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

Nerve Supply, Vasculature, and Muscles

The pudendal nerve innervates the external female genitalia, splitting into the deep and superficial perineal nerves. The deep perineal nerve gives rise to the dorsal nerve of the clitoris, and the superficial perineal nerve gives rise to the posterior labial nerve, its sensory branches innervating the labia minora, with sparse branches to the labia majora.[2,66,77] Deep to the clitoral fascia, the tunica albuginea encapsulates the dorsal clitoral nerve and artery and erectile cavernosa.[78] The dorsal clitoral nerve travels deep, along the medial ischiopubic rami, emerging in its trajectory toward the glans. If the surgeon remains far from the glans and superficial to dartos fascia, injury to the clitoris is unlikely.[2,66,77]

The pudendal artery provides the blood supply to the labia majora and minora via the posterior labial and perineal arteries. The labia minora are supplied by a small anterior artery, a dominant central artery, and two moderate posterior arteries (Figure 4). The external and internal pudendal arteries communicate through branches along the anterior labia minora and also through the frenulum arteries. When planning a wedge labiaplasty, the surgeon should remember that the anterior labium minus is the least perfused. A posteriorly based flap has a more reliable blood supply than one based anteriorly.[72] Of note, the nerves and vasculature of the labia minora travel within interstitial connective tissue, which is nonerectile.[79–81]

The bulbocavernosus muscles are positioned like parentheses deep to the labia majora, uniting posteriorly to form part of the bulk of the perineal body. The medial transverse superficial perineal muscles, arising from the ischial tuberosities, contribute the remaining bulk. The pubococcygeus, the iliococcygeus, and the puborectalis constitute the levator ani muscles. These broad, thin muscles that form a major part of the pelvic floor separate with pregnancy and childbirth, predisposing to vaginal laxity[42,44] (Figure 5).

Figure 5.

Vaginal laxity results from the trauma and stretching associated with pregnancy and vaginal delivery. The stretching can attenuate the tissues and separate the levator ani, bulbocavernosus, and superficial transverse perineal muscles, similar to diastasis of the rectus abdominis. Reproduced with permission from Plast Reconstr Surg. 2020;146(4):451e–463e. doi: 10.1097/PRS.0000000000007349.2