Body Contouring

Continuing Medical Education Article Aesthetic Surgery Journal

2015, Vol 35(2) 165–177
© 2015 The American Society for

Aesthetic Surgery of Female External Genitalia Aesthetic Plastic Surgery, Inc.

Reprints and permission:
journals.permissions@oup.com
DOI: 10.1093/asj/sju020
www.aestheticsurgeryjournal.com

Lina Triana, MD; and Ana Maria Robledo, MD

Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding
The authors received no financial support for the research, authorship, and publication of this article.

Abstract
Aesthetic surgery of the external genitalia in women encompasses many procedures and may address the labia minora, clitoral hood, labia majora, mons pubis, or
vaginal opening. During the initial evaluation, the surgeon should consider all aspects of the external genitalia to develop an appropriate surgical plan. It may be
necessary to perform 2 or more procedures during the same surgical session to achieve the desired aesthetic result. In this continuing medical education (CME)
article, we review the literature and summarize the available cosmetic techniques for female external genitalia. Resection of the labia minora has been described in
several peer-reviewed reports. We also discuss the procedures and modifications to direct resection, wedge resection, and deepithelialization of the labia minora.
Aesthetic surgery of the clitoral hood may involve straight-line resection, extended wedge resection, or inverted V hoodoplasty. The mons pubis may be treated with
mons pubis pexy, wedge resection, or lipomodeling. The labia majora can be managed with direct resection or lipomodeling, and hymenoplasty may be performed
to correct a wide vaginal opening.

Accepted for publication May 28, 2014.

Learning Objectives According to ASAPS,3 the incidence of cosmetic procedures

increased by 3.1% from 2011 to 2012, whereas vaginal reju-
The reader is presumed to have understanding of aesthetic sur- venation procedures increased by >60% in the same
gical procedures. After studying this article, the participant period (from 2142 to 3521 procedures). Despite this
should be able to: growing popularity, knowledge about aesthetic surgery of
(1) Identify the 5 components of the external genitalia in female genitalia is lacking among patients and physicians.4
women that are suitable for surgical modification. The status of vaginal plastic surgery is similar to that of
(2) Classify the patient’s complaint. liposuction in the 1990s: many patients are eligible for
(3) Describe the most common techniques to address the ex- surgery, but few are aware that the procedures exist. Those
ternal vagina appropriately. who know about vaginal plastic surgery may not be able to
find a surgeon or facility, and some patients who desire this
Physicians may earn 1 hour of AMA PRA Category 1 surgery often are too embarrassed to discuss it. Plastic sur-
Credit™ by successfully completing the examination based on geons may practice different approaches and techniques for
this article. American Society for Aesthetic Plastic Surgery female genital surgery5; others may lack experience or have
(ASAPS) members and Aesthetic Surgery Journal (ASJ) sub-
scribers can complete this CME examination online by logging
Dr Triana is a plastic surgeon in private practice in Cali, Colombia.
on to the CME portion of ASJ’s website (http://aes-cme.
Dr Robledo is a plastic surgeon in the Burned Patient Unit at the
sagepub.com) and then searching for the examination by Hospital Universidad del Valle in Cali, Colombia.
subject or publication date.
The popularity of plastic surgery of female external genitalia Corresponding Author:
has increased dramatically in recent years1,2 – in far greater Dr Lina Triana, Calle 3 Oeste #34-19, San Fernando, Cali, Colombia.
proportion to that of cosmetic procedures overall. E-mail: linatriana@drlinatriana.com
166 Aesthetic Surgery Journal 35(2)

misconceptions about patients who desire this surgery. labia minora. The labia majora contain a variable and surgi-
Without sufficient surgeons skilled in these techniques, the cally modifiable amount of fatty tissue. The labia majora con-
increasing demand for surgery of the female external geni- verge with the labia minora at the posterior commissure or
talia will be unmet. A woman usually seeks this type of aes- fourchette. The labia minora are cutaneous folds located
thetic surgery to improve her comfort with her genitalia medial to the base of the labia majora that have much less sub-
and her perception of her body, which are directly related cutaneous tissue and are not precisely symmetric.7 The anteri-
to her sexual function.6 The plastic surgeon who has mas- or portion of the labium consists of the clitoral hood and
tered cosmetic procedures involving the genital area can frenulum.8
educate patients on the best alternatives for their sexual The external opening of the urethra is located in the vaginal
well-being. In the present article, we review the existing sci- vestibule, 2.5 cm behind the glans clitoris and anterior to the
entific literature on this subject and emphasize that more vaginal opening. The bulb of the vestibule is a mass of erectile
research is warranted. tissue positioned along the vaginal and urethral openings and
in contact with the urogenital diaphragm through the bulbo-
spongiosus. The clitoris is a sexual organ present only in
ANATOMY females. The visible rounded portion of the clitoris is located
near the anterior junction of the labia minora, above the open-
The vulva and clitoris are anatomic structures of the female ex- ings of the urethra and the vagina.9 The female clitoris is ho-
ternal genitalia (Figure 1). The vulva includes the mons pubis, mologous to the male penis but does not contain the distal
labia majora, labia minora, vaginal vestibule, and bulb of the urethra. The clitoral body is approximately 2.5 cm long and is
vestibule. The mons pubis is anterior to the pubic bone and attached to the pubic bone by a suspensory ligament. The clito-
contains a variable amount of fatty tissue. The labia majora are ral glans is a round mass covered by the clitoral hood, which
2 cutaneous folds that extend posteriorly from the mons pubis, corresponds to the convergence of the labia minora.
which are wider anteriorly and narrower posteriorly than the

