Labia Minora Hypertrophy 

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Labia Minora Hypertrophy 

Overview

  • labia minora hypertrophy involves protrusion of the labia minora beyond the labia majora and can be symmetrical or asymmetrical
    • variably defined as labial length from 30-40 to > 50 mm based on data on natural female genital variation
    • a quantitative definition of hypertrophy is controversial since labia minora size varies widely among women
    • factors associated with natural variation of labia minora size and perception of its size
      • natural changes that occur with puberty, pregnancy, and menopause can affect labia minora size
      • geographic location and culture can influence how women perceive the size of their labia minora
  • exact incidence and prevalence of labia minora hypertrophy are unknown
  • causes of labia minora hypertrophy are poorly understood
    • may be idiopathic
    • may be due to congenital causes, such as lymphangioma, or acquired causes, such as
      • artificial elongation of the inner labia, which is a ritual performed by various ethnic groups
      • exogenous androgenic hormones
      • chronic inflammation or irritation
      • increased blood flow to the labial tissue, such as with vulvar varicosities
  • pathogenesis beyond typical anatomical variation is poorly understood but may include
    • mechanical stretching of the tissue which occurs during artificial elongation of the labial tissue
    • increased blood circulation with or without inflammation
    • local and transient inflammation episodes or random peaks in estrogen concentration or activity during fetal development
  • labia minora hypertrophy is typically asymptomatic, but clinical presentation may include
    • aesthetic concerns
    • visible swelling
    • insecurity and embarrassment when wearing tight clothing or when naked
    • hygiene difficulties
    • chronic pain
    • vaginal dryness
  • management
    • conservative management may be considered to help reduce discomfort associated with labia minora hypertrophy
      • using simple soaps, avoiding scented gels, and using emollients to reduce discomfort and irritation
      • wearing comfortable underwear made of natural fibers such as cotton
      • avoiding vulvar hair removal, which can increase visibility and irritation
      • Reference – J Pediatr Adolesc Gynecol 2016 Jun;29(3):218
    • labiaplasty is a female genital cosmetic surgery procedure proposed to improve genital appearance in women with labia minora hypertrophy
      • initial considerations for women who request surgical consultation for labia minora hypertrophy
        • women should be asked about their motivation for cosmetic surgery to ensure their autonomy and to rule out possible coercion or exploitation
        • women should be screened for psychiatric conditions and, if psychological concerns are suspected, women should be referred for evaluation before considering surgery
        • women should be informed about typical variation and physiological changes that may occur to the labia minora over the lifespan, and the potential complications of genital surgery
      • indications for elective surgery in women with labia minora hypertrophy may include
        • female sexual dysfunction
        • pain with intercourse
        • interference with athletic activities
        • previous obstetric or saddle injury
      • labiaplasty should only be considered for adolescents < 18 years old in the presence of significant congenital malformation and/or persistent symptoms caused directly by labial anatomy
      • approaches to labiaplasty include
      • complications of labiaplasty may include pain, bleeding, infection, scarring, decreased sensation, dyspareunia, and wound dehiscence
      • follow-up may be considered 2 weeks after surgery and can be repeated at 1 and 6 months after surgery
      • other management may include clitoral hood reduction and/or liposuction or lipoinjection of the labia majora
  • recurrence of hypertrophy after labiaplasty is rarely reported but may be more likely if labiaplasty is provided before labial development is complete

General Information

Etiology and Pathogenesis

Causes

  • many women presenting with concerns about labia minora size have a labia minora that would be considered typical by clinicians; therefore a physiological cause for the perceived hypertrophy beyond typical anatomical variation may be lacking(1)
  • besides typical anatomical variation and typical changes associated with puberty, pregnancy, and menopause, labia minora hypertrophy may be idiopathic, or may be due to
    • congenital causes, such as lymphangioma(1)
    • acquired causes, such as
      • artificial elongation of the inner labia(1)
      • exposure to exogenous androgenic hormones(1)
      • chronic local irritation(1)
      • chronic inflammation, such as in Crohn disease(1)
      • increased local blood circulation, such as in vulvar varicosities(1)
      • lymphedema(1)
      • labial edema, a rare complication of pregnancy that may occur due to underlying systemic disease that may interfere with vaginal delivery and compromise tissue integrity (Case Rep Obstet Gynecol 2014;2014:935267full-text)

