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Labiaplasty (also known as labioplasty, labia minor reduction, and labial reduction) is a plastic surgery procedure for altering the labia minora (inner labia) and the labia majora (outer labia), the folds of skin surrounding the human vulva. There are two main categories of women seeking cosmetic genital surgery: those with congenital conditions such as intersex, and those with no underlying condition who wish to alter the appearance of their genitals because they believe they do not fall within a normal range.

The size, colour, and shape of labia vary significantly, and may change as a result of childbirth, sexual intercourse, aging, and other events. Conditions addressed by labiaplasty include congenital defects and abnormalities such as vaginal atresia (absent vaginal passage), Müllerian agenesis (malformed uterus and fallopian tubes), intersex conditions (male and female sexual characteristics in a person); and tearing and stretching of the labia minora caused by childbirth, accident and age. In a male-to-female sexual reassignment vaginoplasty for the creation of a neovagina, labiaplasty creates labia where once there were none.

A 2008 study in the Journal of Sexual Medicine reported that 32 per cent of women who underwent the procedure did so to correct a functional impairment; 31 per cent to correct a functional impairment and for aesthetic reasons; and 37 per cent for aesthetic reasons alone. The risks of the procedure include permanent scarring, infections, bleeding, irritation, and nerve damage leading to increased or decreased sensitivity. The Observer wrote in 2011 that medical experts had "sounded the alarm" about the procedure and its soaring rates, blaming increased exposure to pornography images on the Internet. Linda Cardozo, a gynaecologist at King's College Hospital, London, told the newspaper that women were placing themselves at risk in an industry that is largely unregulated.

Size of the labia

External image
"Betty Dodson's Vulva Illustrations", showing the wide variety of appearance of the female vulva.

The external genitalia of a woman are collectively known as the vulva. This comprises the labia majora (outer labia), the labia minora (inner labia), the clitoris, the urethra, and the vagina. The labia majora extend from the mons pubis to the perineum.

The size, shape, and color of women's inner labia vary greatly. One is usually larger than the other. They may be hidden by the outer labia, or may be visible, and may become larger with sexual arousal, sometimes two to three times their usual diameter.

The size of the labia can change because of mechanical irritation (stretching and tearing) during coitus (sexual intercourse) and childbirth. Genital piercing can increase labial size and asymmetry, because of the weight of the ornaments. In the course of treating identical twin sisters, S.P. Davison et al reported that the labia were the same size in each woman, which indicated genetic determination. In or around 2004, researchers from the Department of Gynaeology, Elizabeth Garret Anderson Hospital, London, measured the labia of 50 women betwee the ages of 18 and 50, with a mean age of 35.6:

Surgery

Contraindications

Labia reduction surgery is relatively contraindicated for the woman who has active gynecological disease, such as an infection or a malignancy; the woman who is a tobacco smoker and is unwilling to quit, either temporarily or permanently, in order to optimize her wound-healing capability; and the woman who is unrealistic in her aesthetic goals. The latter should either be counselled or excluded from labioplastic surgery. Davison et al write that it should not be performed when the patient is menstruating to reduce potential hormonal effects and the increased risk of infection.

Sex reassignment surgery

In sexual reassignment surgery, in the case of the male-to-female transgender patient, labiaplasty is usually the second stage of a two-stage vaginoplasty operation, where labiaplastic techniques are applied to create labia minora and a clitoral hood. In this procedure, the labiaplasty is usually performed some months after the first stage of vaginoplasty.

Anaesthesia

Labial reduction can be performed under local anaesthesia, conscious sedation, or general anaesthesia, either as a discrete, single surgery, or in conjunction with another, gynecologic or cosmetic, surgery procedure. The resection proper is facilitated with the administration of an anaesthetic solution (lidocaine + epinephrine in saline solution) that is infiltrated to the [labia minora to achieve the tumescence (swelling) of the tissues and the constriction of the pertinent labial circulatory system, the hemostasis that limits bleeding.

Procedures

Edge resection technique

The original labiaplasty technique was simple resection of tissues at the free edge of the labia minora. One resection-technique variation features a clamp placed across the area of labial tissue to be resected, in order to establish hemostatis (stopped blood-flow), and the surgeon resects the tissues, and then sutures the cut labium minus or labia minora. The technical disadvantages of the labial-edge resection technique are the loss of the natural rugosity (wrinkles) of the labia minora free edges, thus, aesthetically, it produces an unnaturally “perfect appearance” to the vulva, and also presents a greater risk of damaging the pertinent nerve endings. Moreover, there also exists the possibility of everting (turning outwards) the inner lining of the labia, which then makes visible the normally hidden internal, pink labial tissues. The advantages of edge-resection include the precise control of all of the hyper-pigmented (darkened) irregular labial edges with a linear scar that can also be used to contour the redundant tissues of the clitoral hood, when present.

