Labiaplasty

Labiaplasty (also labioplasty) is the plastic surgery procedure for altering the labia minora and the labia majora, which are the paired tissue-structures that form the boundaries of the vestibule of the vulva. In surgical praxis, labial hypertrophy of the labia minora is a morphological condition characterized by excessive labial length, width, or girth (3.0 – 5.0 cm.), wherein the enlargement of the labia can be unilateral or bilateral, symmetric or asymmetric; none the less, labial hypertrophy is a variant of the normal anatomy of the vulvo-vaginal complex. Hypertrophy of the labia minora can be caused by mechanical irritation of the tissues, and by endocrine disease; as such, hypertrophic labia minora that are longer than five centimetres (5.0 cm.) present functional and aesthetic problems for the woman who seeks a labioplastic correction, which is an elective surgical procedure for reducing the labia minora.

Labiaplasty: the pre-operative aspect (left), and the post-operative aspect (right) of the surgical reduction of congenital hypertrophy of the labia minora.

The clinical indications for labial hypertrophy are two-fold: (i) the correction of defect and deformity, congenital and acquired; and (ii) the cosmetic refinement of the aesthetics and of the pudendum femininum; hence, labiaplastic correction reduces labia minora that are disproportionately greater than the labia majora, and labia minora that are asymmetric, in order to establish a vulvo-vaginal complex that is functionally and aesthetically satisfactory to the woman.

As a type of corrective plastic surgery, labiaplasty comprehends the correction of congenital defects and of congenital abnormalities, such as the creation of an artificial vagina to resolve the condition of vaginal atresia (congenitally absent vaginal passage), and to resolve a vulvectomy consequent to carcinoma; Müllerian agenesis (malformed uterus and fallopian tubes); and intersex conditions (male and female secondary sexual characteristics in a person). As a type of cosmetic surgery, a labiaplasty procedure is performed for the refinement of the exterior aesthetics of the pudendum femininum, such as the repair of the tearing and stretching of the labia minora caused by the mechanical stresses of childbirth, accident, and age. Furthermore, in a male-to-female sexual reassignment vaginoplasty procedure, the creation of a neovagina, a labioplastic surgery creates and establishes creates labia (major and minora) where once there were none.

Surgical anatomy of the vulva

The vulvo-vaginal complex

The external genitalia of a woman — identified with the collective terms “pudendum femininum” and “vulvo-vaginal complex” — comprise seven anatomic features: (i) the labia majora, (ii) the labia minora, (iii) the clitoris, (iv) the vestibule of the vagina, (v) the vaginal opening, (vi) the Bartholin-gland bulbs of the vaginal vestibule, and (vii) the urethral opening. Given the anatomic variety of pudenda feminina, some women have labia minora that are short, thin, and narrow, and so are hidden by the labia majora, while some women have labia minora that are long, thick, and wide, and so extend beyond the labia majora.

Pudendum femininum: the size and the shape, the appearance and the coloration of the individual anatomic parts of the vulvo-vaginal complex vary with each woman.

Anatomic composition

The fatty labia majora (the large outer-lips) are two folds of skin and adipose tissue that lie to either side of the vaginal opening, and so are the lateral borders of the vulva. At the front, the middle surfaces of the labia unite above the clitoris to form the anterior commissure, at the mons pubis; at the back, the labia connect by means of a poorly defined posterior commissure, which ends at the perineum. The labia majora are separated by a cleft, the rima pudendi, into which the urethra and the vagina open. In girls, the labia majora are in contact, and so conceal the labia minora and the vestibule. In women, the labia minora might protrude from the labia majora, through the rima pudendi cleft.

The vascularised labia minora (the small inner-lips) are the two thin folds of integument that lie just inside the vestibule of the vagina, and between the labia majora and the hymen; as such, the labia minora enclose the vaginal vestibule. As body tissues, the labia minora are two (2) connective folds of flesh that contain some adipose tissue. At the front, each labium minus divides into two smaller folds of skin, which, in turn, unite with similar folds of skin from the opposite labium minor, and so enclose the clitoris. The forward-most labial fold forms the clitoral hood (preputium clitoridis); the rear-most labial fold forms the clitoral bridle (frenulum clitoridis), which is the union of the inner parts of the labia minora to the subsurface of the clitoris.