Figure 1. Illustration of the female genitalia, with anatomic areas indicated: 1, labia majora; 2, labia minora; 3, mons pubis; 4, cli-
toral hood; 5, glans clitoris; 6, urethra; 7, vaginal opening.
Triana and Robledo 167

Table 1. Classification of Labial Hypertrophy Table 2. Classification of Labia Minora by Protrusion Beyond Labia
Majora
Type Length of Labium (cm)
Class Protrusion Characteristics
I <2
1 <2 cm protrusion beyond the fourchette, without extension beyond the labia
II 2-4 majora

III 4-6 2 >2 cm protrusion beyond the fourchette, with extension beyond the labia
majora
IV >6
3 Protrusion as in class 2, and beyond the clitoris anteriorly
Values represent the maximum length of each labium. Classification system developed by
Felicio.13 4 Protrusion as in class 3, and beyond the vagina to the perineum or anus

Classification system developed by Chang et al.14

The vasculature of the female external genitalia includes
the anterior labial arteries, branches of the external pudendal
arteries, the posterior labial arteries, and branches of the inter- Table 3. Classification of Clitoral Hood Abnormalities
nal pudendal artery. The labial veins drain to the pudendal
Description Anatomic Presentation
and femoral veins. The external genitalia are innervated anteri-
orly by the anterior labial nerves, which extend from the ilioin- Type 1: occluded The clitoris is buried under a partially or
guinal nerve, and by the genital nerve, which extends from the completely closed clitoral hood opening
genitofemoral nerve. The posterior pudendal branches inner-
Type 2: hypertrophic-gaping The clitoral hood skin is elongated or thick
vate the external genitalia posteriorly. The bulb of the vestibule
is innervated by perineal nerves, and the clitoris is innervated Type 3: hypertrophic with The thickness of the clitoral hood skin is uneven
by the pelvic plexus, pudendal nerve, and dorsal clitoral nerve. subdermal asymmetry

Classification system developed by Ostrzenski.15

EVALUATION
The surgical consultation should begin with a patient-surgeon classification of the patient’s concern enables the surgeon to
discussion of the patient’s concerns and desired outcomes; this select the most appropriate surgical procedures.
conversation should precede the examination. The patient’s
complaints could involve the pubis, labia majora, labia
minora, clitoral hood, perineum, vaginal opening, or any com-
SURGICAL TECHNIQUES
bination of these. The surgeon also must determine whether Aesthetic surgery of the female external genitalia encompasses
the patient’s concern is aesthetic or functional in nature, or numerous surgical procedures. In this CME article, each proce-
both. Discomfort during intercourse, lack of sexual pleasure, dure is described in terms of the anatomic structures they
issues with exercise or wearing certain clothing, or hygienic manage. Vaginoplasty, perineoplasty, and vaginal tightening
concerns could cause a patient to consider surgery of the exter- address the internal genitalia and are beyond the scope of this
nal genitalia.8,10 For instance, a patient with hypertrophy of article.
the labia minora may experience poor hygiene, discomfort
when wearing tight-fitting pants, and pain during inter-
course due to friction and folding of the labia.11 A patient Reduction of the Labia Minora
with insufficient subcutaneous fat underlying the mons
pubis may experience pain during intercourse along the Women frequently give nonaesthetic reasons for seeking
pubic bone. surgery to correct hypertrophy of the labia minora. This condi-
tion is associated with pain during intercourse, discomfort
when exercising or wearing tight clothing, and concerns about
CLASSIFICATION hygiene. In a multicenter study by Goodman et al16 of plastic
surgery among women, functional issues were the most
Initial findings during physical examination of the genital area common reason for considering labiaplasty (75% of 258 pa-
should be applied toward an anatomic classification. No classi- tients), followed by aesthetic concerns and low self-esteem.
fication exists for deformities of the pubis and labia majora, Reduction of the labia minora has increased in popularity and is
but most authors categorize cases as hypertrophy owing to fat the most frequently performed vaginal procedure. In the United
excess or as atrophy owing to weight loss or aging.12 The labia Kingdom, the number of procedures to reduce the labia minora
minora may be classified according to the maximum length of increased from <400 in 1998/1999 to 1200 in 2007/2008.8
each labium, as reported by Felicio (Table 1),13 or by the Several techniques exist to reduce the labia minora. Direct
amount of tissue protruding beyond the posterior fourchette or excision (Figure 2) is performed most frequently;17-19 it involves
the labia majora, as described by Chang et al (Table 2).14 The amputation of the labial tissue protruding through the labia
clitoral hood may be classified by the extent and thickness of majora and reapproximation of the edges. This technique
its tissue, as proposed by Ostrzenski15 (Table 3). Accurate creates a straight scar positioned along the labial edge and
168 Aesthetic Surgery Journal 35(2)