Pathogenesis

  • pathogenesis beyond typical anatomical variation is poorly understood(1)
  • artificial elongation of the labia minora is a ritual performed by various ethnic groups(1)
    • results in anatomical changes due to mechanical stimulation of the labial tissue
    • often performed on or by girls and adolescents before menarche
    • involves manipulation of the genitalia by stretching the labia minora until they reach a certain length, which may stimulate local blood flow and inflammation, which in turn may increase estrogen levels to induce wound healing and labial tissue growth
    • sometimes involves the application of a mixture of local herbs which contain chemicals that
      • reduce inflammation
      • accelerate blood clotting
      • have antimicrobial activity
      • can alter insulin metabolism
  • other proposed theories include(1)
    • a relationship between increased blood circulation with or without inflammation and labia minora growth as evidenced by labia minor hypertrophy in conditions associated with chronic inflammation or increased blood flow, including
      • Crohn disease
      • vulvar varicosities
    • local and transient inflammation episodes or random peaks in estrogen concentration or activity during fetal development
      • may be involved in the development of congenital labial hypertrophy
      • may help explain high variability of labia minora size among women
  • labia minora hypertrophy involves protrusion of the labial tissue beyond the labia majora(1)
    • variably defined as labial length from 30-40 mm to > 50 mm based on data on natural female genital variation; however a quantitative definition of labia minora hypertrophy is controversial(1,3)
    • may be symmetrical or asymmetrical(1)
    • can also include the clitoral hood, lateral prepuce, and frenulum (Surg Technol Int 2015 Nov;27:191)

Anatomy and Function of the Labia Minora

  • embryology
    • labia minora begin to form at around the third week of fetal development from a double sheet of stratified, nonkeratinized squamous epithelium within a fat-free connective tissue that is rich in vascular and nerve plexus (Aesthetic Plast Surg 2017 Jun;41(3):714)
    • once fully developed, the labia minora are 2 thin skin folds that have sebaceous and eccrine glands but no hair; they are separated by interlabial furrows from the labia majora and border the vaginal orifice(1)
  • typical anatomy of the labia minora
    • typical female genital anatomy varies widely and patient perception of labia minora normality may be affected by geographic location and culture(1,2,3)
    • labia minora are composed of a pair of muco-cutaneous, hairless skin folds that contain sebaceous glands (Aesthetic Plast Surg 2017 Jun;41(3):714)
    • medial part of the labia minora forms the clitoral frenulum while the lateral part ascends to form the clitoral hood or prepuce (Aesthetic Plast Surg 2017 Jun;41(3):714)
    • vascularization
      • vulvar area is vascularized by the internal pudendal artery, which is a branch of the internal iliac artery that passes through the greater sciatic foramen and branches off into the following
        • lower rectal arteries
        • posterior perineal and labial branches
        • bulbar artery
        • deep and dorsal clitoral arteries
      • venous return from the vulvar area is through the internal pudendal vein and vaginal venous plexus, which is anastomosed with the uterine venous plexus
      • Reference – Aesthetic Plast Surg 2017 Jun;41(3):714
    • innervation of the vulvar area
      • posterior innervation is mostly provided by the internal pudendal nerve (S2-4)
      • anterior innervation is provided by branches of
        • ilio-inguinal nerves (T12-L1)
        • genito-femoral nerves (L1-2)
      • Reference – Aesthetic Plast Surg 2017 Jun;41(3):714
    • data regarding typical range of labia minora width and length are limited
      • median labia minora width 19 mm (interquartile range 12.6-27.5 mm) and median length 35.5 mm (interquartile range 27.8-48.9 mm) in 200 premenopausal women (median age 33 years) presenting for gynecological issues other than vulvar diseases in cross-sectional study (J Sex Med 2020 Mar;17(3):461)
      • mean labia minora width 17.9 mm (range 11-30 mm) and length 55.7 mm (range 34-74 mm) in 50 premenopausal women (mean age 30 years) and width 15.4 mm (range 8-27 mm) and length 51.9 mm (range 26-73.5 mm) in 50 postmenopausal women (mean age 55 years) in cross-sectional study (Climacteric 2008 Oct;11(5):416)
      • mean labia minora length 60.6 mm (range 20-100 mm) and width 21.8 mm (range 7-50 mm) in cross-sectional study with 50 premenopausal adult women (mean age 35 years) without history of genital surgery or mutilation having routine procedures such as hysteroscopy or diagnostic laparoscopy (BJOG 2005 May;112(5):643)
  • function of the labia minora
    • labia minora function to prevent vaginal dryness and guide urinary flow (Aesthetic Plast Surg 2017 Jun;41(3):714)
    • labia minora also play a role in the female sexual response
      • labia minora are nonerectile vascular tissues that show an increase in blood flow and blood volume during sexual arousal
      • dense neural innervation also supports a sensory role of the labia minora during the female sexual response
      • Reference – Female Pelvic Med Reconstr Surg 2011 Jul;17(4):180