At the posterior commissure, the labia minora are united by the fourchette (frenulum of the labia minora), which is a transverse fork-fold of mucous tissue that (occasionally) unites the labia minora to the labia majora at their posterior extensions. Moreover, the fourchette and the hymen are separated by the fossa navicularis (a cul-de-sac type of opening); after defloration or after parturition (giving birth), the mucous-tissue fourchette disappears, and leaves the vulva more open from below and from behind. The skin and the mucosa of the labia minora are rich in sebaceous glands and nerve endings, thus the labia minora are very sensitive to the touch. These labial 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 swell with extracellular fluid and moisten during sexual arousal, in preparation for coitus. Furthermore, during urination, the labia minora function to direct the urine stream away from the pudendum femininum, and away from the body.

Labial anatomic variation

The size, the shape, and the skin coloration of the labia minora vary according to the woman, thus, like most paired structures of the human body, the labia of the vagina are not anatomically symmetrical — one labium minus (minor lip) usually has greater dimensions (longer, wider, thicker) than the dimensions of the counterpart labium minus. Such labial asymmetry usually is neither noticeable nor clinically notable, because the labial -length, -width, and -girth are the factors that determine if the labia minora protrude from or are hidden by the labia majora. Moreover, further increases in the sizes of the labia (majora and minora) occur when the woman is sexually aroused — in preparation for coitus — wherein the labia become engorged with blood and increase the labial diameters two-to-three times.

In the course of a woman’s life, her labia minora can become hypertrophied (over-sized), by the mechanical stresses (pulling, stretching, and tearing) occurred during childbirth, lymphatic congestion (stasis), chronic dermatitis, sexual intercourse, masturbation, and the inflammation caused by urinary incontinence. Moreover, labial hypertrophy also can be caused by the mechanical stresses inherent to the cultural practice of genital piercing, either of a labium or of the labia, whereby the soft, labial tissues of the vagina bear relatively heavy metal ornaments, which fact is medically notable, because bearing weight is not a function of the labia minora. Furthermore, hypertrophy of the labia minora can be a genetically inherited anatomical feature of the woman’s vulvo-vaginal complex; to wit, the study Labiaplasty and Labia minora Reduction (2008) reported the occurrence of labia minora of like sizes (length, width, girth) in identical-twin sisters who were treated for labial hypertrophy, which indicates that some women are genetically predisposed to developing over-sized labia minora.

Measures of the vulva

Labial hypertrophy, the excessive length, width, and girth of the labia minora (3.0 – 5.0 cm.), can occur either unilaterally or bilaterally, symmetrically or asymmetrically, and can be caused either by the mechanical irritation of the labial tissues or by endocrine disease; as such, hypertrophic labia minora are more than 5.0 centimetres (1.96 in.) in length, which cause functional and aesthetic problems for the woman. Because there are no standardized methods for grading the degree of labial hypertrophy present in the woman’s labia minora, she (as the patient) and her physician jointly determine if surgical labial reduction applies to her case.

Moreover, to the end of providing a pertinent medical reference vis à vis the matters of labiaplasty and labial hypertrophy, the morphologic study Female Genital Appearance: ‘Normality’ Unfolds (2005) reported the range of the anatomic variety of pudenda feminina of a 50-woman cohort (aged 18–50 yrs., mean age 35.6 yrs.); the statistical variations of the vulvo-vaginal complex are:

The Tanner Scale illustrates the five-stage development of the secondary sexual characteristics (breasts, pubic hair, body fat) of the human female, the biological transit from girl to woman.

External image
“Betty Dodson’s Vulva Illustrations” show the varied labial morphology (appearance) of the vulvo-vaginal complex.

The vulvo-vaginal complex	Range of measures	Mean [Standard Deviation]
Clitoral length (mm)	5.0 – 35.0	19.1 [8.7]
Clitoral glans width (mm)	3.0 – 10.0	5.5 [1.7]
Clitoris to urethra (mm)	16.0 – 45.0	28.5 [7.1]
Labia majora length (cm)	7.0 – 12.0	9.3 [1.3]
Labia minora length (mm)	20 – 100	60.6 [17.2]
Labia minora width (mm)	7.0 – 50.0	21.8 [9.4]
Perineum length (mm)	15.0 – 55.0	31.3 [8.5]
Vaginal length (cm)	6.5 – 12.5	9.6 [1.5]
Tanner Stage (n)	IV	4.0
Tanner Stage (n)	V	46
Color of the genital area compared to the surrounding skin (n)	Same color	9.0
Color of the genital area compared to the surrounding skin (n)	Darker color	41
Rugosity of the labia (n)	Smooth (unwrinkled)	14
Rugosity of the labia (n)	Moderately wrinkled	34
Rugosity of the labia (n)	Markedly wrinkled	2.0

Labial hypertrophy

Etiology

Overdeveloped labia minora arise from etiologically varied causes, either genetic or acquired, such as: the woman was born with over-sized labia (genetic inheritance) or the overdevelopment is consequence of the mechanical stresses (pulling, stretching, and tearing) characteristic of childbirth, urinary incontinence, lymphatic congestion (stasis), chronic dermatitis, granulomatous disease, myelodysplastic disease, coitus (sexual intercourse), masturbation, and clinical applications of topical and systematic hormones.