Figure 2. (A) This 19-year-old woman presented with hypertrophy of the labia minora and clitoral hood. She underwent direct ex-
cision of the labia minora and longitudinal reduction of the clitoral hood. (B) Two years postoperatively.

removes the labial border, which can darken with age and wedge of pinched tissue is resected. This technique, known as
become aesthetically unpleasant.20 However, direct exci- the pinch test, and can be applied to resections of several struc-
sion may distort the labial edge and is not indicated for pa- tures of the female genitalia. When the borders are reapproxi-
tients who wish to retain the labial border. Moreover, the mated, the superior flap reconstructs the defect (Figure 8).24
linear scar may contract and cause tight introitus or tension This approach preserves the free edge of the labium and leaves a
in the posterior fourchette (Figure 3). scar in the posterior, more hidden aspect of the labia minora.
The first modification to direct excision was developed by However, a mild bulging deformity of the contour may result
Maas and Hage21 and involved a zigzag incision. With this ap- because the superior flap is wider than the posterior edge of the
proach, each labium is divided into 2 flaps, and excess tissue in labium.
each flap is resected in a W-plasty that mirrors that of the other Posterior wedge resection is a modification to inferior wedge
flap. The creation of complementary incisions enables closure resection and reconstruction of the superior flap.20 With this pro-
with 1 layer of absorbable sutures (Figure 4). Like the zigzag cedure, more of the anterior labial border is preserved, and most
incision, the lazy S incision7 is made to avoid potential contrac- of the tissue is resected from the middle of the labium. These
tion of a straight scar. With this technique, 1 labium is left modifications reduce tension and decrease the risk of a bulging
slightly larger than the other to improve closure of the introi- deformity but leave a narrow anterior flap with a potentially
tus. reduced vascular supply (Figure 9).
A wedge or V-shaped resection can be centered over the Deepithelialized reduction labiaplasty is indicated in cases
protuberant region of the labia minora (Figure 5)22 to reduce of mild or moderate labial hypertrophy (types II or III; Table 1)
the size of the labia while preserving the labial border. and involves fusiform resection of the epidermis at the inner
However, this resection pattern can create an abrupt color and outer sides of the labium (Figure 10). This technique
change in the labial border, and leaves a linear scar that can reduces the lengths of the labia and preserves the border.
contract and distort the natural contour of the labium. To Moreover, deepithelialization reduces the number of seba-
manage excess tissue at the clitoral hood, the wedge can be ex- ceous glands, thereby reducing the outflow of vaginal secre-
tended anteriorly, and a hockey stick–shaped resection can be tions.25,26 Bidimensional reduction of the labia minora is
made (Figure 6).18 Two modifications have been described to similar to deepithelialized reduction labiaplasty but in-
avoid linear contraction of the scar made by wedge resection. cludes a full-thickness inferior wedge resection (Figure 11).
One modification adds 90° Z-plasties to each arm of the This modification enables treatment of severe hypertrophy.
wedge,23 and the other adds a horizontal wedge to each arm of
the vertical wedge that can be angled according to the location
of the excess tissue (ie, star modification; Figure 7).8
Reduction of the Clitoral Hood
Resection of the inferior wedge and reconstruction of the Excess tissue surrounding the clitoris may reduce sensitivity,
superior pedicle flap are indicated for patients with moderate impair sexual function, and appear aesthetically unpleasant.27
to severe hypertrophy of the labia minora. To mark the tissue Excess tissue at the clitoral hood must be identified preopera-
for resection, the middle portion of each labium is stretched in- tively and excised during resection of the labia minora. Resection
feriorly toward the posterior vaginal introitus. The resulting of the inferior wedge and reconstruction of the superior pedicle
Triana and Robledo 169

Figure 3. Direct excision of the labia minora, with amputation Figure 4. The zigzag incision, a modification of direct exci-
of the labial tissue protruding through the labia majora and sion. Excess tissue is resected in a W-plasty that mirrors the
reapproximation of the edges. pattern of the other flap.

Figure 5. Wedge, or V-shaped, resection positioned over the Figure 6. Hockey-stick modification to wedge resection. The
most protuberant region of the labia minora. anterior modification manages clitoral hood excess.

Figure 7. Star modification to wedge resection. Figure 8. Inferior wedge resection and superior flap
reconstruction.
170 Aesthetic Surgery Journal 35(2)

Figure 10. Deepithelialized reduction labiaplasty, with fusi-

form resection of the epidermis over both sides of each labium.
Figure 9. Full-thickness posterior wedge resection.