Epidemiology

Incidence and Prevalence

  • incidence and prevalence are unknown(2)

Risk Factors

  • conditions that may increase risk of swelling of the labia minora include(1)
    • dermatitis resulting from use of diapers, incontinence briefs, or pads in patients with neurodegenerative conditions, such as myelodysplasia and associated neurogenic bladder
    • vulvar varicosities due to increased blood flow to the region
    • lymphedema
  • age, parity, ethnicity, hormone use, and history of sexual activity not associated with labia minora length or width in premenopausal women
    •  based on cross-sectional study
    • 50 premenopausal adult women (mean age 35 years) without history of genital surgery or mutilation having routine procedures such as hysteroscopy or diagnostic laparoscopy had external genitalia measured with tape measure while in lithotomy position
    • mean labia minora length 60.6 mm (range 20-100 mm)
    • mean labia minora width 21.8 mm (range 7-50 mm)
    • no significant association found between any genital measurements and age, parity, ethnicity, hormone use, or history of sexual activity
    • Reference – BJOG 2005 May;112(5):643

Associated Conditions

  • noncaseating granulomatous inflammation of the skin is a manifestation of Crohn disease

Clinical Presentation and Classification

Clinical Presentation

  • labia minora hypertrophy has been variably defined as labial length from 30-40 to > 50 mm; however a quantitative definition of hypertrophy is controversial(1,3)
  • labia minora hypertrophy is typically asymptomatic(1)
  • women may report(1)
    • aesthetic concerns
    • visible swelling
    • insecurity when wearing tight clothing
    • embarrassment when naked
    • hygiene difficulties
    • chronic infection
    • pain
    • dryness
    • irritation
    • tearing
    • discomfort, including during sexual intercourse
    • distress during physical exercise
    • adverse effects on self-esteem, athletic activity, and/or intimate relationships
  • difficulties reported in cross-sectional study with 200 premenopausal women (median age 33 years)
    • chafing when wearing tight clothing in 59%
    • discomfort during sport such as cycling or swimming in 40%
    • discomfort during intercourse in 25%
    • feelings of uneasiness when visiting a sauna in 21%
    • feelings of uneasiness when visiting public swimming pools in 11%
    • feelings of uneasiness during sexual intercourse in 15%
    • Reference – J Sex Med 2020 Mar;17(3):461
  • women with previous cosmetic surgery or subjective perception of their labia minora as being too large may be more likely to report difficulties (J Sex Med 2020 Mar;17(3):461)
  • many women presenting with labia minora hypertrophy have received negative comments from current or former partners, friends, or family members (J Sex Med 2020 Mar;17(3):461)
  • adolescents aged 14-17 years typically present with concerns about the appearance of their genitalia, including concerns about partners finding their genitalia abnormal or unattractive(4)
  • girls aged 9-13 years typically report rubbing, chafing, and interference with sports, or concerns about their mother’s opinion that their genitalia may be abnormal(4)

