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

Physical Examination

The patient should be examined both standing and in the lithotomy position. An examination chair with retractable stirrups facilitates visualization and promotes patient comfort. In the standing position, the labia minora are noted for the degree of projection beyond the labia majora, and the labia majora are noted for ptosis, volume, and fullness.

Superficial Anatomy of the Vulva

The vulval complex can be divided into structured anatomical regions: the mon pubis, clitoral area, the labial-clitoral complex,[66] labia minora, labia majora, and perineal area (Figure 1). As with facial aesthetics, surgery of the vulva should achieve "genital harmony."[66] Most textbooks and scientific articles illustrate the vulva with little variation, disadvantaging surgeons who may be unprepared for the anatomic variations they encounter[66–69] (Figure 2).

Figure 1.

Systematic assessment of the vulval complex. Dividing the vulval complex into 6 areas allows careful evaluation. B, Careful attention should be paid to each of these areas: labia minora, clitoral complex, labial-clitoral interface (complex), labia majora, pubic area, and perineal area. The quality of the tissues, rugosity, pigmentation and asymmetries should be noted. Reproduced with permission from Hamori CA, Banwell PE, Alinsod R. eds. Female Cosmetic Genital Surgery. Concepts, Classification, and Techniques. New York: Thieme; 2017.

Figure 2.

Anatomic variations seen in clinical practice. Labia minora vary in pigmentation, texture (rugose or smooth), thickness, symmetry, shape, projection, and symmetry. Above left, This patient has a double clitoral hood, with an upper fold and lower fold. In this case, the lateral fold merges onto the superior aspect of the labia minora. Above right, In this patient, the lateral clitoral hood merges with the medial labia minora. The labia minora merge superiorly with the medial labia majora. The clitoris is recessed, and clitoral hood projects more laterally than centrally. Below left, In this patient, the thick mucosa of the fourchette merges with the raphe over an expansive area. Below right, In this patient, the clitoral hood merges onto the medial labia minora, and the labia minora merge superiorly onto the medial labia majora. Reproduced with permission from Plast Reconstr Surg. 2020;146:451e–463e. 10.1097/PRS.0000000000007349.2

Labia minora classification systems often focus on length, measured from introitus to edge; degree of protrusion beyond the labia majora; or the relationship of minora, majora, clitoral hood, and fourchette.[66,68–71] Dimensions help in operative planning but are poor determinants of a patient's candidacy for labiaplasty. Far more important is patient symptomatology.[7,15,47]

Instead of using absolute measurements, one of the authors (PEB) has described 3 main anatomical variants, based on the maximal projecting point of the labium: Type I projects maximally in the upper third, Type II in the middle third, and Type III in the lower third (Figure 3). Contralateral sides can differ. These variants may influence choice of labiaplasty technique, trim or wedge, and the type of wedge[72] (Figure 4).

Figure 3.

The Banwell Classification. The labia minora are divided into three morphological types. Top left, center, and right, The most prominent point (width) of the labia may be seen in the upper third (Type I), middle third (Type II), or lower third (Type III). Example of Type I (lower left), Type II (lower center), and Example of Type III (lower, right). Reproduced with permission from Hamori CA, Banwell PE, Alinsod R. eds. Female Cosmetic Genital Surgery. Concepts, Classification, and Techniques. New York: Thieme; 2017.

Figure 4.

Mapping of the labial arteries. On the y axis, emergence of the arteries found in every subject is noted. An arrow indicates the mean value of emergence for every artery as a distance from the posterior fourchette. The anterior artery is small, the central artery is dominant, and there are two posterior arteries. Reproduced with permission from Plast Reconstr Surg. 2015;136:167–178. doi: 10.1097/PRS.0000000000001394.72

Evaluation for Vaginal Laxity, Rectocele, and Cystocele

Candidates for vaginoplasty and perineoplasty should be evaluated for pelvic organ prolapse (POP), including rectocele and cystocele.[73–75] A cystocele is associated with urinary frequency, urgency, and incontinence; a rectocele is associated with constipation, including a history of digital manipulation to facilitate defecation.[73] Patients with POP, obstructed defecation, or urinary or anal incontinence should be referred to a gynecologist, urologist, or urogynecologist.[2,18,73–75] The short form Pelvic Organ Prolapse/Urinary Incontinence/Sexual Questionnaire (PISQ-12) aids in screening patients.[76]

In the standing position, the female perineum is typically located at a level within 2 cm of the ischial tuberosities. If the perineum lies below this level, at rest or with a Valsalva maneuver, the patient should be referred for an evaluation of POP.[42,44] In the lithotomy position, observation of attenuated mucosa with scant muscle bulk within the perineal body and proximity of the posterior fourchette to the anus should be noted. As the patient bears down and tightens, the surgeon can digitally assess the vaginal width and the levator ani muscles, each finger breadth of separation approximated 1 centimeter.[42] A rectovaginal examination is conducted to assess the integrity of posterior vaginal wall.[2,42,50] Lax, widely separated levator ani muscles are best addressed with a vaginoplasty.[42,44]