Figure 11. Bidimensional reduction of the labia minora, with Figure 12. Longitudinal resection of excess tissue at the clito-
full-thickness inferior wedge resection. ral hood, and reapproximation of the edges.

flap can reduce the labia minora as well as the clitoral hood. resulting scar would be placed outside the mucosa, increasing its
Specifically, when the superior flap is pulled to reconstruct the visibility and tendency to contract.
inferior defect, the traction also pulls excess tissue at the clitoral Alternatively, excess tissue at the clitoral hood can be re-
hood and exposes the clitoris. Similarly, resection of an extended sected in a horseshoe design with the incision at the base of
central wedge18 reduces tissue at the clitoral hood by means of the hood (R. Kalra, personal communication, January 2012).
the anterior hockey stick–shaped resection. These 2 techniques This technique can be performed in patients who have severe
are applicable to patients with Ostrzenski15 type 2 hypertrophic- tissue excess, but care must be taken to avoid overresection
gaping deformities of the clitoral hood but cannot be performed and exposure of the clitoris. The horseshoe resection may be
in patients whose clitoral hood opening is occluded. extended beyond the limits of the clitoral hood to treat hyper-
Mild to moderate excess of the clitoral hood can be treated by trophy of the labia minora (Figure 13).
longitudinal resection.17 This approach involves amputation of
the clitoral hood border and positions the scar in the skin-mucosa Clitoral Hoodoplasty
transition. To perform this procedure, the clitoral hood is lifted,
and the excess skin is resected with scissors (Figure 12). Patients with phimosis of the clitoral hood can experience im-
Sufficient hood tissue must be retained to cover the clitoris, paired sexual function and sensitivity due to a buried clitoris
because permanent exposure of this structure can cause pain and and often have hygienic complaints such as odor and rash
discomfort while walking and sitting. Severely excessive tissue because fluids accumulate around the clitoris.15 Rather than
should not be treated by longitudinal resection because the simple reduction, hoodoplasty is indicated in these patients to
Triana and Robledo 171

Figure 13. Horseshoe resection of excess tissue at the clitoral hood. (A) Dotted lines indicate the resection pattern.
(B) Intraoperative view of the resected clitoral hood prior to reapproximation of the edges.

restore the opening of the clitoral hood and separate the glans involves minimal scarring. However, contour irregularities
clitoris from the hood. In hydrodissection with reverse may arise with time, and existing ptosis may become more
V-plasty, the glans clitoris and hood are separated by hydro- severe. If excess skin is the cause of labia majora hypertro-
dissection, and a V-shaped incision is made in the clitoral phy, resection of skin and fatty tissue is recommended.30
hood to resect the contracted part and correct the phimosis.28 Longitudinal resection of skin and subcutaneous tissue
This modified V-plasty also can be applied to patients with with scar placement in the vulva-thigh crease22 reduces the
excess tissue at the clitoral hood. For patients with asymmet- size of the labia without disturbing the labial edge (Figure 15).
ric subdermal hypertrophy, subepithelial reduction15 is rec- Markings are made in the crural crease, and the tissue to be re-
ommended. This technique involves resection of sected is determined by the pinch test. Resection is parallel to
hypertrophied subepithelial tissues to create a clitoral hood the crural and vulvar creases. Subcutaneous fatty tissue also is
with symmetric thickness bilaterally. resected, and the final scar is positioned in the crural crease.
This method creates a scar in a high-tension area, increasing
Augmentation of the Labia Majora the likelihood of wound dehiscence and potentially opening
the vaginal introitus. This latter complication also is associated
The labia majora are the most visible structures of the vulva with thigh reductions involving only a horizontal incision.31
and account for much of the female genital aesthetic. The size Excess skin and subcutaneous tissue also may be reduced
of the labia majora can be surgically reduced or enlarged to by dermolipectomy of the longitudinal aspect of the labia.32 In
achieve the desired aesthetic outcome, but reports of these pro- this procedure, the resection is marked 1.5 cm from the crural
cedures are limited. Patients who are thin or have undergone crease, and the amount of tissue to be resected is determined
massive weight loss may complain of small labia majora that by the pinch test. Skin and fat are removed in the superficial
are aesthetically unpleasant and associated with pain during planes. This technique usually positions the scar in the labial
sexual intercourse. border, which may cause contraction and distortion of the
The labia may be augmented with fat injections.7,29 Fat is labial edge. Alternatively, the final scar can be placed in the
harvested by liposuction through a 3-mm cannula, pre- skin-mucosa transition, leaving it well concealed (Figure 16).
ferably from a site where liposuction has not been perfor- The wedge-like resection33 is similar to dermolipectomy except
med previously. Fat is collected into 5-mL syringes and is that it positions the final scar in the transition between the
injected evenly into the labia majora, with 1.5-mm injection labia majora and labia minora, thus respecting the labial edge.
cannulae, until the desired size is achieved (Figure 14). The pinch test is performed to mark the excess skin to be re-
Fat injections are technically less complex than other augmen- sected. If the patient presents with deflation of the labia
tation procedures and leave smaller scars. However, fat reab- majora, the existing adipose tissue can be retained to supply
sorption may occur and may be variable and unpredictable. fullness to the area. When performing wedge resection, the
surgeon must be careful to leave enough mucosa so that the
introitus is not widened and to place the scar in a location
Reduction of the Labia Majora where pigment variations are not noticeable.
Overweight or obese patients may present with enlarged, aes-
thetically unpleasant labia majora that may be ptotic and re- Treatment of the Pubic Region
semble a small penis. If the source of the hypertrophy is fat
rather than ptotic skin, liposuction may be performed12,29 by Obese patients may present with an enlarged and ptotic mons
means of ≤3-mm cannulae. This procedure is simple and pubis that creates an unpleasant appearance.34 Liposuction is
172 Aesthetic Surgery Journal 35(2)

