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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. There is no universally accepted definition of labial hypertrophy. 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.

Surgical anatomy of the vulva

The vulvo-vaginal complex

The external genitalia of a woman are collectively denoted the vulvo-vaginal complex, which comprises the labia majora, the labia minora, the clitoris, the urethra, and the vagina. The fatty labia majora (the large outer lips) extend from the mons pubis to the rectum. The vascularized labia minora (the small inner lips) are within the labia majora; however, in some women, the minor lips are short and thin and hidden by the labia majora; and in some women, the labia minora are longer, thicker, and wider, and extend beyond the labia majora.

Composition

The labia minora consist of two (2) connective folds of flesh that contain some adipose tissue; at the front and upper portions of the Vulva (vulva), the labia minora divide into two parts. The first part passes over the clitoris, and forms the prepuce of the clitoris (clitoral hood); the second part of the labia minora joins beneath the clitoris and forms the fourchette (labial frenulum), a transverse fold of tissue that occasionally unites the labia minora to the labia majora at their posterior extensions. The skin and the mucosa of the labia minora are rich in sebaceous glands and nerve endings, thus the labia are very sensitive to the touch. These folds of vulvo-vaginal skin have a core of connective, erectile tissue (analogous to the corpus spongiosum penis), and are covered by stratified, squamous epithelium — thus, the labia minora moisten and swell with extracellular fluid during sexual arousal. Furthermore, during urination, the labia minora function to direct the urine stream away from the vulva.

Labial anatomic variation

The size, the shape, and the color of the labia minora vary according to the woman. Like most paired structures of the human body, the labia are not anatomically symmetrical — one labium minus (minor lip) usually is larger (longer, wider, thicker) than its pair — yet the asymmetry usually is not notable. The length and the width of the labia minora determine whether they protrude from, or are hidden by, the labia majora. Further increases in the sizes of the labia (majora and minora) occur when the woman is sexually aroused — in preparation for coitus — when the labia become engorged with blood and may increase two-to-three times in diameter.

Labial hypertrophy can be caused by the mechanical stresses inherent to the cultural practice of genital piercing, the bearing of relatively heavy-weight metal ornaments attached through the perforated labium or labia, which is medically notable because bearing weight is not a usual anatomic function of the labia minora. Furthermore, large labia minora can also be a genetically inherited anatomical feature of the woman’s vulva. The plastic surgery study Labiaplasty and Labia minora Reduction (2008) reported the occurrence of labia minora of like sizes (length, width, girth) in identical twin sisters treated for labial hypertrophy, which might indicate a genetic predisposition to developing large labia minora.

Measures of the vulva

Because there is no formal, medical definition of labial hypertrophy (length, width, girth), nor a standardized method for grading the degree of hypertrophy present, the plastic surgeon and the patient determine the amount of reduction without a fixed anatomic reference. To the end of providing such a medical reference, the morphologic study Female Genital Appearance: ‘Normality’ Unfolds (2005) reported the range of anatomic variations of the vulvo-vaginal complex of a 50-woman cohort (18–50 y/o, mean age 35.6 yrs.); the statistical variations of the vulva are:

The patient

The woman seeking the surgical reduction of her labia minora may present with labial asymmetry that causes her awkward vulvo-vaginal hygiene (e.g. toilet-paper bits attaching to the labia); the catching of the labia in garment-zipper closures; pubic discomfort when wearing tight clothes; pubic-area pain when practicing sport (bicycling, running, et cetera); either a disrupted or a diffused urinary stream; and dyspareunia (painful sexual intercourse). In the case of labial asymmetry, where one labium minus is longer, wider, and thicker than the corresponding labium minus, only the larger lip is reduced in order to match the smaller lip. Labioplasty can be safely performed any time after sexual maturity (18 years of age or older); it can be performed either before or after pregnancy, in order to minimze hormonal interference with her body’s capacity to heal a surgical wound. Labiaplasty is not performed upon a woman who is menstruating, to minimize the risk of post-operative infection of the surgical-incision site(s). Generally, the patient’s most common complaint of self perception is that, when observed in the standing position, her labia minora protrude too much beyond the labia majora, which may lead to low self-esteem, and subsequent difficulty in achieving emotional and sexual intimacy in her private life. (See: Sex appeal and Body dysmorphic disorder)

