Added: Mikki Mullan - Date: 19.10.2021 06:41 - Views: 49237 - Clicks: 9225
John G. Aesthetic alteration of the genitalia is increasingly sought by women unhappy with the size, shape, and appearance of their vulva. Although the labia minora are usually the focus of concern, the entire anatomic region—minora, labia majora, clitoral hood, perineum, and mons pubis—should be evaluated in a preoperative assessment of women seeking labiaplasty. Labiaplasty is associated with high patient satisfaction and low complication rates.
The three basic labia minora reduction techniques—edge excision, wedge excision, and central deepithelialization—as well as their advantages and disadvantages are discussed to assist the surgeon in tailoring technique selection to individual genital anatomy and aesthetic desires. We present key points of the preoperative anatomic evaluation, technique selection, operative risks, perioperative care, and potential complications for labia minora, labia majora, and clitoral hood alterations, based on a large operative experience.
Labiaplasty competency should be part of large labia skill set of all plastic surgeons. Although ranked relatively low on volume lists of overall cosmetic surgery procedures in the United States, 1 aesthetic alteration of the genitalia is increasingly sought by women unhappy with the size, shape, and appearance of their vulva.
It is therefore essential that the entire anatomic region—labia minora, labia majora, clitoral hood, perineum, and mons pubis—be evaluated in the preoperative assessment of women seeking labiaplasties. Descriptions, reviews, and illustrations of female external genital anatomy and labiaplasty procedures and techniques are abundant, and readily available in the recent literature.
Rather, I offer what I have learned in performing over labiaplasties. Key points of preoperative anatomic evaluation, technique selection, operative caveats, and perioperative care for labia minora, large labia hood, and labia majora alterations are presented. Female external genital cosmetic surgery procedures are viewed by many plastic surgeons and gynecologists as being technically simple operations. They often are. Many women, however, present with anatomic challenges that make achieving good aesthetic outcomes difficult.
Simply reducing the labia minora in women with complex anatomic issues may result in unnatural-appearing genitalia and the perception of genital deformity as unintended consequences. Prominent lateral clitoral hood folds or labial remnants between the introitus and anus Figures 1 and 2proportional to large labia minora before surgery, may appear more unnatural after a simple labia minora reduction, regardless of the labiaplasty technique employed.
Patient dissatisfaction and an augmented sense of genital embarrassment may occur. A year-old woman with thick, hyperpigmented labia minora and redundant labia minora tissue extending between the introitus and anus. Accurate evaluation of anatomic issues, surgical planning, and technical execution are essential in achieving optimal aesthetic outcomes. As ly stated, reduction of the labia minora is by far the most commonly requested female external genital cosmetic procedure Figures 3 and 4. Those seeking surgery, in my experience, have labia minora that, albeit large, fall within the normal minora size range.
Very few women have minora that can be considered abnormally large. Female genital cosmetic surgery is overwhelmingly sought for aesthetic reasons. Although minor functional complaints ie, irritation are common, ificant issues are rare. This experience mirrors the published findings of Crouch et al. The main indication for labiaplasty, therefore, is overwhelmingly the same as for other aesthetic procedures: patient preference. Veale et al 17 found that labiaplasty patients did not differ from controls on measures of depression or anxiety, but reported a ificantly greater frequency of avoidance behaviors.
Eighteen percent of women in their study met the diagnostic criteria for body dysmorphic disorder. A Preoperative photograph of a year-old woman with large labia minora. B Postoperative photograph obtained 3 months after bilateral labia minora reduction edge excision. A Preoperative photograph of a year-old woman with large labia minora and right lateral clitoral hood fold. B Postoperative photograph obtained 3 months after bilateral labia minora reduction wedge excision and right clitoral hood fold excision.