Central wedge resection technique

Labial reduction by means of a central wedge-resection involves cutting and removing a full-thickness wedge of tissue from the thickest portion of the labium minus. Unlike the edge-resection technique, the resection pattern of the central wedge technique preserves the natural rugosity (wrinkled free-edge) of the labia minora. Yet, because it is a full-thickness resection, there exists the potential risk of damaging the pertinent labial nerves, which can result in painful neuromas, and numbness. F. Giraldo et al. procedurally refined the central wedge resection technique with an additional 90-degree Z-plasty technique, which produces a refined surgical scar that is less tethered, and diminishes the physical tensions exerted upon the surgical-incision wound, and, therefore, reduces the likelihood of a notched (scalloped-edge) scar. The central wedge-resection technique is a demanding surgical procedure, and difficulty can arise with judging the correct amount of labial skin to resect, which might result in either undercorrection (persistent tissue-redundancy), or the overcorrection (excessive tension to the surgical wound), and an increased probability of surgical-wound separation. Moreover, as appropriate, a separate incision is required to treat a prominent clitoral hood.

De-epithelialization technique

Labial reduction by means of the de-epithelialization of the tissues involves cutting the epithelium of a central area on the medial and lateral aspects of each labium minor (small lip), either with a scalpel or with a medical laser. This labiaplasty technique reduces the vertical excess tissue, whilst preserving the natural rugosity (corrugated free-edge) of the labia minora, and thus preserves the sensory and erectile characteristics of the labia. Yet, the technical disadvantage of de-epithelialization is that the width of the individual labium might increase if a large area of labial tissue must be de-epithelialized to achieve the labial reduction.

Labiaplasty with clitoral unhooding

Labial reduction occasionally includes the resection of the clitoral prepuce (clitoral hood) when the thickness of its skin interferes with the woman’s sexual response. The surgical unhooding of the clitoris involves a V–to–Y advancement of the soft tissues, which is achieved by suturing the clitoral hood to the pubic bone in the midline (to avoid the pudendal nerves); thus, uncovering the clitoris further tightens the labia minora.

Laser labiaplasty technique

Labial reduction by means of laser resection of the labia minora involves the de-epithelialization of the labia. The technical disadvantage of laser labiaplasty is that the removal of excess labial epidermis risks causing the occurrence of epidermal inclusion cysts.

Labiaplasty by de-epithelialization

Labial reduction by de-epithelialization cuts and removes the unwanted tissue and preserves the natural rugosity (wrinkled free-edge) of the labia minora, and preserves the capabilities for tumescence and sensation. Yet, when the patient presents with much labial tissue, a combination procedure of de-epithelialization and clamp-resection is usually more effective for achieving the aesthetic outcome established by the patient and her surgeon. In the case of a woman with labial webbing (redundant folding) between the labia minora and the labia majora, the de-epithelialization labiaplasty includes an additional resection technique — such as the five-flap Z-plasty (“jumping man plasty”) — to establish a regular and symmetric shape for the reduced labia minora.

Post-operative care

Post-operative pain is minimal, and the woman is usually able to leave hospital the same day. Usually, no vaginal packing is required, although she might choose to wear a sanitary pad for comfort. The physician informs the woman that the reduced labia are often very swollen during the early post-operative period, because of the edema caused by the anaesthetic solution injected to swell the tissues. She is also instructed on the proper cleansing of the surgical wound site, and the application of a topical antibiotic ointment to the reduced labia, a regimen observed three times daily for two days after surgery.

The woman’s initial, post-labiaplasty consultation with the surgeon is recommended one week after surgery. She is advised to return to the surgeon’s consultation room should she develop hematoma, an accumulation of blood outside the pertinent (venous and arterial) vascular system. Depending on her progress, the woman can resume physically unstrenuous work three to four days after surgery. To allow the wounds to heal, she is instructed not to use tampons, not to wear tight clothes (e.g. thong underwear), and to abstain from sexual intercourse for four weeks after surgery.

Medical complications to a labiaplasty procedure are uncommon, yet occasional complications — bleeding, infection, labial asymmetry, poor wound-healing, undercorrection, overcorrection — do occur, and might require a revision surgery. An over-aggressive resection might damage the nerves, causing painful neuromas. Performing a flap-technique labiaplasty occasionally presents a greater risk for necrosis of the labia minora tissues.