Figure 14. (A) Atrophy of the labia majora. (B) Fat injection to improve labial contour.

Figure 15. Resection of labia majora skin and subcutaneous tissue, with placement of scar in the vulva-thigh crease. Illustration
indicates the amount of tissue that can be removed with this procedure.

most commonly performed to decrease the size of the mons on the mons pubis are temporary in obese patients and
pubis. The surgeon should utilize 3-mm cannulae and proceed those who have undergone massive weight loss because
conservatively to avoid contour irregularities. Compared with the tissues are not attached to a fixed structure. To treat the
traditional liposuction, ultrasound-assisted liposuction shrinks pubic region effectively, it is important to predetermine
the skin more evenly and leaves a smoother contour.34 whether the excess tissue is vertical, horizontal, or both.
Abdominoplasties pull the mons pubis upward because the Vertically oriented excess tissue is more common and is re-
skin is streched.35,36 However, the effects of abdominoplasty sected as a horizontal wedge. This lifts the pubic area,
Triana and Robledo 173

Figure 16. (A, C) This 37-year-old woman presented with hypertrophy of the labia majora and underwent wedge resection.
(B, D). Two years postoperatively. Note placement of the scar at the skin-mucosa transition.

shortening the distance between the mons pubis and the virginity is culturally expected or by those who are not sexually
umbilicus to the ideal 10 to 12 cm. When the patient also active but have experienced genital trauma.41 Hymenoplasty
presents with horizontally oriented excess tissue, both hori- generally is performed under local anesthesia with sedation.
zontal and vertical wedges are resected to achieve a narrow The patient is placed in the lithotomy position, and caruncles
and youthful appearance.37 Mons pubis pexy usually is per- are identified under a magnifying lens. The margins of each
formed with abdominoplasty but may be performed alone caruncle are freshened, and the caruncles are sutured together
in patients without tissue laxity. For this procedure, an with 2 layers of absorbable 5-0 single stitches (Figure 18).42
ellipse-shaped resection is made above the pubic crease. The surgeon must preserve an appropriate vaginal opening to
The fascia of the rectus abdominis can be accessed through allow for passage of vaginal and menstrual fluids.33
this incision (Figure 17). When the resection is complete,
the pubic tissues are fixed at 2 or 3 points to the fascia of
the rectus abdominis to prevent them from descending.38,39
This surgical maneuver is essential to the success of the NONSURGICAL TREATMENTS
procedure. The wound is closed by standard methods.
Hyaluronic Acid
Hymenoplasty Patients with irregularities of the mons pubis, labia minora, or
labia majora may be treated by injections of hyaluronic acid.
Hymenoplasty is performed to narrow the vaginal opening.40 This filler is available as prefilled syringes and must be injected
During the first vaginal penetration, the hymen usually is into the deep dermis or immediately below the dermis.
torn into several small fragments or hymenal caruncles. Hyme- Hyaluronic acid injections must be repeated every 6 to 12
noplasty may be requested by individuals in societies where months to maintain the aesthetic effects.43
174 Aesthetic Surgery Journal 35(2)

Figure 17. (A) Mons pubis pexy. Dotted lines indicate the resection pattern, and purple areas indicate the extent of dissection.
(B) The pubis tissue is suspended to the fascia of the rectus abdominis.

Figure 18. (A) Vaginal opening depicting hymenal caruncles. (B) Caruncles sutured together.

OUTCOMES AND COMPLICATIONS cases, a major hematoma may develop that requires surgery.
Hematoma is the primary reason for early reoperation, and
Reduction of the Labia Minora late reoperations are due to asymmetry, aesthetic complaints,
and a postoperatively disproportionate clitoris or labia.47-49
Complications associated with techniques to reduce the Patient satisfaction, albeit subjective, ranges from 90% to
labia minora include suture dehiscence, infection, and 100%.7,17,18
hematoma.44 Some surgeons recommend administering pro- Patient satisfaction rates for the specific procedures
phylactic antibiotics to patients in warm climates to reduce reviewed in this CME article are similar. Deepithelialized re-
the risk of infection.45 The incidence of complications with duction labiaplasty has the associated benefit of reducing
labia minora reduction is <10%,44 and most complications vaginal secretions, which can be a source of hygienic concerns
are minor. Hematomas often drain spontaneously, and mild in some patients. The surgeon should choose wedge resection
wound dehiscence heals by secondary intention.46 In rare and deepithelialization25,26 for patients who wish to preserve
Triana and Robledo 175