Classification

  • classification by protrusion of labia minora beyond edge of labia majora
    • classification by quantitative protrusion
    • classification by qualitative protrusion and extent of hypertrophy
      • Class 1 (typical): labia majora and minora are about equal
      • Class 2: labia minora protrude beyond labia majora
      • Class 3: labia minora protrusion includes clitoral hood
      • Class 4: labia minora extends to perineum
      • Reference – Aesthetic Plast Surg 2013 Oct;37(5):887
  • hypertrophy can also be classified as

Management

Management Overview

  • conservative management may be considered to help reduce discomfort associated with labia minora hypertrophy, including
    • using simple soaps, avoiding scented gels, and using emollients to reduce discomfort and irritation
    • wearing comfortable underwear made of natural fibers such as cotton
    • avoiding vulvar hair removal, which can increase visibility and irritation
    • Reference – J Pediatr Adolesc Gynecol 2016 Jun;29(3):218
  • labiaplasty is a female genital cosmetic surgery procedure proposed to improve genital appearance in women with labia minora hypertrophy
    • initial considerations for women who request surgical consultation for labia minora hypertrophy
      • women should be asked about their motivation for cosmetic surgery to ensure her autonomy and to rule out possible coercion or exploitation
      • women should be screened for psychiatric conditions, such as depression, anxiety, and body dysmorphic disorder, and sexual function disorders and, if psychological concerns are suspected, woman should be referred for evaluation before considering surgery
      • women should be informed about typical variation and physiological changes that may occur to the labia minora over the lifespan, and the potential complications of genital surgery
    • indications for elective surgery in women with labia minora hypertrophy may include
      • female sexual dysfunction
      • pain with intercourse
      • interference with athletic activities
      • previous obstetric or saddle injury
    • labiaplasty should only be considered for adolescents < 18 years old in the presence of significant congenital malformation and/or persistent symptoms caused directly by labial anatomy
    • approaches to labiaplasty include
      • wedge resection, which involves the removal of a wedge-shaped portion of the labia minora in order to preserve the labial edge and associated function and sensation
      • edge resection, which involves the removal of the most protruding portion of excess labia minora tissue by following the contour of the labia minora or an S-, Z-, or W-shaped resection
      • combined wedge-edge resection
      • central resection, which involves the removal of a portion of tissue from the middle of the labia minora while preserving the labial edge
      • radiofrequency and laser, which is not currently FDA approved for cosmetic vaginal procedures or management of vaginal symptoms associated with menopause, urinary incontinence, or sexual function
    • complications of labiaplasty may include pain, bleeding, infection, scarring, decreased sensation, dyspareunia, and wound dehiscence
    • follow-up may be considered 2 weeks after surgery and can be repeated at 1 and 6 months after surgery
    • other management may include clitoral hood reduction and/or liposuction or lipoinjection of the labia majora