Criticism

Labiaplasty is a controversial subject. Critics argue that a woman's decision to undergo the procedure stems from an unhealthy self-image induced by their comparison of themselves to the prepubescent images of women they see in commercials or pornography. In the United States, a labiaplasty surgeon can earn up to $250,000 a month, according to Shameless magazine. Simone Weil Davis, professor of American studies – author of Living Up to the Ads: Gender Fictions of the 1920s (2000), and "Loose lips sink ships" (2002) – told the magazine in 2005 that surgeons are perpetuating the idea that there is a right way for women's genitalia to look. She argues: "Labia are neither inside nor outside, they are gateway tissues, and they kind of represent a part that is confusing." Because most women see only their own vaginas, or pornographic images, it is easy to make them doubt themselves.

Although female genital mutilation – the practice in several African countries of cutting off a woman's labia, clitoris, and in some cases creating a seal across her entire vulva – is illegal in the United States, Canada, Europe and elsewhere, Davis argues that "when you really look carefully at the language used in some of those laws, they would also make illegal the labiaplasties that are being done by plastic surgeons in the U.S." The World Health Organization (WHO) defines "female genital mutilation" as "all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons." The WHO writes that the term is not generally applied to elective procedures such as labiaplasty.

The American College of Obstetricians and Gynecologists (ACOG) published an opinion in the September 2007 issue of Obstetrics & Gynecology. ACOG said that several "vaginal rejuvenation" procedures were not medically indicated, and that there was no documentation of their safety and effectiveness. ACOG argued that it was deceptive to give the impression that the procedures were accepted and routine surgical practices. It recommended that women seeking such surgeries must be given the available surgical-safety statistics, and warned of the potential risks of infection, altered sensation caused by damaged nerves, dyspareunia (painful sexual intercourse), tissue adhesions, and painful scarring.

In the UK, Lih Mei Liao and Sarah M. Creighton of the UCL Institute for Women's Health wrote in the British Medical Journal in 2007 that "the few reports that exist on patients’ satisfaction with labial reductions are generally positive, but assessments are short-term and lack methodological rigour." They wrote that the increased demand for cosmetic genitoplasty (labiaplasty) may reflect a "narrow social definition of normal." The National Health Service performed double the number of genitoplasty procedures in the year 2006 than in the 2001–2005 period. The authors noted that "the patients consistently wanted their vulvas to be flat, with no protrusion beyond the labia majora ... some women brought along images to illustrate the desired appearance, usually from adverts or pornography that may have been digitally altered." The Royal Australian and New Zealand College of Obstetricians and Gynæcologists published the same concern about the exploitation of psychologically insecure women.

The International Society for the Study of Women’s Sexual Medicine produced a report in 2007 concluding that, while the surgery is a woman's right, she should be counseled beforehand, because variations in the appearance of the vulva are normal; and that, based on the four principles of ethical practice of medicine, such surgery is not always ethical, but not always unethical.

In the United States, the feminist organization the New View Campaign—which opposes the medicalization of sex—opposes labiaplasty. They specifically oppose the existence of unregulated cosmetic surgery clinics as business enterprises, which they say trade on women's sexuality by appealing to their low self-esteem, thereby creating health risks.

See also

• Anal bleaching
• Clitoral hood reduction
• Elongated labia
• Labia stretching
• Vaginoplasty

