Labiaplasty, or aesthetic labia minora reduction, has become a more commonly requested procedure by female patients. Increased media attention to labia minora appearance has likely contributed to the increased patient demand for surgery.1 Absence or removal of pubic hair may cause the labia minora to appear more prominent. If a patient subjectively feels that her labia is enlarged or asymmetric, she may exhibit significant emotional symptoms, including embarrassment, anxiety, and loss of self-esteem. Hypertrophic labia minora can cause physical discomfort with tight fitting clothing, walking, exercise, and sexual intercourse. Currently accepted indications for labia minora reduction include aesthetic dissatisfaction, discomfort in clothing, discomfort during exercise, and dyspareunia.2–6
Previously described techniques for labia minora reduction include amputation, inferior wedge resection, central wedge resection, z-plasty, de-epithelialization, use of a horseshoe flap, staged reduction, and w-plasty.7–25 As the demand for this type of surgery has increased, these techniques were more widely studied and used. However, there were drawbacks to each of these techniques. A number of techniques published in the literature result in scars on the leading edge of the labia minora and others may result in visible or unattractive scars.10,13,14 Many current procedures inadequately address excess labia minora tissue in both vertical and horizontal dimensions. Patients presenting for labiaplasty surgery may have excess tissue in the superior, middle, or inferior segments, which cannot be adequately addressed by some techniques mentioned above. Some patients request a clitoral unhooding procedure simultaneously, and with previously described labiaplasty techniques, it could not be incorporated directly and simply into the planning and execution of the surgery. Labial asymmetry is also a problem that other labiaplasty techniques inadequately address. The most significant aspect of this procedure, which differentiates it form previously published techniques, is its reliance on precise measurements to create labial flaps which result in reproducible, symmetrical, and natural results.
The senior author has developed the custom flask labiaplasty to address excess labia minora tissue in all dimensions, limit scars on the normal labial edge, and create an aesthetically pleasing result. The technique precisely reduces the labia minora in the necessary regions in a customized manner to achieve symmetry and a natural appearance of skin to maintain the neurovascular pedicles. Precise planning with measurements is the key to obtaining the desired labial reduction. This design allows superior control for multidirectional reduction. This article will discuss the new technique, its results, and patient satisfaction with the surgical procedure.
PATIENTS AND METHODS
A total of 50 consecutive custom flask labiaplasties were performed between March 2007 and June 2010. All patients presented to the senior author requesting labiaplasty surgery. Each patient was fully evaluated, examined, and photographed. Patients’ ages ranged from 17 to 60 years, with mean of 37.7 years. Eight of the patients underwent other genital cosmetic surgery simultaneously—5 had clitoral unhooding procedures, 1 had a labia majora reduction, 1 had vaginoplasty with clitoral unhooding, and 1 had vaginoplasty with labia majora reduction. In all cases, the custom flask labiaplasty surgery was performed solely by the senior author.
A retrospective study was performed to assess the efficacy and patient satisfaction with the results of the custom flask labiaplasty. Data were extracted from patients’ charts to catalog their initial reasons for seeking surgery. To determine the level of the patients’ postoperative satisfaction, a questionnaire was created. Survey information was obtained by face-to-face interviews, telephone interviews, and questionnaire completion. Responses were obtained from 27 of the 50 patients who underwent surgery. The time from surgery to postoperative assessment ranged from 2 to 38 months (mean, 14.6 mo). The response rate and the type of responses obtained were influenced by distance many patients travelled for surgery and the sensitive nature of this procedure.
Surgery is performed under general anesthesia on an outpatient basis. The patient is placed in stir-ups in lithotomy position. anti deep vein thrombosis boots are put in place and prophylactic intravenous antibiotics are given. Patients were asked to shave the perineum before surgery. The perineum and vagina were prepared with povidone-iodine. The distance from the distal aspect of the clitoral hood to the posterior introitus was measured (Fig. 1). This measurement equaled the sum of the lengths of the newly designed labia minora flaps (Fig. 2B). Superior and inferior flaps were designed with the appropriate height and width. The lateral incision was designed in the sulcus between the labia majora and the labia minora, while the medial incision was planned at the junction of the labia minora skin and the vaginal mucosa. The skin was then marked in a flask pattern (Fig. 2A) and scored with a scalpel for indelible marking. A solution of 0.5% bupivicaine with epinephrine (APP Pharmaceuticals, LLS, Schaumberg, Ill) was then injected at the base of the labium with a 27-gauge needle for anesthesia and hemostasis. The extraneous skin was removed from the labium medially and laterally with scissors and the needle tip cautery on low current in the flask pattern. No subcutaneous tissue was excised. This left the skin only on designed superior and inferior flaps, with the underlying tissue preserved as vascular pedicles (Fig. 3A). The flaps were then brought together (Fig. 3B), and the subcutaneous tissue was approximated with buried 5-0 polydioxanone suture (Ethicon, Inc., Somerville, NJ) in an interrupted fashion between the two flaps and in a running fashion at the lateral edges of the flaps. The skin was then carefully closed with a 5-0 poliglecaprone running suture along the lateral borders and interrupted sutures where the two flaps are joined (Ethicon, Inc) (Fig. 4). Mean surgery time was 98 minutes.
After surgery, the surgical site was treated with antibiotic ointment and ice. The patients were instructed to apply ice to the perineal area for 72 hours. During the first postoperative week, the patients were instructed to avoid exercise, strenuous activity, excessive walking, or prolonged standing. Patient follow-up office visits were scheduled within 2 weeks of surgery and again at 6 weeks after surgery. Patients were instructed to refrain from bicycle riding, horseback riding, or sexual activity for 6 weeks.