Recommendations

  • American College of Obstetricians and Gynecologists (ACOG) recommendations for elective female genital cosmetic surgery(3)
    • women should be informed that elective cosmetic surgery or procedures to alter sexual appearance or function is not medically indicated, may have substantial risks, and does not have established safety or efficacy
    • clinical indications for surgery or procedures include
      • clinically diagnosed female sexual dysfunction
      • pain with intercourse
      • interference with athletic activities
      • previous obstetric or saddle injury
      • reversing female genital cutting
      • vaginal prolapse
      • urinary incontinence
      • gender affirmation surgery
    • women should be counseled about potential complications of surgery, including
      • pain
      • bleeding
      • infection
      • scarring
      • adhesions
      • sensation changes
      • dyspareunia
      • potential reoperation
    • women should be assessed and referred for
      • body dysmorphic disorder
      • sexual function disorders
      • depression
      • anxiety
      • other psychiatric conditions if indicated
    • women with concerns about appearance of external genitalia should be reassured that size, shape, and color of external genitalia vary significantly and may be affected by puberty, age, anatomical changes due to childbirth, and atrophy due to menopause and/or hypoestrogenism
    • inform women about surgeon experience and surgical outcomes
    • labiaplasty for girls < 18 years old should only be considered in those with significant congenital malformation and/or persistent symptoms caused directly by labial anatomy
    • obstetrician-gynecologists should be aware of federal and state laws pertaining to labiaplasty and similar procedures in adolescents and adults
  • Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations for female genital cosmetic surgery(4)
    • counsel women to help them understand their anatomy and individual variations (SOGC Grade A, Level III)
    • obtain a complete medical, sexual, and gynecological history for women requesting vaginal cosmetic procedures (SOGC Grade B, Level III)
      • to ascertain absence of major sexual or psychological dysfunction
      • to rule out any coercion or exploitation
    • women requesting cosmetic genital surgery should be counseled about the following during informed consent (SOGC Grade L, Level III)
      • typical variation and physiological changes over time
      • possibility of unintended consequences of genital surgery
      • lack of evidence about outcomes and impact of subsequent changes during pregnancy or menopause
    • cosmetic genital surgery for enhancement of sexual function should not be offered as a means to improve sexual satisfaction or self-image improvement (SOGC Grade L, Level III)
    • cosmetic genital surgery should not be offered to adolescents until they have fully matured and parental consent is no longer required (SOGC Grade L, Level III)

Counseling and Psychotherapy

  • counseling should be provided to women who request surgical management of labia minora hypertrophy, and should involve(2,3,4)
    • thorough exploration of motivations for surgery, if desired
    • ruling out possible coercion or exploitation by partner or family member, and evaluating any potential relationship issues
    • assessing for
      • body dysmorphic disorder
      • sexual function disorders
      • depression
      • anxiety
      • other psychiatric conditions if indicated
    • looking at pictures of varying vulvas to familiarize and reassure women about natural vulvar variation and decrease their likelihood of requesting labiaplasty
    • reassurance that size, shape, and color of external genitalia vary widely and may be affected by puberty, aging, anatomic changes occurring due to childbirth, and atrophy associated with menopause and/or hypoestrogenism
    • provision of information
      • about the potential positive effects of larger labial surface area, including more satisfying sex and more intense orgasms
      • regarding the lack of evidence that labiaplasty will result in a diminishment of psychological or physical symptoms and may be associated with complications
      • about the lack of evidence regarding the potential impact of subsequent changes during pregnancy or menopause
    • exploration of nonsurgical approaches such as counseling
  • counseling about personal hygiene and the avoidance of tight clothing and underwear may also help reduce psychological and physical discomfort(1)