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. As required by the (transgender) woman’s indications, after a one-stage vaginoplasty, the labiaplasty — which creates the labia majora and the labia minora — can be an elective surgery procedure for refining the aesthetics of the woman’s vulvo-vaginal complex. (See: Male-to-female sex reassignment surgery)

Surgical procedures

General

As with every paired structure of the human body, the labia minora are not perfectly symmetrical and, although the size discrepancy is usually subtle, women often present with one labium minus (minor lip) larger (longer, wider, thicker) than its pair; thus, only the larger lip undergoes tissue resection (cutting and removal). In the woman who presents with one labium considerably larger than its pair, only the larger lip is resected for symmetry with the smaller lip. In the case of the woman who also presents redundant folding — unilateral webbing or bilateral webbing — between the labia majora and the labia minora, the webbing can be removed by means of labioplasty.

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 in order to achieve the tumescence (swelling) of the tissues and the constriction of the pertinent labial circulatory system, the hemostasis that limits bleeding.

Techniques for labial reduction

I. 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.

II. 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.

III. 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.

IV. 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.

V. 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.

Surgical technique

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.

Pre-operative matters

• Consultation — To understand the aesthetic goals of the patient, the plastic surgeon evaluates the appearance of the labia when the patient is standing. Afterwards, in the operating room, with the patient in the lithotomy position (as if for urinary-bladder stone-removal surgery), the surgeon then delineates the resection-pattern markings (incision plan) to each side of each labium (lip) to facilitate the de-epithelialization required for reducing its size (length and width). Afterwards an anaesthetic solution is infiltrated to the labial tissues to numb and swell them for easy resection. Depending on the patient’s health, the physician–surgeon may instruct the woman to take oral antibiotic and anti-inflammatory medications before the operation; if not, they are intravenously administered to the patient at the start of the labiaplasty operation.

Operative technique

For the optimal exposure of the vulvo-vaginal complex, the patient is positioned upon the operating table in the lithotomy position. After confirming regional anaesthesia and labial tumescence, the surgeon then cuts and removes (resects) the unwanted tissues of the labia minora. After the resection step, the suturing of the surgical wound is the procedural step that most influences the aesthetic outcome of the labial reduction — suturing the tissues of the labia minora with a running absorbable-suture occasionally produces a scallop-edged surgical scar-line, whereas suturing the tissues with a running buried-suture usually produces a wound closure (scar-line) of natural appearance.

Post-operative matters

• Convalescence — Post-operative pain and surgical-wound care are minimal, permitting the woman to leave hospital and return home 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 often are 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 wound-care regimen observed 3-times daily for 2-days post-operative.

• Follow-up therapy — The woman’s initial, post-labiaplasty consultation with the surgeon is recommended at 1-week post-operative. 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 wound-healing progress, the woman can resume physically un-strenuous and undemanding work at 3–4 days post-operative. Moreover, to allow the full and proper healing of the labiaplasty surgical wounds, the woman is instructed to not use tampons, to not wear tight clothes (e.g. thong underwear), and to abstain from sexual intercourse for 4-weeks post-operative.

Complications

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

Psychosocial criticism

Patients

Women seek vaginoplastic surgery: (i) to address congenital defects, deformities, 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), etc.; and (ii) for aesthetic reasons. Women usually seek a labial reduction procedure to correct morphologic changes caused by the mechanical stresses (stretching, pulling, tearing) of childbirth, sexual intercourse, accident, and aging. Problems associated with large labia include vulvo-vaginal hygiene problems, chronic irritation of the pudendal skin, painful sexual intercourse (dyspareunia), and pubic pain when wearing tight clothes.

