The Safe Practice of Female Genital Plastic Surgery

Heather J. Furnas, MD; Francisco L. Canales, MD; Rachel A. Pedreira, MD; Carly Comer, MD; Samuel J. Lin, MD, MBA; Paul E. Banwell, BSc (Hons), MBBS, FRCS (Eng), FRCS (Plast)


Plast Reconstr Surg Glob Open. 2021;9(7):e3660 

In This Article


Establish Goals, Motivation, and Expectations

Patients interested in labiaplasty, the most commonly requested procedure, may complain of chaffing, itching, personal hygiene issues, dyspareunia, pain with exercise, tugging, exposure in a bathing suit, recurrent urinary tract infections, and deviation of urine stream.[7–40] Patients interested in vaginoplasty and perineoplasty after vaginal delivery may note loss of friction during intercourse and reduced sexual satisfaction.[42–44] Mons and labia majora concerns are generally cosmetic. Professional cyclists with labia majora hypertrophy may request a labia majora reduction to relieve pain and pressure.[45,46] Validated questionnaires can provide an objective measure of symptoms and motivations.[7,9,10,15,17,29,30,33,47,48]

As with any aesthetic procedure, the surgeon should vet patients for unrealistic expectations and body dysmorphic disorder. Body dysmorphic disorder is defined as a disproportionate dissatisfaction with the appearance of normal-appearing female genitalia, yet an assumption that a woman with normal-appearing anatomy desiring a female genital cosmetic procedure must be experiencing body dysmorphic disorder may indicate an evaluating physician's failure to understand the symptomatology and cosmetic concerns that can be associated with normal anatomy.[7,15,47] The marked drop in body dissatisfaction symptoms following female genital plastic surgery suggests that many of these patients likely have body dissatisfaction rather than true dysmorphia. Nonetheless, these patients should be carefully counseled and screened during consultation.[17] The patient may have already seen online images that may or may not convey an accurate impression of what surgery can accomplish, so a discussion with a review of before-and-after photographs can help establish realistic expectations.

If a vaginoplasty or perineoplasty is considered, a thorough obstetrical and gynecological history, including method of delivery, urinary incontinence, and pelvic maladies, is particularly important to elicit in vaginoplasty and perineoplasty patients.[49,50]

Body Mass Index

A high body mass index (BMI > 30) raises surgical risks in any patient, but it is a particular concern in patients interested in vaginoplasty and perineoplasty. Chronic pressure on the pelvic floor predisposes these patients to POP, urinary incontinence, rectocele, and cystocele.[51,52] Ninety percent of morbidly obese women experience pelvic floor disorders, compared with 23.7% of women in general.[53–55]


The trauma of vaginal childbirth, especially with the use of forceps or vacuum; multiparity; and high newborn birthweight can widen the vagina and injure both the pudendal nerve and the levator ani muscle complex, predisposing to POP.[56–61]


The loss of estrogen production with menopause can result in atrophy of the genital tissues, leading to vaginal pain, vulvar pain, itching, discharge, and dyspareunia from loss of lubrication and narrowing of the vagina. Additionally, an increase in vaginal pH predisposes postmenopausal women to urinary tract infections.[61] Within a decade of menopause, half of women experience these symptoms, defined as the genitourinary syndrome of menopause.[62] Locally active estradiol cream, capsules, tablets, and rings can help increase vaginal mucosa thickness, reduce vaginal pH, improve moisture, and relieve dyspareunia.[63–65]