the labial border and should select amputation procedures complication associated with hymenoplasty is hematoma55
for patients who desire replacement of the labial edge.50 because the caruncles are highly vascularized structures.
However, reports of this procedure are scarce.56
Hoodoplasty and Reduction of the Clitoral
Hood Maximizing Successful Outcomes
Aesthetic procedures for the clitoral hood involve reduction in Individuals may regard numerous conditions of the female ex-
clitoral hood size and improvements to aesthetics and func- ternal genitalia18 as deformities necessitating surgery.57
tionality, without creating permanent overexposure of the Virtually all these conditions involve hypertrophy or atrophy of
glans clitoris.51 Clitoral hoodoplasty enables fluid drainage 1 or more genital structures. Several techniques have been de-
from the vagina and reduces hygienic issues related to phimo- scribed to address each structure specifically;58,59 however,
sis, such as odor. However, these procedures have been de- our experience suggests that the surgeon must address
scribed by few authors. In a cross-sectional study, Minto et al52 several genital structures simultaneously to achieve the
noted diminished sexual pleasure and lack of clitoral sensitiv- most favorable outcomes.
ity in patients with ambiguous genitalia who underwent clito- The surgeon should be aware of all available procedures
ral reduction or clitorectomy during early childhood as part of for female genital surgery, regardless of which techniques he
the sexual assignment process. Surgeons who have performed or she prefers. This knowledge is essential for surgical plan-
clitoral hoodoplasty and clitoral hood reduction reported no ning because patients may desire very different aesthetic out-
surgical complications and indicated that the desired surgical comes. However, the choice of surgical approach is of
outcomes were achieved.42 However, long-term follow-up is secondary importance compared with the surgeon’s initial
lacking among the literature. evaluation, during which he or she must listen to the patient
and ascertain her reason for considering genital surgery. The
patient’s concerns, in conjunction with the anatomic abnor-
Augmentation of the Labia Majora
mality, must guide selection of the surgical procedures. This
Augmentation of the labia majora is often requested to achieve process is vital to ensuring patient satisfaction.
fuller labia that appear more youthful and to avoid pain or dis-
comfort during sexual intercourse. Fat injections produce the
desired outcomes (R. Kalra, personal communication, January CONCLUSIONS
2012), but integration of the fat graft is variable and may neces- The demand for external genitalia surgery is increasing.
sitate a second procedure.29 Thighlifts involving a deepithelial- Aesthetic plastic surgeons should master the bevy of tech-
ized flap are associated with partial necrosis and retraction, niques that enhance female genital structures in the effort to
which may require subsequent fat grafting.53 design the most appropriate surgical plan and achieve the pa-
tient’s aesthetic goals. The external genitalia should be consid-
Reduction of the Labia Majora ered as a whole, rather than as isolated structures, and
surgeons should reject the notion that vaginal plastic surgery is
Resections of the labia majora are made to rejuvenate limited to excision of the labia minora. Because published
the appearance of the vulva. Surgeons must exercise caution reports on many of these techniques are scant, substantially
when performing techniques that leave a scar in the crural more research is warranted.
crease because the vaginal opening may be affected. Surgical
procedures to address the labial border may cause distortion
of the border and leave visible scars. Reported complications REFERENCES
are similar to those of labia minora reduction. 1. Braun V. In Search of (Better) Sexual Pleasure: Female
Genital ‘Cosmetic’ Surgery. Sexualities. 2005;8(4):407-424.
Treatment of the Pubic Region 2. Liao L-M, Michala L, Creighton S. Labial surgery for well
women: a review of the literature. Brit J Obstet Gynaec.
The 2 aesthetic considerations for the pubic region are fat and 2010;117:20-25.
skin. Although liposuction reduces fat volume, it may create 3. Cosmetic surgery national data bank statistics 2012.
contour irregularities and loosen the skin if performed aggres- Aesthetic surgery journal Vol. 33, Supplement 2. July 2013
sively.53 Skin resections rejuvenate the mons pubis, but unless 4. Braun V. Female Genital Cosmetic Surgery: A Critical
the tissues are fixed to the rectus fascia, they are likely to Review of Current Knowledge and Contemporary Debates.
descend with time.54 Complications from these procedures are J Womens Health (Larchmt). 2010;19(7):1393-1407.
rare and include infection, hematoma, and suture dehiscence 5. Mirzabeigi MN, Moore JH Jr, Mericli AF, et al. Current
that could necessitate reintervention in severe cases. Trends in Vaginal Labioplasty A Survey of Plastic Surgeons
Annals of Plastic Surgery. Ann Plast Surg. 2012;68(2):
Hymenoplasty 125-134.
6. Lowenstein L, Gamble T, Sanses TV, et al. Sexual function
Hymenoplasty returns the vaginal introitus to a virgin-like is related to body image perception in women with pelvic
state, and has been designated “revirgination.” The primary organ prolapse. J Sex Med. 2009;6(8):2286-2291.
176 Aesthetic Surgery Journal 35(2)

