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Increasing trends in pubic hair removal, genital piercings that stretch the tissues, exposure to idealized images of genital anatomy, and increasing awareness of cosmetic vaginal surgery have been proposed as reasons for the increased interest in labial surgery. Gynecologists who care for teenage girls say they receive requests every week from patients who want surgery to trim their labia minora. The alarming increasing among teenagers prompted the American College of Obstetrics and Gynecology to release guidelines for adolescents requesting the surgery. The first step is education and reassurance regarding normal variation in anatomy, growth, development and the temporary changes associated with puberty. The second step is nonsurgical comfort and cosmetic measures including supportive garments, personal hygiene measures (such as use of emollients), arrangement of the labia minora during exercise, and use of formfitting clothing may suffice. If emotional discomfort or symptoms persist, then surgical correction can be considered but only after counseling and assessment of the adolescent’s physical maturity and emotional readiness and screening for body dysmorphic disorder. All adults should also be screened for body dysmorphic disorder if there is no obvious medical condition related to enlarged labia. The surgery should not be performed when the patient is menstruating to reduce potential hormonal effects and the increased risk of infection. The use of similar guidelines in Australian public clinics resulted in a 28% decrease in the number of labiaplasties performed in 2015 vs. 2014. Though 2012 through 2014 rates of the surgery in Australia were basically unchanged. Women in Australia who apply to have publicly funded labiaplasty must now provide an expert review panel with photographs of their genitalia, so they can be assessed for unusual physical symptoms that need repair, or they are told that they fall within the range of normal variation and surgery is not required.
Enlarged labia minora can cause dyspareunia (pain with sexual intercourse), chronic urinary tract infections, local irritation with skin/musoca breakdown, hygienic difficulties especially after menses, urination or bowel movements, and interference with sports such as cycling, walking or running. However, there is no accepted exact definition of enlarged labia minora. Labial minora protrusion relative to labia majora is classified as Class I (0-2 cm), Class II (2-4cm), and Class III (>4 cm). A study evaluating 131 patients undergoing labiaplasty found that 32% sought surgery for functional impairment or discomfort, 37% sought surgery for aesthetic purposes, and 31% sought surgery for a combination of these reasons. Often, the issue is that there is an asymmetry and one side is larger than the other so, sometimes, the surgery is only performed on one side. Reports suggest that women prefer a prepubescent aesthetic, with the labia minora tucked within the confines of the labia majora (Class I). Because of poorly defined anatomic parameters and a lack of widely accepted indications, labiaplasty is somewhat controversial despite a high rate of patient satisfaction following the procedure.
While labiaplasty can be done with just local anesthetic, patients are more comfortable with a combination of local anesthetic and sedation. The local should be lidocaine with epinephrine, 1:100,000 injection, to reduce bleeding during surgery and after surgery bruising and swelling.
Several surgical approaches to labiaplasty have been described
- deepithelialization: removes a small amount of surface tissue while preserving the labial contour. It is best suited for patients with minimal hypertrophy.
- direct excision or edge resection: is a straightforward approach to volume reduction by cutting off the free edge of the labia minora. The surgeon puts a clamp across the edge, cuts the protruding tissue and sutures under the clamp before releasing it. The approach is quick however, the aesthetic outcome is poor. The natural color, contour, and texture are lost, the edges may evert exposing vaginal lining and the scar may be highly visible. There is a greater risk of removing too much tissue with this approach so that clitoral area looks overly prominent. An Australian review revealed that some Australian women were being pressured into more extensive surgery to the clitoral hood because doctors had removed so much of their labia that they needed to "balance" out the other areas.
- wedge resection: accomplishes a comparable volume reduction with direct excision while preserving the native labial contour. The other advantage of this approach is reduction in more than 1 plane and ability to adjust the clitoral hood without cutting into it. I prefer this approach with a step in the wedge to prevent notching of the outer edge. It is technically more difficult than edge resection but worth the extra effort.
- composite reduction: aims to correct clitoral protrusion and hooding in addition to labial reduction and is associated with a higher rate of complications and reoperation than other techniques.
- miscellaneous: W-shaped resection, Z-plasty, and laser labiaplasty
wedge resection with step
Vaginoplasty refers to surgery inside above the vaginal opening or creation of a vagina in transgender surgery. It can be performed to correct a congenital deformity, narrow the vaginal diameter, reconstruct the vagina after surgery, treat prolapse or treat urinary incontinence. 5 million women in the US experience stress urinary incontinence, leakage of urine when the sneeze, laugh or cough. Tightening the vaginal tissue in itself cannot guarantee a heightened sexual response, since desire, arousal, and orgasm are complex, highly personal responses, conditioned as much by emotional, spiritual, and interpersonal factors as aesthetic ones.
Historically this was performed by excising a diamond shaped segment of tissue from the back wall.Currently laser resurfacing, laser excision and radiofrequency modalities are more frequently employed.
|Brand Name||Company||Technology||FDA 510(k) Clearance|
|Mona Lisa Touch||Cynosure||Fractional CO2 Laser||vaginal atrophy|
|Viveve||Viveve Medical||Radiofrequency Energy||not yet available in US|
|Femilift||Alma Lasers||Fractional CO2 Laser||post-menopausal vaginal atrophy with dyspareunia|
|Intimalase||Fotona||2940nm Erbium:YAG nonablative laser||gynecologic applications|
|Exilis Protege||BTL||Radiofrequency Energy||dermatologic procedures for noninvasive treatment of facial skin wrinkles|
|CO2RE Intima||Syneron/Candela||Fractional CO2 Laser||gynecology, dermatology and plastic surgery|
|diVA||Sciton||Hybrid Fractional Vaginal Laser Therapy||FDA cleared for ablation and coagulation of soft tissue|
Radiofrequency treatments will likely become the mainstay treatment for overactive bladder, stress incontinence, atrophic vaginitis and orgasm dysfunction as it is a better option than medications or surgery.
Body Dysmorphic Disorder - BDD and Plastic Surgery
Dr. Aaron Stone - Plastic Surgeon Los Angeles
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