Procedures

Sometimes labiaplasty is also referred to as vulvoplasty. Labiaplasty is a procedure performed on women in the genital area for those who dislike their large size or shape of the labia minora, the inner lips.

This may cause embarrassment with a sexual partner, discomfort or contours that can be radiantly visible underpants the garments. They may also have difficulty with sports or issues during sexual intercourse.

The trend today for women is to show less pubic hair in the vulvar area and this has also driven the increase in females seeking these procedures as labial show is more evident when the skin and mucosa in the pelvic area remains barer.  The topic has also seen increased exposure in the media and the internet making it a more comfortable subject matter for women to discuss then it was in the past.

Although the majority of the women seeking labiaplasty are sexually active between the ages of 25-60 years old, there are many women outside of this age range who also desire the procedures associated with vaginal rejuvenation. Most patients who seek out this procedure are average women who are often embarrassed about the look of their vaginal and vulvar area. Contrary to what one may think, these women are not models or exotic dancers but rather students, lawyers, doctors, nurses and other regular people.[1]

There are many areas in the vulvar and vaginal areas where women desire esthetic surgery. The labia minora (inner lips), is the most popular area but women also seek rejuvenation and surgical revision of the labia majora, clitoral hood reduction, mons pubis resection and tightening and vaginoplasty.

How popular are these procedures?

It is one of the fastest growing procedures in cosmetic surgery in the United States and England. In England the rate of labial reductions doubled from 1995 and 2005 with similar trends seen in the United States.[2] In the United States an increase of 44% was seen between 2011 and 2014 according to the American Society for Aesthetic Plastic Surgery[3] and this upward trend continues as reported at the international meeting in 2015 in Montreal, Canada.[4]

What are the reasons women seek out labiaplasty?

Dr. Alter who is one of the pioneers in our present day plastic surgery world in relation to aesthetic genital surgery explains it well in his publications.

The aesthetic ideal associated with the vagina is influenced by today’s cultural influences, and one’s own self-image or concept of beauty. In the past decade woman have become more aware of their genital appearance due to the proliferation of waxing, shaving or the bare genitals look and the widespread availability of more provocative or pornographic material.  Women may avoid sexual contact, gynecological exams and become too self-conscious to discuss this with their physician who most often dismiss it.[5]

Grossly enlarged labia or asymmetrical labia can cause women to feel abnormal and contribute to low self-esteem. It may also hamper their hygiene and cause chronic inflammation. Some also claim discomfort during sexual intercourse due to invagination of the labia or complain of discomfort in tight clothing.[5-11]

In summary, women seek out this surgery for aesthetic and functional reasons. Indications for labia minora reduction include females as young as 15 years of age if the enlargement affects their self-esteem significantly.[5] [12]Note: Obviously due to the younger age of these patients and laws, it is imperative that parents are involved in the discussion and consent for this procedure.

Labia Minora

This is the most frequent performed aesthetic procedure of the vaginal area.  Many women are born with large or over-hanging labia and desire labiaplasty to reduce the size and shape of the labia minora or inner lips.  The procedure will be explained in detail below in the section called “Procedures in More Detail”

The procedure involves excision of the excess tissue of the inner lips so that they do not protrude past the curvature of the labia majora.

Labia Majora

Surgical correction of the outer lips or labia majora is also a common procedure in this area. With age, and weight loss the fat deposits beginning at the mons pubis (hump above the vagina and below the underwear line) descend causing a drooping of the labia majora. Along with wrinkling of the skin due to atrophy, some women seek correction in this area by surgical excision, or a “tuck” of the skin. Sometimes fat grafting from the abdomen and excision and lift of the mons pubis accompanies this operation.

Patients complain of feeling self-conscious in swimwear or their underwear due to the sagging skin and soft tissue in the area of the labia majora. The labia majora may look elongated or clam shell in appearance.[1]

Younger patients on the other hand who seek labia majora surgery usually complain about excess tissue that can feel swollen and make them feel uncomfortable.

 

Clitoral Hood

This operation involves excision of the skin tissue above the clitoris. The hood of the clitoris may be too large causing irritation or self-consciousness to some women. This procedure is often combined with labiaplasty if needed or desired. The nerves, sensation and the clitoris itself are not touched or damaged by this operation. Rather, the clitoral hood reduction helps to eliminate the protrusion of the clitoris.

Mons Pubis

This is the pubic area just above the vagina. Excess fat, sagging or bulge can be uncomfortable and undesirable for many women. Most women seek excision, liposuction and a possible lift in this area. The goal of the procedure is to remove any excess fat, trim any excess skin and tighten the area up to reduce the bulge.

What is vaginal rejuvenation?

Vaginal rejuvenation is a term used that combines vaginoplasty (tightening of the vaginal vault) with that of vulvoplasty/labiaplasty. Tightening of the vagina can be accomplished through surgical excision and tightening of the inner vaginal pouch at the floor of the vagina or by specific lasers and radiofrequency devices that heat the tissue to shrink and tighten them.