7. Alencar Felicio Y Labial Surgery. Aesthet Surg J. 2007;27: labioplasty). Plast Reconstr Surg. 105(1):419–422. discus-
322. sion 423–424.
8. Tepper OM, Wulkan M, Matarasso A. Labioplasty: 27. Hodgkinson D, Hait G. Aesthetic Vaginal Labioplasty.
Anatomy, Etiology, and a New Surgical Approach. Aesthet Plast Reconstr Surg. 1984;74(3):414-416.
Surg J. 2011;31(5):511-518. 28. Ostrzenski A. A New, Hydrodissection with Reverse
9. Delgado A. Pelvis En: Anatomía Humana Funcional y V-Plasty Technique for the Buried Clitoris Associated
Clínica. Universidad del Valle. 3a Edicion. CATORSE, 1981: with Lichen Sclerosus. J Gynecol Surg. 2010;26(1):
238-242. 41-48.
10. Vaginal “rejuvenation” and cosmetic vaginal procedures. 29. Vogt PM, Herold C, Rennekampff HO. Autologous fat trans-
ACOG Committee Opinion No. 378. American College of plantation for labia majora reconstruction. Aesthetic Plast
Obstetricians and Gynecologists. Obstet Gynecol. 2007; Surg. 2011;35(5):913-915.
110:737-738. 30. Mottura A. Labia majora hypertrophy. Aesthetic Plast Surg.
11. Miklos JR, Moore RD Labiaplasty of the Labia Minora: 2009;33(6):859-863.
Patients’ Indications for Pursuing Surgery. J Sex Med. 31. Aly A. Comment on “Does Thighplasty for Upper Thigh
2008;5:1492-1495. Laxity After Massive Weight Loss Require a Vertical
12. Felicio Y. Plástica do púbis e da genitália externa: duas Incision?” Aesthet Surg J. 2009;29(6):522-523.
décadas de experiencia. Rev Bras Cir Plást. 2011;26 32. Lapalorcia LM, Podda S, Campiglio G, Cordellini M. Labia
(2):321-327. majora labioplasty in HIV-related vaginal lipodystrophy:
13. Felicio Y, Chirurgie Intime. La Ver Chir Esth Lang Franc. technique description and literature review. Aesthetic Plast
1992;67(7):37-43. Surg. 2013;37(4):711-714.
14. Chang P, Salisbury M, Narsete T, et al. Vaginal Labiaplasty: 33. Triana L Incorporating Genital Surgery into your Practice.
Defense of the Simple “Clip and Snip” and a New Genital surgery panel. ASAPS Aesthetic meeting 2013
Classification System. Aesthetic Plast Surg. 2013;37(5): New York.
887-891. 34. Hughes C. Body Contouring of the Suprapubic Region.
15. Ostrzenski A. Selecting Aesthetic Gynecologic Procedures Aesthet Surg J. 2000;20(5).
for Plastic Surgeons: A Review of Target Methodology. 35. Wallach SG. Abdominal Contour Surgery for the Massive
Aesthetic Plast Surg. 2013;37(2):256–265. Weight Loss Patient: The Fleur-De-Lis Approach. Aesthet
16. Goodman M, Placik O, Benson R, et al. A Large Surg J. 2005;25(5):454-465.
Multicenter Outcome Study of Female Genital Plastic 36. Lockwood T. Lower-Body Lift. Aesthet Surg J. 2001;21(4):
Surgery. J Sex Med. 2010;7(4 Pt 1):1565-1577. 355-370.
17. Triana L, Robledo AM. Refreshing labiaplasty techniques 37. Matarasso A, Wallach S. Abdominal Contour Surgery:
for plastic surgeons. Aesthetic Plast Surg. DOI:10. Treating All Aesthetic Units, Including the Mons Pubis.
1007/s00266-012-9916-z. Aesthet Surg J. 2001;21(2):111-119.
18. Alter G, Aesthetic Labia Minora and Clitoral Hood. 38. Nóbrega ESS, Silva HLA. Rejuvenescimento da região
Reduction Using Extended Central Wedge Resection. pudenda, associado ou não a dermolipectomia abdomi-
Plast Reconstr Surg. 2008;122(6):1780-1789. nal Rev. Bras Cir Plást. 2009;24(3):351-356.
19. Capraro VJ. Congenital anomalies. Clin Obstet Gynecol. 39. Kaluf R, Zanato AAG, Martins DL, et al. Tratamento da
1971;14(4):988-1012. região pubiana na abdominoplastia de pacientes após
20. Kelishadi SS, Elston JB, Rao AJ, Tutela JP, Mizuguchi grande perda ponderal. Rev Bras Cir Plást. 2008;23(4):
NN. Posterior Wedge Resection: A More Aesthetic 302-304.
Labiaplasty. Aesthet Surg J. 2013;33(6):847-853. 40. Mirzabeigi M, Jandali S, Mettel R, Alter G. The
21. Maas S, Hage JJ. Functional and aesthetic labia minora Nomenclature of “Vaginal Rejuvenation” and Elective
reduction. Plast Reconstr Surg. 2000;105(4):1453-1456. Vulvovaginal Plastic Surgery. Aesthet Surg J. 2011;31(6):
22. Alter G. A new technique for aesthetic labia minora re- 723-724.
duction. Ann Plast Surg. 1998;40:287-290. 41. Ostrzenski A. Cosmetic gynecology in the view of
23. Giraldo F, González C, Haro F. Central Wedge evidence-based medicine and ACOG recommendations:
Nymphectomy with a 90-Degree Z-Plasty for Aesthetic a review. Arch Gynecol Obstet. 2011;284:617-630.
Reduction of the Labia Minora. Plast Reconstr Surg. 42. Vishwa Prakash. Hymenoplasty – How to do. Indian
2004;113(6):1820-1825; discussion 1826-1827. J Surg. 2009;71(4):221-223.
24. Munhoz AM, Filassi JR, Ricci MD, et al. Aesthetic Labia 43. De Lorenzi F, Mascolo E, Albani F, Sideri M. Female
Minora Reduction with Inferior Wedge Resection and Genital Surgery. In: Pongprutthipan Alam (eds.) Body
Superior Pedicle Flap Reconstruction. Plast Reconstr Surg. Rejuvenation. Springer 2010.
2006;118(5):1237-1247; discussion 1248–1250. 44. Cihantimur B, Herold C. Genital Beautification: A
25. Mayer H, Elizalde ML, Duh N, Loustau HD. Concept That Offers More Than Reduction of the Labia
Bidimensional labiaminora reduction. Eur J Plast Surg. Minora. Aesthetic Plast Surg. 2013;37(6):1128–1133.
2011;34(5):345–350. 45. Felicio Y. Considerations in Female External Genital
26. Choi HY, Kim KT. A new method for aesthetic reduction Aesthetic Surgery Techniques. Letters and brief commu-
to the labia minora (the deepithelialized reduction nications. Aesthet Surg J. 2008;28:107.
Triana and Robledo 177