Patient psychology

The psychosocial study of women who pursue beauty by means of cosmetic plastic surgery, Body Dysmorphic Disorder: A Treatment Manual (2010) indicates that, in addition to labial reduction, some women pursue genital surgery to acquire a flat vulvo-vaginal complex in the style of the “prepubescent aesthetic” portrayed in pornography and in commercial adverts. Nonetheless, the investigators David Veale and Fugen Neziroglu, reported that “no studies have been done on the prevalence of BDD in women seeking labiaplasty. It may be important for cosmetic gynecologists to define when the degree of protrusion, or hypertrophy, of the labia minora is no longer minor (which would exclude a diagnosis of BDD). One of the authors has seen several women seeking labiaplasty in recent years, because of her affiliation with gynecologists. Most of the women had either bulkiness or a slight protrusion of their labia , but were not abnormal in size. Because it is not appropriate for mental health professionals to assess the size and shape of the labia of women, a clinician must rely on a gynecologist or a family doctor who has examined the patient.” The body dysmorphia findings reported in the Veale–Neziroglu study confirm the psychosocial findings of the earlier study Female Genital Appearance: ‘Normality’ Unfolds (2005), which indicated that a woman — as a plastic surgery patient — might be motivated to seek labiaplasty (genitoplasty) because she feels that her vulva is not within a given “normal” aesthetic range of labial size, appearance, and color.

Patient satisfaction

The retrospective study Labiaplasty of the Labia minora: Patients’ Indications for Pursuing Surgery (2008) reported that in a 131-woman group, 32 per cent of the women underwent labial reduction to correct a functional impairment; 31 per cent to correct a functional impairment and for aesthetic reasons; and 37 per cent underwent labiaplasty solely for aesthetic purposes. Concerning the technical and procedural efficacy of labiaplasty, the study Hypertrophy of Labia minora: Experience with 163 Reductions (1999) reported a 93 per cent rate of patient satisfaction with the surgical outcome of the labial reduction procedure, and concluded that labiaplasty is a technically simple surgical operation with a high rate of patient satisfaction.

Cultural criticism

Semantic distinctions

In Western culture, the term Female Genital Cutting (FGC) denotes the cutting off of any part(s) or portion(s) of the vulva — either for religious or for cultural reasons, or both — but not the surgical correction of congenital defects and developmental abnormalities of the vulvo-vaginal complex, such as vaginal atresia (undeveloped vagina), Müllerian agenesis (absent uterus and fallopian tubes), and intersex conditions. Yet, in social and cultural discourse, the layman opponents of such religiously- and culturally-motivated sexual mutilations inaccurately use the terms Female Genital Mutilation (FGM) and Female Circumcision (FC) as interchangeably synonymous with female genital cutting. Therefore, from the physician’s perspective, it is important to formally observe the semantic distinction between a religious or cultural practice and the medical practice of labiaplasty, which is an elective plastic surgery operation for a woman, involving the modification of the vulva for aesthetic purposes or to address a functional problem. The study Hypertrophy of Labia minora: Experience with 163 Reductions (1999) reported a 93 per cent rate of patient satisfaction with the labiaplasty outcomes; and the subsequent psychological improvements reported by the women included increased self-esteem derived from the refined aesthetic body image. The study Labiaplasty of the Labia minora: Patients’ Indications for Pursuing Surgery (2008), reported that 32 per cent of the women underwent labial reduction for the correction of a functional impairment; that 31 per cent of the women underwent the correction of functional and aesthetic impairments; and that 37 per cent of the women underwent labiaplasty solely for aesthetic corrections.

