Labiaplasty, Minora Reduction

Anatomy and Physiology

A comprehensive understanding of female genital anatomy is essential to reduce the risk of clitoral injury and minimize the potential for postoperative sensory impairments. The anatomy of the labia minora varies widely in terms of size, thickness, and color. The glans clitoris is located directly beneath the prepuce. The frenula are folds of skin that extend from the clitoral glans and merge with the clitoral hood to form the labia minora. The external blood supply to the female genitalia is provided by branches from the external superficial pudendal artery, the internal pudendal artery, and the internal circumflex artery. The external superficial pudendal artery anastomoses with the posterior labial artery within the labium majora, giving rise to multiple branches that supply the labia minora.[3][4]

Indications

Labia minora enlargement is primarily congenital, though women may also experience enlargement after childbirth, during hormone therapy, or with advancing age.[5][6][7] Labia minora reduction is typically considered for symptomatic women, including those as young as 12, who experience self-esteem issues, discomfort, or social stigma due to enlargement. Aesthetic concerns are the primary motivation for labial reduction procedures in sexually mature women, who often perceive ideal labia minora as light, thin, straight, and symmetrical.

Felicio et al categorized labial hypertrophy by size, and it ranges from type I (<2 cm) to type VI (>6 cm). As labial hypertrophy is rarely considered medically necessary, this scale is primarily used for research purposes. Functionally, labiaplasty can be performed as long as the removal of excess tissue does not compromise critical structures, aligning with the patient’s aesthetic goals. When planning labia minora reduction, ancillary procedures such as clitoral hood reduction should be considered, as unaddressed hood redundancies may lead to unsightly bumps and bulges. The 2 reliable techniques for reducing labia minora are the "trim technique" (or the edge method), introduced by Hodgkinson, and the "wedge technique," pioneered by Alter. The choice of technique is guided by the patient's anatomy, goals, and preferences.[8][9][10][11]

Contraindications

Labiaplasty is contraindicated in individuals who actively use tobacco, those with body dysmorphic disorder, and patients who seek the procedure with the expectation that it will enhance their sexual performance or increase their ability to achieve orgasm.

Equipment

Labiaplasty minora reduction requires precise, specialized surgical instruments to ensure optimal outcomes and patient safety. The tools used are selected for their accuracy and ability to minimize tissue trauma.

Essential equipment for the procedure includes:

• Basic surgical tray with a ruler
• Marking pen
• Finely serrated scissors
• Electrocautery device
• Silk sutures
• Absorbable sutures (eg, chromic and vicryl)
• Marcaine (0.25%) for long-lasting local anesthesia

Postoperative dressing typically includes antibiotic ointment, nonadherent gauze, fluff gauze, and surgical underwear.

Personnel

A labia minora reduction procedure typically involves a small, highly skilled surgical team. The healthcare team includes a board-certified plastic or gynecologic surgeon with experience in aesthetic vulvar surgery, a scrub technician or surgical assistant, a perioperative nurse for patient preparation and monitoring, and possibly an anesthesiologist or nurse anesthetist to provide sedation and ensure patient comfort. While a second surgeon is not required, they may be present to assist with fine retraction or for educational purposes.

Preparation

Patients should be examined preoperatively in the lithotomy position. Using a mirror to visualize the female genitalia, the patient should communicate her concerns to the surgeon. This practice ensures alignment between the patient's and surgeon's aesthetic goals. Photographs should be taken with the patient in both the lithotomy position and a standing position, with legs slightly abducted to shoulder width, to properly visualize labial protrusion. Standardized photographic documentation aids in surgical planning and helps align patient and surgeon expectations. As with any gynecological or genital procedure, it is advisable to have an assistant or chaperone present during the examination for the sake of patient comfort and medicolegal safety. Ideally, this individual should be of the same assigned and chosen gender as the patient.

In addition to a physical preoperative examination, patients undergoing labia minora reduction should receive a thorough assessment, including a detailed medical and surgical history to identify any factors that could affect healing or anesthesia. A psychological evaluation is crucial to ensure the patient has realistic expectations and is pursuing the procedure for appropriate reasons, free from external pressures or underlying body image disorders. Education and informed consent are vital, with comprehensive discussions about the risks, benefits, alternatives, and postoperative expectations. Additionally, assessing sexual and functional health ensures that the procedure addresses both aesthetic and physical concerns. 