The most common reason for seeking surgery was dissatisfaction with labial appearance (Table 1). Patients were also concerned about discomfort or pain with clothing, during sexual activity, with exercise or walking, general irritation, and hygiene or infection issues.
Only 1 postoperative complication was recorded in the entire patient population (n = 50). The only complication was labia minora suture line dehiscence that occurred at the junction of the superior and inferior flaps, and no other wound healing problems occurred. This was easily corrected by placement of sutures under local anesthesia in the office. No urinary tract infections occurred after surgery, and pain was controlled in all cases with oral pain medication. No patient reported change in sensibility or sensitivity in the genital area. None of the patients noted pain or difficulty with sexual activity postoperatively, and several noted increased pleasure with intercourse. No fistula formation has occurred in any custom flask labiaplasty procedure performed.
Of the 27 patients who underwent labiaplasty and provided postoperative follow-up information for the study, 25 (93%) were satisfied or very satisfied with the results of their surgery. Of the 2 patients who were not satisfied, one felt that too much tissue had been removed and the other felt that not enough tissue had been removed (Table 2). Although the response rate is low, the satisfaction rate is similar to other large studies.8,26
Representative case preoperative and postoperative photographs are presented (Figs. 5–11).
The literature suggests that multiple factors can contribute to labia minora enlargement. The most common factor is likely congenital. However, stretching, early sexual activity, pregnancy, chronic irritation, and androgenic hormones have also been implicated.27–35
In the past decade, there has been a steady rise in the number of female cosmetic genital surgical procedures.1 The demand for this type of surgery has been driven by patients’ issues of discomfort as well as a developing sense of female genital aesthetics and function. Although the College of Gynecologists has decried labiaplasty surgery,5 a growing number of plastic, urologic, and gynecological surgeons have treated patients seeking genital aesthetic surgery with high patient satisfaction.8,26
The vascular supply of the labia minora was perhaps best described by Hwang et al.25 The labia minora is supplied by the anastomosis of the external superficial pudendal artery (branch of the femoral artery) and the internal pudendal artery (branch of the internal iliac artery). This anastomosis gives rise to a number of branches that directly supply the labia minora. The labia minora is innervated by the posterior labial nerve, which is a continuation of the pudendal nerve. The pudendal nerve also branches off into the dorsal nerve of the clitoris. The custom flask labiaplasty preserves the neurovascular anatomy of the labia minora.
The custom flask labiaplasty technique was designed by the senior author to provide patients with an optimal result regardless of the presenting morphological deformity. The labia minora can be reduced in both length and height in a measured fashion. Superficial dissection with consideration of the anatomy and creation of subcutaneous flap pedicles ensures that vascularity and innervation are not interrupted. The length of the superior and inferior labia minora flaps is based on the length of the opening measured from the distal end of the clitoral hood to the posterior labial minora commissure and is customized for each patient. Flap closure is consequently performed under no tension avoiding distortion, any tendency of flaps to pull apart, or unnatural appearance. The unique visible edge of the labia minora is maintained, and most of the suture lines are hidden (on the medial labia minora surface and in the sulcus between the labia minora and the labia majora). With the maintenance of skin texture and color in anatomical position, the final result is very natural in appearance and the suture lines are not visible. This procedure can also be combined with a clitoral unhooding procedure using the same surgical planning, bringing together the most proximal ends of the surgical incisions at the anterior commissure.
The wedge resection technique described by Alter7,8 can significantly reduce the vertical dimension of hypertrophic labia, and the de-epithelialization technique of Laub significantly reduces the horizontal dimension of hypertrophic labia. The custom flask labiaplasty incorporates aspects of each of these techniques to reduce hypertrophic labia in both dimensions. The preoperative measurements and markings focus on the final size and shape of the reconstructed labia minora resulting in good symmetry. By creating measured, designed flaps, this technique can be customized to provide excellent results regardless of the patient’s deformity or wishes. Patients with superior, central, or inferior hypertrophy of the labia or with asymmetrical labia can all be treated with surgical precision.
The most common presenting complaint of patients requesting labiaplasty in this study was undesirable appearance. Various discomfort issues comprised the next most common complaints. The low complication rate (2%) and the high satisfaction rate (93%) with the custom flask labiaplasty are comparable with the results reported in other large series of female aesthetic genital surgery.8,26
Although the response rate (27/50, 54%) was low, this may be due to the sensitive nature of the surgical procedure and the high percentage of patients traveling from out of state. Despite that, the low complication rate and the high satisfaction rate continue to be demonstrated in data analyzed subsequent to the completion of the present study.
The custom flask labiaplasty was designed to improve current surgical techniques for labia minora reduction. The use of measurements and planned flaps in the design of this operation provide consistency and predictability in the execution of the procedure and the results. This is particularly beneficial when the patient has asymmetrical labia minora, large or thick labia minora, or webbing of the labia minora. This technique preserves the neurovascular supply of the labia, produces predictable and reproducible results, has a low complication rate, achieves a natural and aesthetically pleasing result, and results in high patient satisfaction.
The custom flask labiaplasty is designed to improve on current surgical techniques for labia minora reduction. The key aspects of this surgical technique are custom planning for each patient’s deformity, a design pattern based on measured vascularized flaps, labial reduction in both vertical and horizontal planes, preservation of the normal visible edge of the labia minora, and minimal visible scars. This technique preserves the neurovascular supply of the labia; produces predictable and reproducible results; has a low complication rate; achieves a natural, aesthetically pleasing result; and results in high patient satisfaction.
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