Labiaplasty

Who is it considered for?

Labiaplasty is usually considered for functional complaints related to the size of the inner labia:

• Pinching, rubbing and irritation when wearing tight clothes, leggings or a swimsuit
• Discomfort and pain when walking, running, cycling or horse riding
• Difficulty keeping the area clean because sweat, discharge or menstrual blood collects between the folds
• Pain during sex because the labium is pulled inwards

Some people, on the other hand, come because of concern about appearance. An important point to know here is this: the size, shape and colour of the external genital area vary greatly from person to person; there is no single medically defined "normal" measurement. See is it normal for the inner lips to be visible or asymmetrical?

Under the age of 18: the genital tissues continue to develop until the age of 18. If there is no serious functional problem, it is recommended that information about anatomical variety is given first and that surgery is postponed until after the age of 18.

Two main families of technique

Many techniques have been described for reducing the inner labia. The two most widely used are these:

• Edge trim: tissue is removed along the free edge of the labium.
• Wedge resection: a full-thickness "slice" of tissue is removed from the most protruding part of the labium and the edges are rejoined.

Edge trim is technically simpler and also removes darkened edges; however, the natural edge of the labium is lost. The wedge technique preserves the natural edge and colour, but because of the tension along the stitch line the risk of the wound separating is higher. In selected cases a de-epithelialisation technique (peeling away the surface layer of tissue) is also used, in which only the surface layer of the middle part of the labium is removed without touching the edge; it preserves the edge and the nerves, but may not be enough for large and thick labia.

The wedge technique was first described in 1998. Its notable features are that it preserves the natural edge of the labium, leaves a shorter scar, and produces less sensitivity in the scar area. A two-year review published in 2008 covering 407 extended wedge labiaplasties reported that a modification of the technique narrowed the clitoral hood and reduced the excess tissue that arises when a wedge alone is used; the rate of complications was found to be low.

Notable features of the wedge technique

• Wedge reduction is described as a safe and effective procedure.
• The small horizontal scar it produces usually becomes barely noticeable once healed.
• The technique preserves the important nerves and maintains the arterial blood supply.
• It is usually performed under local anaesthetic and most often takes less than an hour.
• Using low-temperature plasma radiofrequency cautery may help wound healing and early recovery.
• Complications such as notching of the edge, separation of the stitches and a collection of blood are uncommon.

When is the wedge technique preferred?

Labia that extend outwards

Wedge techniques are the most suitable option where the inner labia extend radially and the edge pigmentation is uninterrupted. A full-thickness slice is taken from the most protruding part to reduce the circumference, so that the protrusion of the inner labia beyond the outer labia is reduced.

Thickened inner labia

Labia thickened by excess mucosa or submucosal tissue are also suited to wedge resection. In these people the edge-trim technique is difficult: thinning the submucosal tissue would require removing almost the whole labium. The result is remnants that are very short and have lost their natural edge.

The wedge technique allows the amount of submucosal tissue removed to be adjusted.

Thin and thinned labia

In thin or thinned (atrophic) labia with little submucosal tissue, that tissue is preserved; the wedge is then performed by taking only the mucosa. People with little submucosal tissue are also suited to wedge resection.

The "ruffled" type

Labia with excess length front to back, or of the ruffled type, are also among the suitable candidates.

Who should it not be performed on?

A young person whose inner labia are already small on examination may still request labiaplasty. The source states that these people should not be operated on: the scarring and the risks would outweigh the change in appearance that could be achieved.

This holds however keen and insistent the person may be. Part of the doctor's responsibility is to protect the person from their own decision where necessary.

The balance between expectation and finding

A patient selection criterion described in plastic surgery looks at the ratio between the size of the finding and the distress the person feels:

• People whose finding is clear and whose concern is proportionate generally reach acceptable and satisfactory outcomes.
• In people whose finding is very small but who perceive it as very large, the risk is high; they may not find any result acceptable.

For this reason the consultation covers not only anatomy but also why you want the procedure. This matters in order to anticipate how someone would react if healing were delayed or additional scarring occurred.

Why is body dysmorphic disorder asked about?

Body dysmorphic disorder (BDD) is when a person perceives an aspect of their appearance as ugly or defective — although the appearance is usually ordinary and other people either do not see the defect at all or consider it insignificant. Among the areas most often worried about are the ears, nose, shape of the mouth, breasts, buttocks and the genital area.

This is not a rare situation in aesthetic practice:

• Its frequency in the population is estimated at 1.7–3.3%.
• Among people presenting for aesthetic surgery it has been found to be 13.2%.
• About 10% of health professionals may not recognise the condition.

Suicidal thoughts and attempts are also common in this condition, which is why recognising it and directing the person appropriately matters. This is one reason your expectations are explored at the consultation.

Consultation and consent

This surgery carries a clear emotional dimension. The consultation covers the person's goals, expectations and the influences around them together.

Care is needed in the use of images: drawings and photographs must not be presented in a way that suggests an "expected result". The source states specifically that healing and scarring vary from person to person and that possible outcomes should be described as a range.

A chaperone who is a health professional must always be present during the examination; this applies to female doctors and female patients too. A family member is not considered suitable for this role.

The day of the procedure

Labiaplasty can be performed under local anaesthetic (numbing of the area), local anaesthetic combined with sedation (light sleep), or general anaesthetic. The procedure usually takes about an hour and is a day procedure; after a short rest you go home the same day. Because self-dissolving stitches are used, there is no need to have stitches removed.

The recovery period

• First 1–2 days: swelling and bruising are to be expected; applying cold at intervals reduces the swelling and pain.
• Return to work: desk work can usually be resumed after 3–5 days.
• Sex and tampons: wait at least 4–6 weeks.
• Sport: activities that strain the stitch line, such as heavy exercise, cycling and horse riding, should be avoided for at least 4–6 weeks.
• Care: after using the toilet, clean the area gently and pat it dry; in the first weeks, choose a lukewarm shower standing up rather than a bath, jacuzzi or pool; wear loose, cotton clothing.

Possible complications

• Wound separation: the most common problem; excessive tension, straining too early and smoking increase the risk.
• Bleeding and a collection of blood (haematoma): small collections may clear up on their own; large ones may need to be drained.
• Infection
• Asymmetry: slight differences between the two sides may remain.
• Removal of too much tissue: a serious problem that results in dryness, irritation and a loss of protection.
• Change in sensation and pain during sex: temporary changes in sensation may occur during healing; rarely they may be permanent.

Where wound separation or a marked irregularity remains, a second corrective procedure may be needed after 3–6 months.

What the guidelines say

The American College of Obstetricians and Gynecologists (ACOG) stresses that genital surgery for cosmetic purposes is not a medical necessity and that people should be informed objectively about the risks and limits. Where there are functional reasons, such as pain during sex, discomfort during sport, difficulty keeping the area clean or marked enlargement, it states that the procedure can be performed. It should also be known that a considerable proportion of the studies in this area are small and have short follow-up.

Pregnancy and childbirth

Once healing is complete, labiaplasty does not prevent a future pregnancy or a vaginal birth. However, the stretching and tears that occur in later births may change the shape of the inner labia again. For situations that need repair related to childbirth, see Perineoplasty.