History of Female Genital Surgery

One of the first articles written in the modern plastic surgery literature occurred in the 1980’s by Hodgkinson and Hait. In the article the authors discovered that some women found that when the labia minora extended well beyond the labia majora, it was an interference functionally and aesthetically unpleasing.[7] Three women went to the plastic surgeon after seeing a gynecologist who refused them a labial reduction. All 3 patients underwent an elliptical edge resection. The authors noted that all the patient had a high degree of satisfaction at 5 years.

Awareness for female genital aesthetics has increased here in the United States and many parts of the world due to increasing influence from magazines, video the internet and pornography.

Women are feeling more self-conscious about the appearance of their vaginal area including the labia majora known commonly as the outer lips and the labia minora which is known as the inner lips. With age the female labia will descend and their fat deposits and skin in this area will droop. This may make a female feel that their genital area below is unsightly. Unfortunately there are not many physicians that deal with these type of issues. Women desire a more youthful looking labia minora where the lips are mostly concealed and labia majora where the contour looks firm and smooth.

This website will inform you and help you find a surgeon. Let’s take a look below at some of the most frequently asked questions regarding female genital surgery and what type of female genital surgery is offered.

What do normal female genitals look like?

There is no consensus on what is considered normal when discussing the female genitals. Youthful or prepubescent appearances of the female genitalia has been promoted by the latest media channels, especially the Internet. The internet is full of models wearing underwear and bikinis with a short and neat vulvar cleft, smooth and youthful looking labia majora with no visible inner lips i.e. labia minora) and also no clitoral hanging hood when looking at their frontal view. This is been discussed in detail by numerous publications by plastic and other surgeons. [1]

There has also been strong opposition within the medical community regarding the ethics and promotion of vaginal aesthetic surgery. The opinion is that women should not be put under any pressure or made to feel uncomfortable in relation to the appearance of their genitals. A recent aesthetic plastic surgery regarding labiaplasty was published that by Dr. Hamori, a plastic surgeon discusses these issues. Her article stated that the “media in the quest for sensationalism frequently portray labiaplasty as unnecessary and potentially dangerous. For instance in the July 2010 edition of Cosmopolitan magazine, the cover read vagina is under attack; Don’t Let the Greedy Gyno Talk You Into This Horrible Mistake.” Dr. Hamori went on to explain that the perception that doctors encourage patients to undergo these procedures is false whereas in reality the reverse occurs; most patients seek out the doctor for this surgery.[1] [13]

The American College of obstetrics and gynecology released the committee statement to thousands in seven regarding the necessity safety and marketing of cosmetic gynecology. They condemned the use of marketing for franchise procedures for laser vaginal rejuvenation or routinely performed genital surgical procedures. They stated that the absence of scientific studies led them to the recommendation that the state procedures were unwarranted. However they also did stay in the committee that the treatment of significant labial hypertrophy, meaning size, because of disease or severe congenital asymmetry was appropriate if medically indicated. [14]

Female Genital Anatomy

Below in Figures 1a, Figure 1b is an artist’s rendering of the basic anatomic parts of the female vulva.  The area above the vulva is known as the mons pubis. The most superior important structure is the clitoris and the clitoral hood (prepuce). The labia minora extend from the frenulum of the clitoris. The labia minora are often referred to as the “inner lips of the vagina.” Deep to that is the urethral opening whereby urination occurs and just inferior to that is the vaginal opening or introitus. The area between the fourchet of the vagina and the anus is known as the perineum. The labia majora begins more outward at the outer crease of the labia minora. The labia majora in youth have a smooth outward curve with firm skin and underlying firm soft tissue.

Figures 1a, b

Female Pelvic External Anatomy: The Vagina and Vulva

A simple classification system was proposed in a recent published paper in the Plastic and Reconstructive Surgery Journal by Saba Motakef, MD and colleagues, 2014. [3] See Figure 2.

Figure 2: Classification for labial protrusion, which classifies degree of protrusion of labia minora past the labia majora[3]

The authors researched several published articles in medical journals evaluating different techniques used in labiaplasty.  The different methods in achieving labiaplasty reduction were narrowed down to 3 main methods as seen in Figure 3. [3]

Figure 3: Methods of labiaplasty reduction[3]

Techniques used for Labiaplasty

The different techniques in labiaplasty will be described here.  There are many variations of this surgery especially related to labiaplasty of the labia minora. Ellsworth and colleagues described the different methods and the possible scenarios whereby each method could be applied.[15, 16]

When discussing the different techniques, one you look at figure 3 to understand the method used. Also when you book an appointment with your surgeon, they can discuss what they feel may be best suited for you.

Labia Minora Procedure

As discussed before, labiaplasty of the labia minora is the most frequently performed vaginal aesthetic procedure. [1, 17] The two main methods used to reduce protruding labia minora is the wedge excision and the edge trim procedures. The choice method should be directed by the anatomy of the patient. As described by Dr. Alter and then Dr. Hamori, the central wedge technique is good for those who present with central protrusion or elongation of the labia minora, and have an even pigment distribution.[1, 6, 17] An excision or wedge is carried out in a “V” or pie shape and then the upper edge and lower edge are brought together. See Figure 3

Sometimes the wedge resection is extended vertically to address minor clitoral hood tissue redundancy as well.

