Labiaplasty



Editors-In-Chief: Martin I. Newman, M.D., FACS, Cleveland Clinic Florida, [mailto:Newmanm@ccf.org]; Michel C. Samson, M.D., FRCSC, FACS [mailto:samsonm1@ccf.org]

Overview
Labiaplasty (sometimes spelled labioplasty and sometimes referred to as labia minor reduction or labial reduction) is plastic surgery of the labia majora and/or the labia minora, which are the external folds of skin surrounding the vaginal opening. The procedure involves reducing elongated labium. When labia are created where there were none, it is usually part of a vaginoplasty.

Surgical procedures
Labiaplasty reduces the size of one or both sets of labia. It may also be employed to repair the labia following disease or injury, or especially after childbirth. In addition, a hoodectomy may be performed at the same time, which exposes the clitoris in an attempt to increase sexual stimulation. Hoodectomy is sometimes used to treat sexual dysfunction such as anorgasmia.

As recently as 1999, surgeons usually performed labium reduction by straight amputation of the protuberant sections and then by suturing the edges together. However, this procedure sometimes created a fragile and stiff suture line as well as eliminating the natural contour and pigmentation of the labia minora. Moreover, other procedural and clinical problems existed with amputation that did not ensure a favorable outcome.

Several years later, more surgeons introduced lasers into their armamentarium and began using more refined surgical procedures like one known as inferior wedge resection and superior pedicle flap reconstruction. In one outcome study, surgeons studied the results of 20 patients undergoing labiaplasty via the procedure. 95.2 percent of patients at 46 months reported being very satisfied. While five complications cropped up, all but one were handled immediately postoperatively and did not require additional hospital stays or interfere with healing.

Labiaplasty is almost always an outpatient procedure performed under local anesthesia. After surgery, patients may experience some mild discomfort and swelling, which usually disappear completely after one to two weeks. Recovery times ranging from three days to one or two weeks are often listed on surgeons’ websites.

Risks
While statistics on any botched plastic surgery procedures are rare, the comparable rate of satisfaction for other commonly performed cosmetic plastic surgery procedures in the United States is about the same or slightly less than labiaplasty. According to Jeffrey Rawnsley, an assistant professor and director the UCLA Facial Aesthetic Center at the University of California, Los Angeles, about 90 percent of patients report a positive outcome for breast augmentation. Experts report about an 85 percent positive outcome for rhinoplasty (the “nose job”), while liposuction patients in the late 1990s suffered a mortality rate of about 20 per 100,000, according to author Christine Rosen. While liposuction outcome rates have improved, many breast augmentation and rhinoplasty revisions are performed worldwide, because the procedure was not done correctly the first time.

Labiaplasty—in comparison to other popular rejuvenation surgeries—requires additional treatment in five to seven percent of cases. While the American Society of Plastic Surgeons (ASPS) listed only about 1000 “vaginal rejuvenations” during 2006, the most current year for which U.S. statistics have been compiled, surgeons in both the U.S. and the U.K.—as well as in other developed nations—report that the procedure seems to be growing exponentially. The professional plastic surgery organizations like ASPS, the American Society for Aesthetic Plastic Surgery, the British Association of Aesthetic Plastic Surgeons (BAAPS) and the International Society of Aesthetic Plastic Surgeons do not count labiaplasties among the other yearly statistics of plastic cosmetic procedures.

Patient reports and reactions
According to plastic surgeons, patients often ask for labiaplasty for functional or aesthetic reasons, or a combination of the two. Many patients complain that elongated labia become painful during exercise, or while sitting for long periods of time. A retrospective study conducted by Dr. John R. Miklos and Dr. Robert D. Moore found that close to two-thirds of women seeking labia reduction do so for reason such as pain or discomfort.

Other patients explain to physicians that the elongated lips can be painfully drawn inside them during sexual penetration. Some models, dancers and actors feel embarrassment when wearing swimsuits and other revealing clothing, because their labia are visible through form-fitting clothing, or because their labia slip out of skimpy garments altogether. Labiaplasty patients also report feeling embarrassment with their sex partners.

Physicians and mainstream mass media report that the widespread use of pornography has increased demand for labiaplasty. Consequently, many more people have seen pornographic actresses with shortened labium, and come to regard that as an ideal. Those who consider labiaplasty for this reason may not be aware that the actresses have had surgery, but may wish to get the surgery to appear what they believe to be "normal". Trends like thong underwear, bikini waxes or shaved pubic hair add to the noticeability of protruding labia. The procedure is often the subject of articles in women's magazines, complete with before-and-after pictures.

Writing in the May, 2007 British Medical Journal, psychologist Lih Mei Liao and gynecologist Sara M. Creighton, noted that demand for cosmetic genitoplasty is increasing and that the National (U.K.) Health Service (NHS) has apparently doubled the number of labiaplasty procedures performed in the last five years. Liao and Creighton interviewed healthy adults who had the procedure to learn their motivations for electing for labiaplasty. Many seemed to be moved by appearance. Wrote the authors: “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.”

A study over nine years on 163 labiaplasty patients who underwent reduction of the labia minora showed a 93 percent rate of satisfaction.

Controversy
Labiaplasty is controversial amongst some professionals and non-professionals who raise concerns that the desire for this procedure is driven by marketing, and an unhealthy self-image derived from media images of what the "ideal" female genitalia should look like. The increasing attention this procedure is receiving in various media is believed to be generating a growing market for this surgery. For most women, it is cosmetically unwarranted, and constitutes a needless exposure to the risks inherent in any surgery. Some have likened the procedure to other forms of genital modification and mutilation.

Another concern about choosing this surgery for cosmetic reasons is that the ring of scar tissue created at the vaginal opening can later cause pain and complications during childbirth. As this surgery is more and more frequently performed on younger women, a concern is that surgeons are not warning women of the long-term physical risks they may undertake by electing for labiaplasty.

In May 2007 an article published in the British Medical Journal blasted the "designer vagina" craze, citing its popularity being rooted in commercial and media influences.

Recently, the appropriateness of the procedure has come into question among academics, feminists and health care providers, especially in the U.S. and the U.K. Because some critics argue that women were reporting to plastic surgeons only to have more “acceptable” genitalia created, six scholars, including the heads of two women’s centers and the chiefs of four departments of obstetrics and gynecology at major U.S. universities gathered for a list serve discussion sponsored by The International Society for the Study of Women’s Sexual Medicine. The participants took a serious look at elective vulvar plastic surgery, among other topics like female genital cutting in Third World nations, and assigned six experts with special or strong, evidence-based opinions about vulvar health. Several noted that variations in the appearance of the vulvar region are normal but that labiaplasty, like any medical treatment, is a woman’s right. The group concluded that vulvar plastic surgery may be warranted only after counseling if it is still the patient’s preference, provided the procedure is conducted safely and not solely for the purpose of performing surgery.

Labiaplasty as part of sex reassignment
In the case of transwomen, labiaplasty is frequently the second part of a two-stage vaginoplasty, where labia and a clitoral hood are created. This is often performed a few months after the first part of the procedure. In some cases, labiaplasty is an elective procedure to improve appearance after a one-stage vaginoplasty.