Complications of Female Cosmetic Genital Surgery

Christine A. Hamori

Key Points

• Complications of cosmetic vulvar surgery are low, between 2% and 4%.1,2

• Labia minora reduction is a safe and effective surgery. Complications occur in smokers and in those with high BMIs. Edge dehiscence is the most common complication of both linear resection and wedge resection.

• Large hematomas are rare but require surgical drainage in the operating room. Smaller hematomas resolve with time but cause bruising and pain.

• Various complications such as scar widening, fenestrations, “coin slot,” webbing, and pigment mismatch may occur with the wedge technique.

• Edge trim complications include contour irregularity, amputation, and “penis deformity.”

• Fat grafting and fillers to the mons pubis and labia majora restore volume but may require more than one treatment. Fat necrosis is uncommon but may occur.

• Labia majora reduction complications include scar visibility and vaginal gaping. Conservative resection and tension-free closure will prevent these problems.

In general, complications of cosmetic vulvar surgery are low, between 2% and 4%.1,2 The neurologic structures are quite deep and well collateralized (Fig. 10-1). Complications vary depending on the procedure. Because labiaplasty is the most common female aesthetic procedure performed, information about complication rates primarily pertain to labia minora reductions. In a review of 407 labia minora reductions, Alter² reported an overall reoperation rate of 2.9%.

Fig. 10-1 Superficial and deep nerves of the female perineum.

Labia Minora Reduction Complications

Wedge Resection Complications

Labia minora reduction is a safe and effective technique to reduce the size and protrusion of the labia minora. Complications can occur, and surgeons must be adept in handling them. Complications of wedge labiaplasties that require revision occur in 4% of cases.2,3 These include hematoma, edge dehiscence, fenestrations, pigment mismatch, and scar widening (Figs. 10-2 through Figs. 10-6). Patients who develop wound-healing problems usually present with high BMIs or have a history of smoking. The linear edge resection technique may be a better choice in these patients. Wound complications from edge trim procedures are less common in general.

Fig. 10-2 This 33-year-old smoker is shown 8 weeks after wedge labiaplasty with right webbing (partial dehiscence).

Fig. 10-3 This 22-year-old smoker, shown 4 months after a wedge labiaplasty, has a large, right notch deformity.

Fig. 10-4 This 18-year-old smoker, shown 8 weeks after a wedge labiaplasty, has a fenestration.

Fig. 10-5 This 42-year-old patient, shown 2 years after a wedge labiaplasty, has scar widening and pigmentation stepoff.

Fig. 10-6 This 25-year-old smoker, shown 4 months after a wedge labiaplasty and labia majora reduction, has pigment mismatch, scar widening, edge webbing, and narrowing of the introitus.

Bruising and Hematomas

Postoperative bruising is common during the first week after labiaplasty. Those prone to bruising may take Arnica montana around the time of the procedure to help reduce the duration of the discoloration. True hematomas are rare among postoperative perineal surgical complications (Fig. 10-7). Smaller hematomas present with pain, localized swelling, and tenderness. Patients frequently are frightened and anxious to know if surgical intervention is necessary. Using a cell phone camera, patients can take a snap shot of the area and send it to the surgeon, who can use it to help determine the course of action. Small hematomas usually get absorbed, but sometimes the dark “crank case oil” (colored fluid) may ooze from the incision several days or even weeks later. Patients should be informed of this possibility if a hematoma is noted in the physical examination. Labia minora hematomas are usually unilateral, which may cause concern for patients regarding asymmetry. Reassurance is necessary to alleviate fears of a persistent deformity. Icing, pressure, and close observation for the enlargement of the lesion are the main treatments.

Fig. 10-7 Day 1 postoperative images of two patients. A, Mild bruising. B, Moderate bruising.

Large hematomas usually form within the first 24 hours of surgery (Fig. 10-8). In my experience, surgical hematomas occur more frequently after labia majora reduction. The fascial planes of the perineum and potential spaces of the vulva allow large amounts of blood to accumulate before bleeding is tamponaded (Fig. 10-9). These cases need to be treated promptly with the patient under general anesthesia. After the clots have been irrigated and hemostasis obtained, suction drain catheters should be placed to prevent seroma formation. Once the drains are removed and the swelling decreased, a good cosmetic outcome is possible.

Fig. 10-8 A, This 24-year-old female has a large hematoma 8 hours after a labia majora reduction. B, Two weeks after drainage of the large hematoma.

Fig. 10-9 The perineal muscles and potential spaces.

Edge Dehiscence

The most common complication for the wedge technique is an edge dehiscence or notch deformity.2 These are seen most frequently in smokers and obese patients. Careful preoperative counseling on smoking (complete cessation of smoking 8 weeks before surgery) and weight management should be part of the preoperative management of labiaplasty patients.

Edge dehiscence or notching usually occurs at the most distal edge of the wedge closure (see Fig. 10-3). The mucosal edges tend to invert, thus preventing submucosal approximation and proper healing. Interrupted buried sutures of 4-0 Monocryl placed in the dermis of the wedge defect significantly decrease the incidence of edge dehiscence and webbing. Tension on the closure is another cause of dehiscence; thus conservative wedge resection is important. The anterior and posterior labial remnants must approximate with little or no tension. A vertical mattress suture of 5-0 Monocryl along the leading edge helps to reduce the incidence of notching and dehiscence.