Woman as plastic surgery patient

Sociologically, labiaplasty is a controversial subject among laymen and physicians who believe that a woman’s decision to undergo cosmetic genital surgery is psychologically induced by the commercialism of medicalized sex appeal; that she desires a mentally unhealthy sexual body image derived from pornography — hence, some opponents of cosmetic plastic surgery semantically liken labiaplasty to genital modification and mutilation. Moreover, specifically regarding female genital mutilation, the World Health Organization (WHO) cited the Hippocratic Oath to publicly declare and establish the medical and ethical obligation that “health professionals must never perform female genital mutilation”, and so harm a woman patient.

• In the Feminist Studies journal essay “Loose Lips Sink Ships” (2002) and in the Shameless online magazine article “Making the Cut” (2005), Prof. Simone Weil Davis said that plastic surgeons perpetuate for women the cultural concept of aesthetically ideal female genitalia, and that because the “labia are neither inside nor outside , they are gateway tissues, and they kind of represent a part that is confusing”; and proposed that because women know only their vaginas and the pornographic pre-pubescent ideal, women readily see themselves as aesthetically abnormal, as being outside the ideal beauty range, which is a cultural construct.

Moreover, in addressing the matter of FGM (labial- and clitoral-mutilation as religious and cultural practices) which is illegal in Canada and the U.S., Prof. Davis addressed the semantic dilemma that arises “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.” Nonetheless, although the official WHO resolution Eliminating Female Genital Mutilation (2008) defined FGM 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 document’s Annex 2: Note on the Classification of Female Genital Mutilation states that: “The guiding principles for considering genital practices as female genital mutilation should be those of human rights, including the right to health, the rights of children, and the right to non-discrimination on the basis of sex. Some practices, such as genital cosmetic surgery and hymen repair, which are legally accepted in many countries, and not generally considered to constitute female genital mutilation, actually fall under the definition used here.” Therefore, the woman and her plastic surgeon resolve said semantic ambiguity in the exclusive context of the Doctor-and-Patient relationship.

• In the U.K., the medical article Requests for Cosmetic Genitoplasty: How Should Healthcare Providers Respond? (2007) indicated that “the few reports that exist on patients’ satisfaction with labial reductions are generally positive; but the assessments are short-term and lack methodological rigour”; and that the increased demand for cosmetic genitoplasty (labiaplasty) was indicated by the British National Health Service (NHS) having performed double the number of genitoplasty procedures in the year 2006, than were performed in the 2001–2005 period; and that the women who elected to undergo genitoplasty did so because having a pretty vulva was important them. Nonetheless, the authors, the clinical psychologist Lih Mei Liao and the gynæcologist Sarah M. Creighton, reported 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 advertisments or pornography that may have been digitally altered.” The report concluded that the “designer vagina craze” originated from the commercialism of sexual medicalization. Elsewhere, in Oceania, The Royal Australian and New Zealand College of Obstetricians and Gynæcologists published a like concern about the commercial exploitation of psychologically insecure women to undergo cosmetic genitoplasty.

• In the U.S., the American College of Obstetricians and Gynecologists (ACOG) published Committee Opinion No. 378: Vaginal “Rejuvenation” and Cosmetic Vaginal Procedures (2007), the college’s formal policy statement of opposition to the commercial misrepresentations of labiaplasty, and associated vaginoplastic procedures, as medically “accepted and routine surgical practices”. The ACOG doubted the medical safety and the therapeutic efficacy of the surgical techniques and procedures for performing labiaplasty, vaginal rejuvenation, the designer vagina, revirgination, and Gräfenberg Spot amplification, and recommended that women seeking such genitoplastic surgeries must be fully informed, with the available surgical-safety statistics, of the potential health risks of surgical-wound infection, of pudendal nerve damage (resulting in either an insensitive or an over-sensitive vulva), of dyspareunia (painful coitus), of tissue adhesions (epidermoid cysts), and of painful scars.