Labiaplasty

General Information

  • labiaplasty is the surgical reduction of the labia minora for the treatment of labia minora hypertrophy, and is the most commonly performed cosmetic genital surgical procedure(2,3)
  • indications of successful labiaplasty include(1)
    • contoured, reshaped, and decreased labia with minimal cutting
    • lack of a visible scar on the outer rim of the labia, which may decrease complications
    • maintenance of natural labial pigmentation, with the outer rim sometimes darker than other surrounding tissue
  • reasons for requesting labiaplasty(1,2)
    • dissatisfaction with genital appearance (most common reason)
    •  functional impairment, such as pain or physical discomfort
  • ethical concerns regarding labiaplasty(2)
    • weighing the influence of social pressure against the importance of patient autonomy
      • shame and low self-esteem that can occur in women with larger labia minora may be caused by social pressure
      • labiaplasty has been compared to both female genital mutilation and cosmetic breast surgery
    • insufficient evidence regarding potential complications of surgery
    • variations in physician predisposition to labia minora appearance
    • provision of surgery to patients before age 18 years
  • common approaches to labiaplasty include(3)
  • radiofrequency and laser labiaplasties have also been reported but are not FDA approved(3)
  • Ellsworth algorithm for selection of labiaplasty technique(2)
    • central resection (also called de-epithelialization technique) for Franco type I (< 2 cm) or type II (2-4 cm)
    • full-thickness excision for Franco type III (4-6 cm) or type IV (> 6 cm)
      • edge resection if wishing to remove corrugated, naturally darker edge
      • superior pedicle technique if wishing to retain corrugated, naturally darker edge
  • patient satisfaction reported in 97%, improved self-esteem in 86%, and complications in 12% of women having labiaplasty
    •  based on case series
    • 58 women (mean age 32 years) having labiaplasty under local anesthesia were included
    • follow-up at 3-6 months after surgery
    • reasons given for seeking labiaplasty
      • aesthetic concerns in 81%
      • functional impairment (pain related to sports, clothing, or sexual activity, erythema, pruritis, irritation, or scuff) in 56.9%
      • urinary or vaginal infectious episodes in 10.3%
    • wedge excision in 44 women (75.8%) and W-shaped edge excision in 14 women (24.2%) with severe asymmetry or unwanted dark labial edges
    • rating of surgical experience as good or excellent in 96.6%
    • improved self-esteem reported in 86.2%
    • complications in 12.1%, including wound dehiscence in 6 women (10.3%), hematoma in 1 woman, and partial necrosis in 1 woman
    • revision surgery due to underresection requested by 3 women (5.2%)
    • Reference – Ann Plast Surg 2018 Apr;80(4):316
  • improved functional and sexual discomfort reported by 100% of 18 women who had labiaplasty for labia minora hypertrophy with median follow-up 17 months in case series (Int J Gynaecol Obstet 2011 Oct;115(1):40)

Wedge Resection

  • wedge resection(2)
    • most common approach to labiaplasty
    • designed to improve aesthetic outcomes, including preservation of the shape and color of the labia, and prevent loss of function or sensation
  • technique(1,2,3)
    • wedge is marked on smallest labium if there is a size differential, and mark is then transferred to other labium
    • wedge can be V shaped, Y shaped, or Z shaped
    • location of the wedge may be adjusted to the most protruding part of labia minora, and can be central, inferior, or posterior
    • local anesthesia such as xylocaine and adrenaline is administered
    • reduction is achieved by resecting the wedge that was marked, which is done by incising the skin with a scalpel and the labia tissue with diathermia
    • layers of the labia are reattached using vicryl 4.0, and the skin is closed using vicryl 4.0 or 5.0 or monocryl 5.0
  • technical variations include
    • central wedge resection in which the resection can be performed with or without first identifying and preserving the main labial artery(2)
    • posterior wedge resection or inferior wedge resection and superior pedicle flap reconstruction
      • involves using the redundant labium skin to close the resection
      • medial part of labia minora is stretched to the posterior portion of the vaginal introitus and, if tension is observed, then the pinch is moved posteriorly
      • wedge is resected between pinch point and posterior point it reaches, and resection results in a superior flap that can be used to close the defect
      • aggressive undermining and hemostasis may compromise vascular supply to the flap because it is not an axial flap
      • Reference – Aesthetic Plast Surg 2012 Oct;36(5):1078
  • wedge resection is not associated with risk of labia overreduction which is a complication of edge resection in which care must be taken to leave enough labia minora length to avoid complications(2)
  • selected case series on satisfaction with results of wedge resection
    • satisfaction with results of posterior-lateral wedge resection with preservation of central blood vessels and nerve bundle in 100% of 21 women aged 20-45 years with minor dehiscence not requiring additional treatment in 1 woman in case series (Aesthetic Plast Surg 2019 Jun;43(3):742)
    • satisfaction with results reported in 17 women (81%), separation of labial edge in 1 women, and no flap necrosis, infections, pain, or sexual dysfunction reported in 21 women having wedge resection labiaplasty in case series (Ann Plast Surg 2018 Apr;80(4):323)
    • satisfaction with results of wedge resection of labia minora plus lipofilling of labia majora reported in 96.3% of 27 women (mean age 32 years, range 16-45 years) with wound dehiscence in 3 women and surgical correction under local anesthesia in 1 woman with mean follow-up 1 year in case series (Acta Chir Plast Fall 2017;59(2):60)
    • satisfaction with results of wedge resection reported in 87.8% of 98 women who completed follow-up at median 30 months and reoperation due to wound dehiscence in 11 women (6.7%) in case series of 163 women (median age 26 years, range 12-67 years) (Am J Obstet Gynecol 2000 Jan;182(1 Pt 1):35)