In some women, vaginal childbirth can cause labial hypertrophy with the formation of a hematoma occurred during the parturition. The cultural practice of genital piercing can cause hypertrophic and asymmetric labia when said fatty tissues of the vagina are made to bear heavy weight metal ornaments, inserted either to the labium or to the labia. Furthermore, the study Labiaplasty and Labia minora Reduction (2008), reported the occurrence of same-size labia minora in identical-twin women treated for labial hypertrophy, which indicates a genetic determination of the size of the labia minora.

Labial hypertrophy is an adaptive change in the tissues, which results when the tissue’s constituent normal cells increase in size, in consequence to the labia minora being subjected to the mechanical stresses of pulling, stretching, and tearing. Whereas hyperplasia is an excessive increase in the number of the tissue’s constituent normal cells.

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Labial hypertrophy: the standing and supine pre-operative aspects (left), and the like post-operative aspects (right) of a labia minora and clitoral prepuce reduction procedure.

Clinical definition and determination

To determine the degree of labial hypertrophy present, the plastic surgeon examines and considers the unique anatomy of the woman’s vulvo-vaginal complex, and what she (as the patient) considers and does not consider to be an aesthetically normal and proportionate vulva, and what she considers is an ideal body image. (See: Body dysmorphic disorder and Body image)

Pathophysiology

• The dimensions of over-sized labia minora are established by:

1. horizontally measuring the size of each labium minus, from the midline.
2. vertically measuring the size of each labium minus, between the base and the free-edge of the labium.
3. applying a 3.0 – 5.0 cm. range of measure as “hypertrophy” of the labia minora.

• The degree of labial hypertrophy is characterized as:

1. No hypertrophy — the labia minora are concealed within, or extend to, the free edge of the labia majora.
2. Mild-to-moderate hypertrophy — the labia minora extend approximately 1.0 – 3.0 cm. beyond the free edge of the labia majora.
3. Severe hypertrophy — The labia minora extend an approximate distance >3.0 cm. beyond the free edge of the labia majora.

Presentation

The woman who seeks labial reduction usually presents asymmetric labia, which causes her functional problems such as: (i) difficult vulvo-vaginal hygiene (e.g. toilet-paper bits attaching to the labia); (ii) difficult urination, featuring either a disrupted urine flow, or a diffused urine flow that wets her vulvo-vaginal complex; (iii) dyspareunia, painful sexual intercourse; (iv) catching the labia in garment zipper-closures; (v) pubic discomfort when clad in tight clothes; and (vi) pubic-area pain when practicing sport (bicycling, running, etc.). In the case of labial-asymmetry, wherein one labium minus is longer, wider, and thicker than the corresponding labium minus, only the hypertrophied labium is reduced to symmetrically match the smaller labium. In surgical praxis, a labiaplasty procedure can be performed after the woman is sexually mature (and is of majority age, minimally 18 years of age); and either before or after pregnancy, in order to minimize hormonal interference with her body’s capacity to heal a surgical wound. Labiaplasty is not performed upon a woman who is menstruating, lest she risk post-operative infection of the surgical-incision site(s).

Generally, the most common complaint of the woman who seeks labiaplasty is one of self perception, her belief that, when observed in the standing position, her labia minora protrude beyond the labia majora; such a perception of a physical condition is conducive to low self esteem, and subsequent problems achieving emotional and sexual intimacy in her private life. (See: Sex appeal and Body dysmorphic disorder)

The patient

Indications

I. Hypertrophy of the labia minora

The woman afflicted with labial hypertrophy presents labia minora that are disproportionately over-sized in relation to the size of the labia majora, which, in her self-perception, appear aesthetically displeasing, and cause practical problems with her vulvar hygiene, such as a disrupted urine stream or a diffused urine stream that wets her vulvo-vaginal region; chronic irritation of the pudendal skin; painful sexual intercourse; and regional pubic pain when wearing tight clothes. Anatomically, like all the paired structures of the human body, it is uncommon for the labia minora to be perfectly symmetrical. Usually, the labial-size discrepancy is slight; some women present one labium minus (minor lip) that is considerably larger (longer, wider, thicker) than its pair labium; and some women present redundant folding (webbing), either unilateral or bilateral, between the labia majora and the labia minora that can be surgically resolved.