• To determine whether or not women truly seek labiaplasty solely to have “more socially acceptable genitalia” the International Society for the Study of Women’s Sexual Health (ISSWSH) considered the practices of elective plastic surgery of the vulva and of FGC (female genital cutting) in the Third World. The report, Is Elective Vulvar Plastic Surgery ever Warranted and What Screening Should be Done Preoperatively? (2007) indicated that physical variations in the external appearance of the vulvo-vaginal complex are statistically normal, but that labiaplasty — like access to all types of medical treatment — is a woman’s human right. Nonetheless, the ISSWSH report concluded that vaginoplastic surgery might be medically warranted only after the woman undergoes a pre-operative psychological screening, and only if the woman afterwards remains so decided — yet also recommended that vaginal surgery can be performed if the surgeon deems it medically necessary for her health.

• In the U.S., the feminist organization The New View Campaign formally opposed labiaplasty (genitoplasty) as part of the medicalization of female sexuality, which the organization said is a great public mental health problem of contemporary American society. The specific opposition was to the existence and operation of legally un-regulated cosmetic surgery clinics that function as business enterprises trading upon the medicalized sexuality of women, by appealing to their low self-esteem and poor body image, thereby creating new health risks, and social norms about what prettiness is and what prettiness is not. To the end of making socially legitimate the natural morphologic diversity of the bodies of women, The New View Campaign proposed that countering sexual and bodily self-hatred among American women requires changing the U.S. societal norms defining what beauty is and what beauty is not, and by re-defining what social and personal behaviors constitute mental health.

See also

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

References

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   • Also see Navarro, Mireya. "The Most Private of Makeovers", The New York Times, 28 November 2004.
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31. Davis, Simone Weil (2002). "Loose Lips Sink Ships". Feminist Studies. 28 (1): 7–35. doi:10.2307/3178492. JSTOR 3178492.
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33. "Eliminating Female Genital Mutilation", World Health Organization, 2008.
34. Menage J (2006). "Female genital mutilation: whose problem, whose solution? Psychological damage is immense". BMJ. 333 (7561): 260. doi:10.1136/bmj.333.7561.260. PMC 1523486. PMID 16873873. {{cite journal}}: Unknown parameter |month= ignored (help)
35. Bibbings LS (2006). "Female genital mutilation: whose problem, whose solution? Mutilation or modification?". BMJ. 333 (7561): 259–60. doi:10.1136/bmj.333.7561.259-b. PMC 1523441. PMID 16873868. {{cite journal}}: Unknown parameter |month= ignored (help)
36. "Top Medical Journal Blasts "designer vagina" Craze". AFP via breitbart.com. 24 May 2007. Retrieved 29 May 2007.
37. Liao, Lih Mei (26 May 2007). "Requests for Cosmetic Genitoplasty: How Should Healthcare Providers Respond?". BMJ. 334 (7603). British Medical Journal: 1090–1092. doi:10.1136/bmj.39206.422269.BE. PMC 1877941. PMID 17525451. Retrieved 29 May 2007. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
38. http://www.breitbart.com/article.php?id=080801145404.zfnnx1i6&show_article=1
39. Navarro, Mireya (28 November 2004). "The Most Private of Makeovers". The New York Times. Retrieved 6 June 2009.
40. American College of Obstetricians and Gynecologists (2007). "Vaginal "Rejuvenation" and Cosmetic Vaginal Procedures" (PDF): 2. {{cite journal}}: Cite journal requires |journal= (help)
41. Goodman MP, Bachmann G, Johnson C, Fourcroyo JL, Goldstein A, Goldstein G, Sklar S. Is Elective Vulvar Plastic Surgery ever Warranted and What Screening Should be Done Preoperatively? Journal of Sexual Medicine 2007;4:269–276
42. New View Campaign - The Campaign
43. New View Campaign :: W E L C O M E
44. Video | Betty Dodson with Carlin Ross

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.

Template:Link GA

• Use dmy dates from September 2011
• Genital modification
• Plastic surgery
• Surgical removal procedures
• Gynecological surgery