46. Ellsworth W, Rizvi M, Lypka M, et al. Techniques for genitalia: a cross-sectional study. Lancet. 2003;361
Labia Minora Reduction: An Algorithmic Approach. (9365):1252-1257.
Aesth Plast Surg. 2010;34:105-110. 53. Alter G. Management of the Mons Pubis and Labia Majora
47. Hamori C. Postoperative clitoral hood deformity after in the Massive Weight Loss Patient. Aesthet Surg J.
labiaplasty. Aesthet Surg J. 2013;33:1030. 2009;29(5):432-442.
48. Koning M, Zeijlmans IA, Bouman TK, van der Lei B. 54. Bloom JM1, Van Kouwenberg E, Davenport M, Koltz PF,
Female attitudes regarding labia minora appearance and Shaw RB Jr, Gusenoff JA. Aesthetic and Functional
reduction with consideration of media influence. Aesthet Satisfaction After Monsplasty in the Massive Weight
Surg J. 2009;29(1):65-71. Loss Population. Aesthet Surg J. 2012;32(7):877-885.
49. Alter G. Labia Minora Reconstruction Using Clitoral 55. Raigosa M, Avvedimento S, Fontdevila J. Self-made
Hood Flaps, Wedge Excisions, and YV Advance- Compressive Dressing for Vaginoplasty. Aesth Plast Surg.
ment Flaps. Plast Reconstr Surg. 2011;127(6):2356- 2013;37:844-845.
2363. 56. Cartwright R, Cardozo L. Cosmetic vulvovaginal
50. Murariu D, Jackowe D, Parsa A, Parsa F. Comparison surgery. Obstet Gynaecol Reprod Med. 2008;18(10):
of Wedge versus Straight-Line Reduction Labioplasty. 285-286.
Plast Reconstr Surg. 2010;125(3):1046-1047; author reply 57. Plowman TM. The Perfect Vagina. Reprod Health Matters.
1047–1048. 2010;18(35):111-114.
51. Goodman MP, Female Cosmetic Genital Surgery. 58. Zwang G. Vulvar reconstruction. The exploitation of an
Obstetrics and gynecology vol 113, N1. 1, Jan 2009. ignorance. Sexologies 2011;20(2):81-87.
52. Minto C, Liao LM, Woodhouse C, Ransley P, Creighton S. 59. Likes WM, Sideri M, Haefner H, Cunningham P, Albani F.
The effect of clitoral surgery on sexual outcome in indi- Aesthetic practice of labial reduction. J Low Genit Tract
viduals who have intersex conditions with ambiguous Dis. 2008;12(3):210-216.