Therapy

• Medical — Labial hypertrophy is not managed medically.

• Surgical — The woman’s specific clinical indications of over-sized labia minora determine the appropriate labioplastic technique. The correction of labial hypertrophy can be performed upon a patient either as a discrete labiaplasty (single surgery) procedure, or in conjunction with a genitoplastic repair procedure, or in conjunction with a cosmetic labioplasty procedure.

Contraindications

• Absolute contraindications — There are no absolute contraindications to labioplastic surgery, either for altering or for reducing the labia minora or the labia majora.

• Relative contraindications — Labial reduction surgery is relatively contraindicated for: (i) the woman afflicted with an active gynecological disease, i.e. an infection or a neoplastic malignancy; (ii) the woman who is a tobacco smoker unwilling to quit (either temporarily or permanently) in order to optimize the capability of her body to heal a surgical-incision wound; and (iii) the woman with unrealistic expectations about the labioplastic outcome, derived from unrealistic aesthetic goals for her self-image and for her body image. Such a woman should either be psychologically counselled or be excluded from labioplastic surgery.

II. Sexual reassignment

In sexual reassignment surgery for the male-to-female transgender patient, labiaplasty usually is the second stage of a two-stage vaginoplasty operation, wherein the plastic surgeon creates labia minora and a clitoral hood. 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 cosmetically refining the aesthetics of the woman’s vulvo-vaginal complex. (See: Male-to-female sex reassignment surgery)

Surgical procedures

Pudendum femininum: the external anatomy of the vulvo-vaginal complex, indicating the clitoris, the clitoral prepuce, the labia majora, and the labia minora.

General

As with every paired structure of the human body, the labia minora are not symmetrical, and, although the size discrepancy usually is subtle, and not readily noticed, a woman usually presents one labium minus (minor lip) that is considerably over-sized (longer, wider, and thicker) than its pair; thus, only the over-sized labium minus is resected (cut) to symmetry with the smaller labium. In the case of the woman who also presents redundant folding (webbing), either unilateral or bilateral, between the labia majora and the labia minora, the excess labial tissues are excised in the procedural course of the labiaplasty.

In surgical praxis, the labiaplasty procedure can be performed upon a patient who is under local anaesthesia, conscious sedation, or general anaesthesia, either as a discrete, single surgery, or in conjunction with a gynecologic surgery procedure, or in conjunction with a cosmetic surgery procedure. The resection 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 labial tissues, and the constriction of the pertinent labial circulatory system, the haemostasis that limits bleeding.

Techniques for labial reduction

I. Edge resection technique

The original labiaplasty technique was a simple resection of the excess tissues at the free edge of the labia minora. A variant resection technique features a clamp placed across the area of labial tissue to be cut (resected), in order to establish haemostasis (stopped blood-flow); the surgeon resects the excess tissues, and then sutures the cut labium minus or the cut labia minora.

The technical disadvantages of the labial-edge resection technique are: (i) the loss of the natural rugosity (wrinkles) of the labia minora free edges, which produces an unnaturally “perfect appearance” to the vulva; (ii) the greater risk of damaging the pertinent nerves endings (see: Pudendal nerve); and (iii) the possibility of everting (turning outwards) the inner lining of the labia, which then makes visible the normally hidden internal, pink labial tissues.

The technical advantage of the labial-edge resection technique is the precise control of the dark-skin (hyper-pigmented) irregular edges of the labia with a linear scar that also contours the redundant tissues of the clitoral hood, when present, which the woman reported as functionally and aesthetically undesirable.

II. Central wedge resection technique

The central-wedge resection labiaplasty procedure 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. To avoid that risk, the central-wedge resection technique was refined 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 to the labium or labia.

The central-wedge resection technique is a demanding surgical procedure, because of the difficulty in determining the correct amount of labial skin to cut out. The risks are under-correction (persistent tissue-redundancy); over-correction (excessive tension to the surgical wound); and increased probability of surgical-wound separation. Moreover, as appropriate, the labioplastic procedure will require a separate incision to resect and reduce a prominent clitoral hood.

III. De-epithelialization technique

The de-epithelialization labiaplasty involves cutting the epithelium of a central area, on the medial and lateral aspects, of each labium minus, either with a scalpel or with a medical laser. This labiaplasty technique reduces the vertical excess tissue, whilst preserving the natural rugosity (wrinkled free-edge) of the labia minora, and thus preserves the sensory and erectile characteristics of the labium or labia.

The technical disadvantage of the de-epithelialization labiaplasty is that the width of the individual labium might increase if a large area of labial tissue must be de-epithelialized in order to achieve the labial reduction.

