical), clitoral gland size, and degree of clitoral exposure.
Hood deformities are best noted with patient standing.
Note:
Alteration of the minora may affect the appearance of the clitoral hood.
Mons Pubis
Mons descent
Observe the related enlargement, descent, or protrusion of the labia majora.
Assess the labia majora with simulated elevation of the pubic fat pad, noting the amount of inferior labial protrusion.
Examine the majora with the mons lifted.
Panniculus
Determine the amount of pubic skin above the hairline that will need to be excised transversely.
Simulating a possible lift, note the position of the anterior labial commissure.
Should be at the pubic symphysis
Reference point for magnitude of lift and subsequent amount of skin to be excised
Note:
The skin excision extent may vary with fat removal.
Informed Consent
Postoperative course and complications
Labial swelling
Labia minora and clitoral hood edema
Change in position of the anterior labial commissure
Inadequate reduction
Pain
Color change
Suture line may create a contrast between lighter and darker tissue or between coarse and finer hair.
Seen in all forms of labia minora and labia majora reduction
Reduction of one area of the total complex may result in prominence of other areas.
Reduction of the labia majora alone may result in more prominence of the labia minora or clitoral hood.
Sexual dysfunction
Change in position, sensation, or even tethering of the vaginal introitus
Exposure of the clitoral glans
Vaginal dryness
Changes in sexual sensation
Scarring—widened, hypertrophic, painful
Hematoma
Infection
Transient dyspareunia
Fistula or major wound dehiscence
Techniques
All techniques are performed with patients in the lithotomy position. Markings are made, and local anesthesia is injected.
Labia Minora
Volume Reduction
Labiaplasty (labia minora reduction)
Edge trim (most common) 3
Wedge resection patterns, as originally described by Alter 6 , 18 – 20 or a variant of such techniques
Bilateral deepithelialization technique
Composite reduction 33
Edge resection
Box 63-2% Labia Minora Reduction Techniques–Elliptical Excision: Pros and Cons
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