Labiaplasty and Vaginoplasty

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Vaginal labiaplasty or simply labiaplasty refers to surgical reduction of the size of the labia minora or creation of labia in transgender surgery. This blog only covers the reduction surgery. The procedure has become an increasingly popular in recent years and is carried out for a variety of reasons. In its 2014 national totals for cosmetic procedures, ASAPS reported surgeons performed 7,535 labiaplasty procedures in 2014. Labiaplasty increased by 49% compared to the prior year, and nearly 90% of those patients were 19 to 50 years old. In 2015 the number of procedures increased another 16% to 8,745. However, the number of labiaplasties performed on girls 18 under was 80% greater in 2015 than 2014, which is alarming. Since these number only include Plastic Surgeons the actual US numbers are likely much higher when procedures performed by Gynecologists are included. During this same period of time breast augmentation for teenagers and adults together only went up 6.7%

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

1. deepithelialization: 
removes a small amount of surface tissue while preserving the labial contour. It is best suited for patients with minimal hypertrophy.
2. 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.

edge resection
3. 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.

wedge resection with step
4. 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.
5. miscellaneous:
W-shaped resection, Z-plasty, and laser labiaplasty

The technique chosen depends on patient anatomy, goals, and surgeon comfort while preserving the vaginal opening, color/texture match, and the nerve/blood supply. The most common complications following labiaplasty are separation of the suture lines, hematoma/bleeding, unsatisfactory scarring, and superficial infections. Excessive or insufficient tissue removal and asymmetry after surgery can also be problems. In addition, flap necrosis has been reported with wedge resection. Despite that the procedure is increasingly popular with high satisfaction rates. Suture line separation is minimized by tension free closure, use of longer lasting absorbable sutures (removing non-absorable sutures is painful and uncomfortable for the patient and the surgeon) and restraining from sex or exercise until the area is healed. One of my patients went dancing within a week of surgery, tore the repair on one side and had a less than optimal result on that side.

Care after surgery involves topical antibiotic ointment covered with gauze or sanitary pad for the first 24 hours. The area is cleansed with water sprayed from a water bottle like device after urinating and patting dry with gauze to prevent urine from getting on the suture line for the first 3 to 5 days after surgery. Exercise, vigorous physical activity including dancing, tampons and sexual activity should be avoided for 3 to 4 weeks after surgery. Activities like cycling may be resumed after 6 weeks.

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

Thermiva handpiece that is inserted for radiofrequency vaginoplasty. The radiofrequency heats up and shrinks the tissue. After 3 to 5 treatments patients report a high degree of satisfaction, resolution of urinary incontinence... The treatment is relatively new but it appears that short maintenance treatments are then required once a year.

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

Female Genital Cosmetic Surgery
Dr. Aaron Stone - Plastic Surgeon Los Angeles
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