IV. Labiaplasty with clitoral unhooding

Labiaplasty with clitoral unhooding: the pre-operative aspect of hypertrophied labia minora and a hypertrophied clitoral prepuce (left); the post-operative aspect of the reduced labia minora and the reduced clitoral prepuce (right).

A labial reduction procedure occasionally includes the cutting and removal (resection) of the clitoral prepuce (clitoral hood) when the thickness of that 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

Laser-ray labial reduction involves the de-epithelialization of the pertinent hypertrophied labium minus, or the labia minora. The technical disadvantage of laser de-epithelialization 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 excess tissues and preserves the natural rugosity (wrinkled free-edge) of the labia minora, and so preserves the capabilities for tumescence and sensation. Yet, when the patient presents much excess labial tissue, a combination procedure of de-epithelialization and clamp-resection usually is more effective for achieving the aesthetic outcome established by the patient and her plastic 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 labial hypertrophy that the woman presents when standing. Afterwards, in the operating room, with the patient in the lithotomy position (as if for a 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 of the excess tissues. As required by the patient’s health, the physician–surgeon might 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 excess 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, which conditions permit the woman to leave hospital and return home the same day she underwent the labial reduction procedure; 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. Moreover, she is 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 plastic 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. In accordance with 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 the occasional complications — bleeding, infection, labial asymmetry, poor wound-healing, under-correction, over-correction — do occur, and might require a revision surgery. An over-aggressive resection might damage the nerves, which condition subsequently causes painful neuromas. Furthermore, performing a flap-technique labiaplasty occasionally presents a greater risk for necrosis of the labia minora tissues.

Criticism

Further information: Body dysmorphic disorder, Female genital mutilation, Body image, and Beauty

Psychosocial criticism

Patients

Pudendum femininum (1-2) — a definition of depilated Beauty: The Birth of Venus (1486), by Sandro Botticelli.

Two categories of women seek vaginoplastic surgery: (i) Women physically afflicted with 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), et cetera; and (ii) Women who seek genital cosmetic surgery to enhance the beauty of their pudenda feminina.

Therefore, a woman usually seeks a labial reduction procedure to correct morphologic changes caused by the mechanical stresses (pulling, stretching, and tearing) of childbirth, sexual intercourse, accident, and aging. The symptoms of labial hypertrophy are 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), by David Veale and Fugen Neziroglu, indicated that, in addition to labial reduction, some women pursue genital surgery to acquire a flat vulvo-vaginal complex in the style of the idealized “prepubescent aesthetic” portrayed in pornography and in commercial adverts. Moreover, the authors of the BDD study, Veale and Neziroglu, further reported that:

. . . no [psychosocial] studies have been done on the prevalence of BDD [Body Dysmorphic Disorder] in women seeking labiaplasty. In this regard, it may be important for cosmetic gynecologists to define when the degree of protrusion, or hypertrophy, of the labia minora is no longer a minor defect (which would exclude a diagnosis of BDD). One of the authors [Fugen Neziroglu] 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 [minora], 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 [psychological] clinician must rely on a gynecologist or a family doctor who has examined the patient.

— Body Dysmorphic Disorder: A Treatment Manual (2010)

The body dysmorphia findings reported in the Veale–Neziroglu study confirmed 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 cosmetic labiaplasty (genitoplasty) because she feels that her vulva is not within a given “normal” aesthetic range of labial size, appearance, and skin coloration.

Patient satisfaction

The retrospective study Labiaplasty of the Labia minora: Patients’ Indications for Pursuing Surgery (2008) reported that in a 131-woman cohort, 32 per cent of the women underwent labiaplasty 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 cosmetic enhancement of the vulva. 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 procedures, 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 vulvo-vaginal complex — either for religious or for cultural reasons, or both — but not the plastic surgery correction of the congenital defects and the developmental abnormalities of the vulva, 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 and cultural practice and the medical practice of labiaplasty, which is an elective plastic surgery operation for a woman requiring the correction of either a functional or a cosmetic problem of her vulva. 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.

File:Origin-of-the-World.jpg

Pudendum femininum (2-2) — A definition of hirsute Beauty: The Origin of the World (1866), by Gustave Courbet.

• 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 to women the cultural concept of aesthetically ideal female genitalia, and that because the “labia are neither inside nor outside [the body], they are gateway tissues, and they kind of represent a [body] part that is [culturally] confusing”; and proposed that because women know only their vaginas and the pornographic pre-pubescent ideal, women readily doubt 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 Britain, 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, about the women 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 adverts 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 the 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

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.