This procedure can be performed in the office with conscious sedation and local anesthesia or as an outpatient surgery under monitored anesthesia care or general endotracheal anesthesia. Preoperative antibiotics are administered within 30 minutes of the incision. The patient is positioned in the dorsal lithotomy position for the procedure.

Technique or Treatment

Labia minora reduction can be achieved using 2 primary surgical techniques—the wedge technique and the trim technique. The choice of technique depends on the patient's individual anatomy, desired outcomes, and the surgeon's expertise.

Trim Technique 

Asymmetric or protuberant labia minora can be addressed by excising or trimming excess tissue with a scalpel or scissors, followed by oversewing for closure.[7][12][13] Retaining a 1 cm cuff of the labia minora is essential to maintain a functional seal of the introitus. This technique is particularly suitable for cases involving significant redundancy or excessive thickness of the labia minora, provided the patient is informed and accepts the potential changes in visible labial pigmentation.

Although the trim method offers benefits such as shorter operative time and the creation of light-colored labial edges, it may be less favorable for individuals with darker skin tones. However, the technique has several notable drawbacks, including the potential for an irregular or scalloped longitudinal scar line along the labial edge, which may lead to reduced sensation and discomfort. Risks of asymmetry and overresection are also notable and may be difficult or impossible to correct. Additionally, maintaining the normal transition between the frenulum of the clitoris, clitoral hood, and labia can be challenging, potentially resulting in aesthetically unappealing "dog ears" at the superior and inferior edges.

Wedge Technique 

The wedge technique was introduced by Dr Gary Alter, and it maintains the natural labial edge by resecting only a "wedge-" or "V"-shaped portion from the most protuberant area of the labia minora. This technique is particularly well-suited for patients with triangular-shaped labia or those with labial tissue that extends beyond the labia majora. This method is favored for its discreet scar placement and favorable healing outcomes. However, it does come with limitations, including a longer operative time, the need for advanced surgical expertise, and the potential for persistent pigmentation along the labial edge in patients with darker skin tones.[14][15] This technique involves 3 key phases—preoperative, intraoperative, and postoperative evaluation.

Preoperative evaluation

During the preoperative assessment, the patient is positioned in lithotomy with the head elevated for optimal visualization. Using a mirror or a real-time camera, the surgeon and patient collaborate to discuss the desired aesthetic goals and determine the surgical markings for excision, based on the length, thickness, and shape of the labia minora. Evaluation includes a detailed examination of the clitoral hood for protrusion, symmetry, skin pigmentation, extra folds, and the exposure of the clitoral glans.

The posterior introitus is also assessed, particularly for signs of a high posterior lip or gaping related to prior episiotomy. A large wedge or "V-shaped" marking is drawn at the point of maximal labial protrusion and pigmentation, with a gentle hockey-stick-shaped extension superiorly on both the medial and lateral surfaces to ensure symmetry and a natural contour.

Intraoperative evaluation

• In the operating room, the patient is placed in the lithotomy position, under either general or regional anesthesia. The upper labial incision of the wedge is typically placed at or just posterior to the convergence of the glans frenulum and clitoral hood. The goal is to create a straight, nonredundant labial contour that can be approximated without tension. Before tissue excision, the planned edges are temporarily approximated to confirm a tension-free closure, marked with a surgical pen, and secured with 2 silk sutures to facilitate gentle retraction and precise maneuverability. Overresection, which could result in an overly tight introitus, is avoided by maintaining a space of 2 fingerbreadths in the vagina. The medial 'V' extends internally, terminating just distal to the hymeneal ring, while the lateral 'V' curves anteriorly in a hockey-stick design to eliminate any 'dog-ear' and remove redundant lateral clitoral hood or folds. In rare cases, an additional posterior 'V' incision may be necessary for symmetry or adequate reduction.

• Excision is performed with a 15-blade scalpel and electrocautery or curved scissors, with careful attention to hemostasis to minimize postoperative bruising. The subcutaneous tissue of the anterior and posterior labia is reapproximated in 2 layers using 4-0 Vicryl on a small, tapered TF needle. Any internal or external subcutaneous "dog ears" are excised if present. The labial edges, as well as the medial and lateral closures, are approximated with interrupted horizontal mattress sutures using 4-0 chromic on a TF needle, allowing for postoperative swelling while minimizing the risk of tissue necrosis. The lateral clitoral hood is closed with a running subcutaneous chromic suture, aiming to create a single small transverse incision line along the leading edge of the labium, ideally projecting slightly beyond the introitus.