Labia minora size and shape show almost unlimited variations. Surgical procedures large labia be tailored to individual anatomy and preference. Labia thickness, pigmentation, and pigment variation, if present, must be considered. Clitoral hood redundancy, in either a vertical hood too long or horizontal redundant lateral folds dimension, should be addressed if present. ificant pigmentation variation from the labia free edge inward, if present, may warrant edge preservation.
This situation is most often encountered large labia women of color. Excising the pigmented edge in this cohort may result in unnatural-appearing labia. Edge excision techniques are preferable for these patients. Prominent lateral clitoral hood folds and redundant labial tissue posterior to the introitus, when present, should be excised Figure 5.
Failure to do so may yield an unacceptable result.
A Preoperative photograph of a year-old woman with large labia minora, bilateral lateral clitoral hood folds, and labial tissue posterior to introitus. B Postoperative photograph obtained 3 months after bilateral labia minora reduction edge excisionlateral clitoral hood fold excision, and excision of posterior labial tissue. Labiaplasty technique selection should be based on the patient's unique anatomy and aesthetic preference. Generally, the minora should remain at least one centimeter in length from free edge to base inter-labial sulcus in its central portion.
Edge excision, with its many variations, was the first popularly reported labiaplasty technique. Overzealous resection, however, is possible, and can result in labial amputation: a disastrous outcome. Excision of the minora edges can result in unnatural-appearing labia in women with ificant pigmentation variation. Although commonly reiterated in the literature, but rarely, in my opinion, observed in clinical practice, edge excision techniques can be complicated by tender scars or scar contractures. Edge scalloping may also occur and, if ificant, compromise the aesthetic result.
It has been suggested that it may be mitigated by minimizing tension when tying sutures. Wedge excision techniques, first described and popularized by Alter, 1418 preserve labia edges and edge pigmentation. As ly stated, this is often desirable in those women with ificant pigmentation variation from the free minora margins inward. Incision line dehiscence, usually a consequence of excess tension, can be problematic. When it occurs, repair is required to avoid notching of the labium with persisting deformity. Wedge excision techniques also frequently require modification to adequately address clitoral hood issues or other anatomic variations.
Central deepithelialization or excision procedures are, in my opinion and practice, less commonly utilized than either edge excision or wedge resection techniques. The procedures have several shortcomings. They result in multiple incision lines medial and lateral surfaces of the labia and prolonged postoperative minora edema.
Inclusion cyst formation, as a consequence on incomplete deepithelialization, can occur. Central deepithelialization can increase labia minora thickness, which, in my experience, is usually undesirable. Furthermore, it is difficult to make the minora as small as is possible with the other, aforementioned labiaplasty techniques. Clitoral hood redundancy, when present, may be in the horizontal or vertical planes, or both. Horizontal excess, in the form of extra hood folds parallel and lateral to the central portion large labia the clitoral hood, is most commonly observed Figure 6.
Clitoral hood folds may be unilateral or bilateral, and result in a widened appearance. Vertical excess manifests as a ptotic, elongated clitoral hood. A Preoperative photograph of a year-old woman with prominent bilateral lateral clitoral hood folds and hyperpigmented, thick labia minora. B Postoperative photograph obtained 3 months after bilateral labia minora reduction edge excision and excision of bilateral lateral clitoral hood folds. When present, clitoral hood redundancy large labia be dealt with during labiaplasty. Not doing so may yield unnatural-appearing genitalia. Excision is generally oriented parallel to the sulcus between the clitoral hood and the labia majora Figure 7 A.
Vertical hood excess is addressed by transverse excision of a portion of the hood, usually as an inverted V wedge, across its full width. Excision is usually done cephalic to the free margin of the hood Figure 7 B. In no circumstance, in my opinion, should the clitoral glans be exposed if covered or further exposed if partially covered.
Doing either will result in an unpredictable, and perhaps undesirable, effect on clitoral sensation. In all cases, excision must be superficial. Photographs of a year-old woman with digitally-added clitoral hood alteration markings. A Lateral vertically-oriented excision markings for horizontal excess, with digitally-added wedge excision minora reduction markings patient's left labium and edge excision minora reduction markings patient's right labium.
