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


Types of Anesthesia

Local anesthesia with oral sedation is ideal for labiaplasty. Majoraplasty, perineoplasty, and mons liposuction can be done under local with oral or intravenous sedation, but general anesthesia may be preferred if the operative site is scarred, multiple procedures are being performed, or the surgeon anticipates difficulty. A vaginoplasty can be performed under general anesthesia or pudendal block.[2] Local anesthesia avoids potential complications associated with general anesthesia (like nausea, vomiting, and the rarer aspiration pneumonia, malignant hyperthermia, and thromboembolic events), but some patients are more comfortable under general anesthesia.[2]

Prevention of Deep Venous Thrombosis and Pulmonary Embolism

Risk factors for deep venous thrombosis and pulmonary embolism include age older than 35, BMI more than 25, hypercoagulability, family history, smoking, and estrogen therapy.[82] To lower those risks, patients can lose weight and temporarily cease taking exogenous estrogen 3–4 weeks before and after surgery. Sequential compression devices can be used during surgery and the stirrups positioned so the hips flex at 90 degrees in the lithotomy position, maximizing venous drainage. After surgery, patients should engage in early ambulation and hydrate themselves sufficiently.[83–86] The American Society of Plastic Surgeons and American Association of Plastic Surgeons advocate the Caprini scoring system for risk assessment, which should be filled out before surgery and guide intraoperative and postoperative prophylaxis.[87,88]

Prevention of Nerve Injury

The dorsolateral position, with the lower extremities in stirrups, can result in pressure or stretching of the femoral and lateral femoral cutaneous nerves. Hip flexion more than 90 degrees and knee extension can create tension along the sciatic nerve and compress the peroneal nerve against the head of the of the fibula.[89,90] Patients who are thin, diabetic, and/or alcoholic; and those who smoke; have peripheral vascular disease, or have subclinical neuropathies are at a higher risk for neuropraxia. Compressive and stretch mechanisms should be eliminated, and patients' legs should be removed from stirrups after 90 minutes.[89,91] "Candy cane" leg holders can place direct pressure on the nerves, whereas Allen YelloFin Elite Lift Assist stirrups have a boot fin design that limits points of contact and uncontrolled abduction. Fortunately, preventative measures lower injury rates to under 0.5%, and sensory nerve injuries typically resolve within 6 months.[89,92] Motor nerve injuries are possible, but rare.[93]

Prevention of Compartment Syndrome

The dorsolateral position creates hemodynamic changes that can result in compartment syndrome of the leg. Cases are rare, but the consequences are severe, including compromised limb function and muscle damage, leading to rhabdomyolysis, myoglobinemia, and acute tubular necrosis.[94] Signs and symptoms include pain on passive stretch, confirmed by compartment pressures more than 30 mm Hg or within 20 mm Hg of diastolic blood pressure.[94,95] For complete recovery, release of the affected fascial compartment must be performed within 6 hours of onset.[91] Normalizing leg position every 90 minutes, avoiding hypotension, and limiting operative times drops the risk of compartment syndrome to under 0.3%.[96]