Edge Resection

  • edge resection involves the removal of the most protruding portion of excess labia minora tissue(2)
  • edge resection techniques include(2)
    • straight excision
      • excision line follows the curve of the labia, which has been reshaped with subcuticular polyglycolic acid sutures
      • can be completed using a scalpel, diathermia, or a combination of both
    • lazy S-shaped resection which has been proposed to reduce the effects of scar contraction, to interrupt the straight line, and to increase the length of the scar
    • double-W-shaped resection
      • a modification of the lazy S-shaped resection
      • starts alternately on the inner and outer side of the labia minora so that the tissue can be folded into place easily
      • used to reduce extent of scar contraction

Combined Wedge-Edge Resection

  • combined wedge-edge resection involves surgically removing both a wedge of labia minora tissue and a portion of the edge of the labia minora (Aesthetic Plast Surg 2015 Feb;39(1):36)
  • proposed technique
    • labia minora are slightly stretched laterally and wedge resection area is marked with methylene blue or marker pen
    • total length of the new edge of the labia minora should not be less than the length of the labia minora to prevent sexual dysfunction due to elevation of the vaginal introitus
    • local anesthetic is administered
    • wedge-shaped area is resected
    • hemostasis is achieved before closure
    • relatively small area of labial edge is resected to reduce the labia minora horizontally
    • margins are reapproximated with layered interrupted sutures of skin and subcutaneous tissue
    • mattress suture of 4 corners can be used to reduce V-shaped wound dehiscence
    • additional suture of subcutaneous tissue in the cross point may be necessary if tissue is thick enough
    • erythromycin ointment can be applied and operative area dressed with sterile sanitary pad
    • Reference – Aesthetic Plast Surg 2015 Feb;39(1):36

Central Resection

  • central resection is used to maintain the original texture, contour, and pigmentation of the labial edge(2)
  • central resection techniques proposed in the literature include(2)
    • de-epithelialization
      • a triangle-shaped marking is made in the center of the labia minora
      • local anesthesia is administered
      • central marked part of the tissue is de-epithelialized, and edges are sutured together
    • fenestration
      • “bicycle helmet”-shaped marking is made in the center of the labia minora
      • local anesthesia (lidocaine and adrenaline) is administered
        • into the labia minora
        • at the superficial part of the deep branch of the perineal nerve and posterior labial nerve
      • excision is performed with a scalpel
      • inner and outer surface of the labia minora are sutured separately without suturing the erectile tissue between them

