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)

Disclosures

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

In This Article

The Procedures

Labiaplasty (Labia Minoraplasty)

Several labiaplasty techniques have been described, but this article focuses on the most commonly performed: the trim and wedge labiaplasties. The patient's unique anatomy and personal goals should guide the choice of technique. The wedge is a good option for patient wanting to retain her natural labial edges, but if she dislikes her thick, rough, hyper-pigmented edge, she may prefer a trim technique.[97] Mastering more than one technique enables the surgeon to optimally address a variety of patients.[97,98]

Trim

The trim technique is also known as a linear, curvilinear, edge, direct excision, or amputation labiaplasty. The novice labiaplasty surgeon may discover too late how easy it is to over-resect the labia minora.[7,97,99] A running suture closure can permanently scallop the edge. If the suture is pulled too tight, the tension can strangulate the blood supply, scarring and shortening the surviving labium. Alter has described the use of clitoral hood flaps, wedge excisions, and YV flaps to reconstruct amputated labia minora.[100] In the absence of local tissue, reconstruction is difficult.

Thick labia can heal wide and flat without a tapered edge. If the posterior excisions are separated by less than a centimeter or are in continuity, the scar can contract across the fourchette, interfering with intercourse. An excision that extends too far cephalad can divide the frenulum, untethering the clitoris, allowing it to rotate anteriorly and subjecting the patient to chafing, irritation, and pain. Sensation has been shown to remain intact after a trim.[101] (See Video 1 [online], which demonstrates a trim labiaplasty and clitoral hood reduction. Part 1. The surgical technique is shown, and the steps are narrated with subtitles. Reproduced with permission from Plast Reconstr Surg. 2020;146(4):451e–463e. 10.1097/PRS.0000000000007349.) (See Video 2 [online], which demonstrates a trim labiaplasty and clitoral hood reduction. Part 2. The surgical technique is shown, and the steps are narrated with subtitles. Reproduced with permission from Plast Reconstr Surg. 2020;146(4):451e–463e. 10.1097/PRS.0000000000007349.)

Wedge

Dehiscence after a wedge labiaplasty can result from resecting an over-sized segment and closing under tension. Over-resection can pull the clitoral hood too far inferiorly and advance the fourchette, narrowing the introitus, resulting in discomfort during intercourse. Notching and color mismatch can occur along the incision line. Dehiscence can also occur with poor blood supply or if only the mucosal surfaces are sutured in the closure. (See Video 3 [online], which demonstrates a wedge labiaplasty. The surgical technique is shown, and the steps are narrated with subtitles. Reproduced with permission from Plast Reconstr Surg. 2020;146(4):451e–463e. 10.1097/PRS.0000000000007349.)

Poor labiaplasty results can result in amputation of the labia, dehiscence, scarring, pain, dyspareunia, reduced erotic sensation, deformity, and loss of self-esteem.[15,33,102] Dryness, painful scars, scar contracture, and deformity can result from over-resection and amputation of the labia.[99,100] These complications are minimized with appropriate patient selection, choice of procedure, and good operative technique.

Clitoral Hood Reduction

Failure to address a heavy clitoral hood at the time of a labiaplasty can result in patient complaints of a masculine, "penis-like" appearance.[100]

Majoraplasty (Labia Majora Reduction), Majora Liposuction, and Majora Augmentation

Labia majoraplasty consists of reduction and reshaping of the labia majora to address redundant, ptotic, full labia majora.[29,103,106] Professional cyclists may have functional concerns associated with vulvar lymphadenopathy.[45,46] Redundant skin is excised medially, and adipose tissue can be excised directly in patients who desire reduced fullness and projection. The majora flap should not be precut, to avoid over-excision, but instead should be elevated from medial to lateral, and the redundancy confirmed before establishing the final incision line. Up to 50% of the majora skin is typically excised. A scar placed within the interlabial sulcus is less noticeable than one placed along the medial hairline.

Over-excision of the labia majora can result in a widened introitus that predisposes the patient to dryness and irritation.[103] Other potential complications include scarring, pain, impaired erotic sensation, increased vaginal secretions, dyspareunia, and diminished self-esteem.[103] Vulvar lymphadenopathy may limit the long-term results in intensive cyclists.[45,46]

Minimal fullness without ptosis may be addressed with liposuction, which should be performed with a cannula under 3 mm in diameter to reduce the risk of bleeding and contour irregularities.[103]

Labia Majora Augmentation

Fat grafting is the most common technique to volumize flat or atrophic labia majora.[69,100,105] A volume of 10–25 ml injected with a 1-ml syringe is recommended, although injections of up to 120 ml have been reported.[105,106] It is far better to undertreat than to overtreat. The possibility of future weight gain should be considered, particularly in the younger patient.