References

1. ^ Lloyd, Jillian et al. "Female genital appearance: 'normality' unfolds", British Journal of Obstetrics and Gynaecology, May 2005, Vol. 112, pp. 643–646. PMID 15842291
2. Miklos JR and Moore RD. "Labiaplasty of the Labia minora: Patients’ Indications for Pursuing Surgery", Journal of Sexual Medicine. 2008;5(6)1492–1495.
3. Davis, Rowenna. "Labiaplasty surgery increase blamed on pornography", The Observer, 27 February 2011.
   • Also see Navarro, Mireya. "The Most Private of Makeovers", The New York Times, 28 November 2004.
4. Masters, William H.; Johnson, Virginia E.; and Kolodny, Robert C. Human sexuality. HarperCollins College Publishers, 1995, p. 47.
5. Sloane, Ethel. Biology of women. Cengage Learning, 2002, p. 32.
6. ^ Davison S.P. et al. "Labiaplasty and Labia Minora Reduction", eMedicine.com, 23 June 2008.
7. Nevárez Bernal R.A. and Meráz Ávila, D. "Fusion of the Labia Minora as a Cause of Urinary Incontinence in a Postmenopausal Woman: a Case Report and Literature Review," Ginecología y Obstetricia de México, 77(6), June 2009, pp. 287–290.
8. Hodgkinson, Darryl J.; Hait, Glen (1984). "Aesthetic Vaginal Labioplasty". Plastic and Reconstructive Surgery. 74 (3): 414–6. doi:10.1097/00006534-198409000-00015. PMID 6473559.
9. ^ Alter, Gary J.; Alter, G J (1998). "A New Technique for Aesthetic Labia Minora Reduction". Annals of Plastic Surgery. 40 (3): 287–90. doi:10.1097/00000637-199803000-00016. PMID 9523614.
10. Alter, Gary J. (2005). "Central Wedge Nymphectomy with a 90-Degree Z-Plasty for Aesthetic Reduction of the Labia Minora". Plastic and Reconstructive Surgery. 115 (7): 2144–5, author reply 2145. doi:10.1097/01.PRS.0000165466.99359.9E. PMID 15923876.
11. Rouzier, Roman; Louis-Sylvestre, Christine; Paniel, Bernard-Jean; Haddad, Bassam (2000). "Hypertrophy of labia minora: Experience with 163 reductions". American Journal of Obstetrics and Gynecology. 182 (1 Pt 1): 35–40. doi:10.1016/S0002-9378(00)70488-1. PMID 10649154.
12. Alter, Gary J. (2007). "Aesthetic Labia Minora Reduction with Inferior Wedge Resection and Superior Pedicle Flap Reconstruction". Plastic and Reconstructive Surgery. 120 (1): 358–9, author reply 359–60. doi:10.1097/01.prs.0000264588.97000.dd. PMID 17572600.
13. Maas, Sylvester M.; Hage, J. Joris (2000). "Functional and Aesthetic Labia Minora Reduction". Plastic & Reconstructive Surgery. 105 (4): 1453–6. doi:10.1097/00006534-200004040-00030. PMID 10744241.
14. Giraldo, Francisco; González, Carlos; de Haro, Fabiola (2004). "Central Wedge Nymphectomy with a 90-Degree Z-Plasty for Aesthetic Reduction of the Labia Minora". Plastic and Reconstructive Surgery. 113 (6): 1820–1825, discussion 1826–1827. doi:10.1097/01.PRS.0000117304.81182.96. PMID 15114151.
15. Alter GJ. A New Technique for Aesthetic Labia Minora Reduction. Annals of Plastic Surgery. 1998 March;40(3);287–290
16. Choi, Hee Youn; Kim, Kyung Tai (2000). "A New Method for Aesthetic Reduction of Labia Minora (the Deepithelialized Reduction Labioplasty)". Plastic & Reconstructive Surgery. 105: 419–422, discussion 423–424. doi:10.1097/00006534-200001000-00067.
17. Alter GJ. Aesthetic Labia minora and Clitoral Hood Reduction using Extended Wedge Resection. Plastic and Reconstructive Surgery. December 2008. 122(6):1780–1789.
18. Pardo J, Solà V, Ricci P, Guilloff E. Laser Labioplasty of Labia minora. International Journal of Gynaecology and Obstetrics. 2006 April;93(1)38–43
19. Veale, D. and Neziroglu, F. Body Dysmorphic Disorder: A Treatment Manual. John Wiley and Sons, 2010, p. 104.
20. ^ Cormier, Zoe. "Making the Cut", Shameless, Fall 2005.
    • Davis, Simone Weil. "Loose lips sink ships", Feminist Studies, 28(1) (Spring 2002), pp. 7–35.
21. "Female genital mutilation", World Health Organization, February 2010.
22. "Eliminating Female Genital Mutilation", World Health Organization, 2008.
    • For a brief discussion of elective procedures and their relationship to FGM, see Annex 2, p. 24.
    • For the statement about medical ethics, and the 1994 resolution, see p. 12.
23. "ACOG Advises Against Cosmetic Vaginal Procedures Due to Lack of Safety and Efficacy Data", American College of Obstetricians and Gynecologists, 1 September 2007.
    • "Vaginal 'Rejuvenation' and Cosmetic Vaginal Procedures", American College of Obstetricians and Gynecologists, 2007, p. 2.
24. Liao, Lih Mei, and Creighton, Sarah M. "Requests for Cosmetic Genitoplasty: How Should Healthcare Providers Respond?", British Medical Journal, 334(7603), 26 May 2007, pp. 1090–1092.
25. Goodman, M.P. et al. "Is Elective Vulvar Plastic Surgery ever Warranted and What Screening Should be Done Preoperatively?", Journal of Sexual Medicine, 4, 2007, pp. 269–276.
26. "Female Genital Cosmetic Surgery (FGCS) Activism", New View Campaign, accessed 19 September 2011.

Further reading

• Boston Women’s Health Book Collective. "Our Bodies, Ourselves", Simon and Schuster, 2005.
• Revill, Jo. "The new nose job: designer vaginas", The Observer 17 August 2003.
• Rogers, Lisa. "The quest for the perfect vagina", The Guardian 15 August 2008.
• Rogers, Lisa. "The Perfect Vagina", Channel 4 documentary, 17 August 2008, accessed 18 September 2011.

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