• If the clitoral hood exhibits additional vertical medial folds or medial hypertrophic skin, these can be excised with vertical elliptical incisions. In such cases, the lateral "V" labial excision may extend to the lateral labium. Conversely, if the patient presents with redundant horizontal folds, vertical transverse ellipses may be performed for excision. However, caution should be exercised to avoid overexposing the glans clitoris, as this can lead to hypersensitivity or an undesirable aesthetic outcome, highlighting the importance of conservative excision.

• If the introitus appears overly tight or presents with a prominent posterior lip, a midline incision at the 6-o'clock position can be made, followed by aesthetically appropriate closure of any resulting dog ears. When performing additional procedures such as perineoplasty, posterior vaginal repair, or introital tightening alongside extensive labial reduction, caution must be taken to avoid creating an overly tight introitus. To prevent this, perineal and vaginal repairs should be postponed until after the labial reduction is completed, allowing for necessary adjustments to the introitus during closure.

Postoperative evaluation

Patients are typically scheduled for a follow-up appointment 1  week postoperatively to remove any remaining sutures and assess the progress of their healing. Itching may be intense as the sutures dissolve, so patients should be educated in advance and advised to apply a generous amount of antibiotic ointment twice daily to the incision site to keep the sutures soft and minimize irritation. Postoperative restrictions include avoiding vaginal penetration for 6 weeks, preventing pressure on the suture lines, and refraining from activities that could place tension on the incisions.

Patients should be informed about the likelihood of significant swelling, which may persist for several weeks. Revision surgery may be considered once complete healing has occurred, typically at least 6 months after the surgery. Patient feedback should be carefully considered and addressed promptly. Persistent asymmetry is a common concern and may warrant revision if the patient desires. Other variations of the techniques mentioned, such as deepithelialization and pedicled flap methods, have been described but have not consistently produced the desired outcomes.

Complications

Although most patients experience excellent healing outcomes, minor complications, such as slight separation of the labial edge closure or the formation of a small fistula, occur in less than 2% of cases and typically resolve with conservative management or minor surgical revision. Major dehiscence is rare when the procedure is performed appropriately. Chronic scar discomfort or interference with intercourse is uncommon and can be corrected if needed. In some cases, labial stretching or scar elongation may develop over time, but these issues are usually easily addressed through revision surgery. Additional excision procedures may be considered for patients seeking further reduction of the affected area.[16][17]

Clinical Significance

Labiaplasty is a surgical procedure that can significantly improve the appearance of the vulva, helping women feel more confident during intimacy. However, if too much tissue is removed by the surgeon, it can lead to severe and irreversible complications. Therefore, it is essential for the surgeon to exercise sound judgment and for the patient to engage in open, thorough communication with the surgeon to ensure the best possible outcomes.[18]

Enhancing Healthcare Team Outcomes

Labiaplasty requires a comprehensive and well-coordinated patient-centered approach involving various healthcare professionals to ensure optimal patient-centered care, safety, outcomes, and overall team performance. Physicians, advanced practitioners, nurses, pharmacists, and other allied healthcare professionals each have distinct and complementary roles across the preoperative, intraoperative, and postoperative phases of care.

Physicians and advanced practitioners, particularly surgeons specializing in plastic surgery or gynecology, are responsible for assessing patient candidacy, performing the procedure, and managing any complications that may arise during or after the procedure. Their role requires advanced surgical skills, clinical expertise in patient assessment, and the ability to effectively communicate the risks and benefits of surgery. Nurses play an essential role in patient education, preoperative preparation, intraoperative assistance, and postoperative care. They provide emotional support, assist in obtaining informed consent, and closely monitor patients for signs of complications throughout the recovery process.

Additionally, nurses assist during the procedure by maintaining sterile technique and facilitating communication between the surgical team and other healthcare professionals. Pharmacists contribute by ensuring appropriate medication management, including preoperative prophylactic antibiotics and postoperative pain management. Their expertise in pharmacology helps mitigate adverse drug interactions and optimize patient safety.

Effective interprofessional communication and collaboration are crucial throughout the entire continuum of care, facilitating seamless transitions between phases and ensuring that patient needs are addressed comprehensively. This multidisciplinary approach not only enhances patient satisfaction and promotes positive clinical outcomes but also helps reduce the risks associated with labiaplasty procedures.