Labia majora alteration is sought by women bothered by puffy, prominent majora at one extreme, and deflated, sagging majora at the other Figure 8. Fatty fullness without skin redundancy may occasionally be effectively treated by liposuction. Improvement is usually modest. Prolonged postoperative edema is common. Women with flat majora, or deflated majora with minimal skin excess, may seek augmentation.
It is easily achieved utilizing standard autologous fat grafting techniques. Usually several grafting sessions are necessary to achieve the desired result. In general, no more than 20 cc of fat should be injected into each labium at one sitting. Ptotic, deflated labia majora, in my opinion, are best treated by reduction rather than augmentation. Surgical excision of large labia majora, in my experience, yields consistently excellent and high patient satisfaction. Although others suggest that excision should be from the central portion of the majora 20 or laterally at the vulva-thigh crease, 5 I disagree.
I see no benefit in placing the resulting excision scar in the thigh crease or on the labia majora itself. I always resect the medial segment of the majora. The medial incision is in the sulcus between the minora and majora, with the lateral incision in the majora. Incisions are made along the full anterior-posterior length of the majora.
Cresenteric excision of the redundant width of the majora is performed. The resulting scar, located within the interlabial sulcus, is virtually imperceptible. It is therefore determined with the patient supine in maximum frog leg position. Pinching of redundant majora, without tension on the introitus, is done. The lateral incision line is then marked. Resection should always be in a superficial plane: skin and subcutaneous tissue only. The labia majora are very vascular. Absolute hemostasis prior to closure is essential to avoid hematoma formation.
A Large labia labia majora reduction markings on a year-old woman with ptotic labia majora and moderately large, asymmetric labia minora. B Immediately postoperative photograph after bilateral labia majora and labia minora edge excision large labia and left clitoral hood fold excision. A Preoperative photograph of a year-old woman with redundant labia majora.
B Postoperative photograph obtained 3 months after bilateral labia majora reduction using the described technique note the absence of visible scars. Although many recommend general anesthesia, 214 I perform virtually all labiaplasty procedures, including combined majora and minora reductions, using local anesthesia, with mild oral sedation mg of diazepam.
Topical anesthetic ointment or cream is applied at the same time oral sedation is administered. Approximately half of women undergoing minora procedures will not experience injection pain if 45 minutes elapse between topical anesthetic application and injection. Anesthetic buffering with sodium bicarbonate, if utilized, will further reduce infiltration discomfort. One dose of a cephalosporin oral antibiotic or clindamycin for Beta-lactam allergic patients is taken 2 hours preoperatively.
Procedures are performed with the patient supine, large labia frog leg position.
Lithotomy position, although commonly recommended by many authors for labiaplasty procedures, 214 should be avoided in my opinion, as external genital anatomy can be distorted. All surgical markings must be made before local anesthetic injection. Deviation from markings should be avoided. Tissue distortion should be avoided.
Adequate time should be allowed for vasoconstriction to occur. Twenty minutes is ideal for maximum effect, but a minimum of 10 minutes is suggested. In combined labiaplasty procedures, the majora should be done first. For labia minora edge excision techniques, use of a traction large labia placed in the most prominent portion of the labium is helpful.
Clitoral hood large labia, if present, should be excised first, followed by minora excision. Resection of redundant labial tissue posterior to the introitus may occasionally be difficult with the patient in frog leg position. It can be facilitated, if necessary, by placing gauze p between the buttocks posterior to the anus to separate them and increase visualization of the posterior perineum.
The operating table may also be placed in a slight Trendelenburg position if further exposure is needed. I perform the procedures using 15 scalpel blades and a needle-point electrocautery. Absolute hemostasis is essential. A single-layer closure with interrupted 4.Large labia
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