Hyaluronic acid has been injected both subcutaneously and deep to the dartos fascia as a volume filler, with reports of injected volumes ranging from 2 to 6 ml.[105] Adverse sequelae include swelling, bruising, and palpable nodules, which can be treated with light massage, intralesional corticosteroid, or hyaluronidase injection.[46,107,108]

Monsplasty and Mons Liposuction

The fatty mons with no ptosis can be treated by liposuction, but redundant skin and adipose tissue are best addressed with direct excision through a monsplasty.[103,109,110] Monsplasty candidates are often obese, adding to perioperative concerns,[111] but the surgery has been shown to improve urinary dysfunction and hygiene in massive weight loss patients.[112,113] After the redundant tissue has been excised, Scarpa's fascia should be anchored to the rectus abdominis muscle fascia to avoid descent.[109,110] Potential complications include bleeding, hematoma, and scarring.

Perineoplasty and Vaginoplasty

Vaginal tightening procedures, referred to variably as vaginoplasty, perineoplasty, colporrhaphy, and perineorraphy, have historically been performed for repairs after obstetrical delivery; only recently have they been performed to address sexual and aesthetic concerns.[18,114] Up to 76% of women experience decreased sensation, decreased friction during intercourse, and altered sensation associated with a generalized feeling of vaginal laxity.[14,50,115–119] Gaping of the vaginal vestibule with visibility of the vaginal mucosa, excessive vaginal secretions due to mucosa exposure, altered ability to achieve orgasm, and vaginal air entrapment resulting in embarrassing sounds during sexual intercourse are other sequelae women may experience from vaginal laxity.[50,120,121]

Because sexual satisfaction is impacted by multiple factors, patients hoping for improvement may not achieve what they wish, and patients should be screened and counseled so their expectations are realistic.[17,50] A history of vulvodynia, dyspareunia, or chronic pelvic pain are relative contraindications to vaginal tightening surgery.[48,50]Postmenopausal patients considering vaginoplasty should be on estrogen to thicken their vaginal tissues before surgery.[63–65]

Indications for a perineoplasty include aesthetic concerns, laxity of the introitus, and decreased sexual satisfaction after vaginal delivery.[43,117] Redundant, atrophic perineal mucosa is excised up to the hymen ring, and the bulbocavernosus and the medial transverse superficial perineal muscles are reapproximated to reestablish the pre-delivery anatomy of the perineal body and introitus. After perineoplasty, nearly 90% of patients experience improved rates of sexual intercourse satisfaction.[122] A perineoplasty without muscle plication can be performed for aesthetic reasons in the nulliparous patient.

A vaginoplasty can be done by tightening the anterior vaginal wall by plicating the vesicovaginal fascia. Some surgeons favor tightening the lateral wall to avoid a posterior scar where the pressure and sensitivity are the greatest.[115,123–125] More commonly, the posterior vaginal wall is tightened by plicating the rectovaginal fascia and approximating the levators up to 7–10 mm proximal to the hymen ring. Even without muscle plication, a wedge excision of the vaginal epithelium and rectovaginal fascia shows favorable results in narrowing the vagina.[74,115,126] (See Video 4 [online], which demonstrates vaginoplasty. The surgical technique is shown, and the steps are narrated with subtitles. Reproduced with permission from Plast Reconstr Surg. 2020;146(4): 451e–463e. 10.1097/PRS.0000000000007349.)

Risks include bleeding, hematoma, injury to bowel or bladder, and rectovaginal fistula scarring, vaginal stenosis, dyspareunia, and altered sensation.[14,43,50,53] Since no objective, reproducible method of measuring vaginal laxity has yet been developed, the measure of surgical outcome is limited to physical examination and patient questionnaire.[116]

Clinical Case Studies

A series of clinical case studies of female genital plastic surgery appear in Video 5 (See Video 5 [online], which demonstrates clinical cases of female genital plastic surgery. This narrated video shows different surgical cases with anatomical variations. The cases shown through preoperative and postoperative photographs include trim and wedge labiaplasties, clitoral hood reduction, majoraplasty, and perineoplasty. Reproduced with permission from Plast Reconstr Surg. 2020;146(4):451e–463e. 10.1097/PRS.0000000000007349). Postoperative instructions for all patients are listed in Table 1.

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