The edge trim method is used most frequently when one needs to excise redundancy, but also eliminate selected pigmented areas. Authors of this method tout its avoidance of dehiscence (suture line or wound falling apart) and any notching in the soft tissue sutured edge that may occur with the wedge technique.[18] Notching with the wedge technique however can be avoided by using eversion type suture techniques.[1]

Complications of the edge trim are usually due to over-resection leaving too little tissue behind which may cause more clitoral show if one has a prominent clitoris to begin with. [1] This sometimes needs to be corrected with a more challenging flap method using tissue from the clitoral hood.[19]

Also dog-ear type deformities may occur with a straight edge resection. This can be avoided by taking just the right amount without over-resecting and curving the incision as seen in figure 3, under “the direct excision method.”

Labia Majora

Labia majora resection is performed by removing a wedge or curve on either side just far enough away from the labia minora. The edges are then sewn together to reduce the size of the labia majora or excise any excess sagging skin. See Figure 4

Figure 4: Labia Majora Resection

Conservative resection is warranted in order to avoid too much tension against the inner lips/labia minora. This can cause the labia minora to be pulled outward, spreading the lips, and over –exposure of the vaginal opening.[1]

One can also use fat grafting from the abdomen of the mons pubis to firm up the labia majora. The goal is to make the labia majora look smoother and more firm; more youthful.

Clitoral Hood Procedure

Sometimes excess tissue covering the clitoris causes wrinkling and sagging. The excess tissue can also make the clitoral area look enlarged. The technique described is fairly straightforward on the right hands obviously. It involves an inverted “V” shape resection of the tissue covering the clitoris or what is known as the clitoral hood. The upside down “V” is designed above the edge of the lowest margin of the hood tissue and then resection and sewing of the incision is performed meticulously. The clitoris is protected while performing the surgery and the nerves come from deep anatomy and so damage to clitoral sensation is extremely difficult and infrequent in occurrence.

See Figure 5. Insert diagram here

Mons Pubis Procedure

The mons pubis procedure involves excision of any excess skin just like one would see in a tummy tuck. Deflation of the mons pubis due to age, weight loss or hormonal changes can cause significant sagging that extends to the labia majora. Resection of the mons pubis and/or labia majora with fat injection augmentation can sometimes give the areas a more youthful appearance.

Vaginal Tightening

Vaginal loosening can occur due to child birth, trauma or with age and hormonal changes. Although Kegel exercises may help some, the majority of women who seek out a plastic surgeon find the area loose and distressing. Sometimes this loosening is accompanied by urinary incontinence as well. It is important to take into consideration all your issues and plan out the best procedure or combination of procedures needed.

Vaginal rejuvenation is a term sometimes used when discussing labiaplasty but also to make things confusing, it is also frequently referred to in those terms regarding vaginal tightening procedures.

There are a few ways vaginal tightening can be accomplished. One is by meticulous resection of the vaginal floor and sewing of the edges together to produce a smaller and tighter vaginal vault. The other techniques involve technology in the form of lasers and radiofrequency devices. These devices sendoff energy to the internal vaginal tissues which causes contraction and tightening of the area.

Some of the common device names are the FemLIft™,  THERMIva®, or the Mona Lisa Touch®

Note: Some or all of the above procedures can be combined in the same session if needed. Discuss this with your cosmetic surgeon and see if it is in your situation.

What are some of the complications that can occur?

Although the procedures are considered safe, there is always a chance that some complications can occur. Talk to your doctor about these during consultation and they will be able to discuss with you how common certain complications could be and the methods used to decrease or prevent the complication from occurring. Some of the common described complications reported:

  1.  dehiscence of the incision
  2. hematoma
  3. infection
  4. bleeding
  5. scarring
  6. asymmetry
  7. over-resection

What is the satisfaction rate overall associated with labiaplasty?

The rate of satisfaction with female genital surgery is very high. The satisfaction rate ranges from 91.6% shown in a study that looked at many combined female genital surgery procedures.[20] When the authors looked at labiaplasty and/or clitoral hood surgeries alone, the satisfaction rate was greater than 97%.[20] Other studies have shown satisfaction rates of greater than 95% as well. [18]

Cost and Financing of Procedure

The prices in the tables below show a range of costs for each procedure separately. These are estimates. Your surgeon will have more details during your consultation. An important note is that most surgeons will discount the second procedure anywhere from 20% to 30%. Also the ranges reflect the reality that some cases are more challenging or require adjunct procedures such as fat grafting or liposuction.

Labiaplasty (minora vs, majora) $3500 – $7000
Clitoral Hood Reduction $2500 – $3500
Vaginoplasty $4000 – $8000
Mons Pubis Liposuction/Resection $3500 – $5000