Radiofrequency and Laser Labiaplasty

  • radiofrequency and laser labiaplasty are nonsurgical approaches to labiaplasty
    • less invasive than surgical approaches
    • reported to improve labial appearance, vaginal laxity, and pelvic floor dysfunction
    • reported to induce inflammatory cascade at temperatures between 100.4 degrees F and 107.6 degrees F (38 degrees C and 42 degrees C) that results in a decrease in labia minora size over 3-4 months by stimulating the proliferation of glycogen-enriched epithelium, collagen formation, and neovascularization
    • Reference – Plast Reconstr Surg Glob Open 2020 Apr;8(4):e2418full-text
  • FDA has not approved energy-based medical devices, such as radiofrequency or laser, for cosmetic vaginal procedures or management of vaginal symptoms associated with menopause, urinary incontinence, or sexual function
    • safety of these devices for these purposes has not been established
    • may be associated with complications such as vaginal burns, scarring, pain during intercourse, recurring or chronic pain, and other serious adverse events
    • Reference – FDA 30 Jul 2018, updated 20 November 2018
  • patient satisfaction in 100% and no significant complications or need for additional procedures reported in 10 patients (mean age 44 years) treated with bipolar radiofrequency labiaplasty (3 for aesthetic concerns, 3 for functional complaints, and 4 for both) with mean follow-up 8 months in case series (Plast Reconstr Surg Glob Open 2020 Apr;8(4):e2418full-text)
  • patient satisfaction in 100% and minimal suture dehiscence during early postoperative period in 7% of 55 women having laser labiaplasty for moderate labia minora hypertrophy with aesthetic and/or functional impairment or labia asymmetry in case series (Int J Gynaecol Obstet 2006 Apr;93(1):38)

Other Management

Follow-up

  • follow-up after labiaplasty should be performed at
  • advise patient that bruising, pain, and swelling are common and typically last about 2-4 weeks(1)
  • measures to reduce pain and swelling should be considered after surgery
  • certain activities should be avoided after labiaplasty, including(1)
    • walking for 48 hours
    • showers for 1-2 days
    • exercise, including biking, swimming, and running for 2 weeks
    • baths and rubbing rather than patting the treated area for 3-4 weeks
    • sexual activity for 4-6 weeks

Complications

Complications of Labia Minora Hypertrophy

Psychological Complications

  • psychological complications of labia minora hypertrophy may include(1)
    • loss of self-esteem
    • emotional distress
    • anxiety
    • embarrassment and insecurity, such as when naked, wearing tight clothing, or changing clothes in shared rooms and spaces
    • frustration

Other Complications

  • other complications of labia minora hypertrophy may include(1)
    • hygiene difficulties
    • chronic infection
    • pain
    • dryness
    • irritation
    • tearing
    • dyspareunia
    • discomfort, including when wearing tight clothing or during sexual intercourse
    • distress during physical exercise such as running, biking, or swimming or during sexual intercourse
    • adverse effects on athletic activity and/or intimate relationships

Complications of Labiaplasty

  • complications are typically minor and may include(1,2,3)
    • bleeding
    • pain
    • discomfort
    • hematoma
    • difficulties with urination
    • infection
    • scarring
    • swelling
    •  wound dehiscence
    • vaginal dryness
    • vaginal discharge
    • hypersensitivity or loss of sensation
    • sexual problems, such as decreased sensation, pain during intercourse, orgasm difficulty, aching or stretching introitus, and reduced arousal
  • reasons for additional surgery may include
  • postoperative asymmetry and wound dehiscence each reported in 16% of 77 adolescents and women having central wedge excision for labia minora hypertrophy
    •  based on case series
    • 77 women aged 14-53 years (mean age 30 years) who had central wedge excision for labia minora hypertrophy (45 women) or extended central wedge excision for labia minora and clitoral hood hypertrophy (32 women) were included
    • liposuction of mons pubis also conducted as additional procedure in 4 women
    • mean follow-up 37.4 months
    • complications
      • postoperative asymmetry/redundancy in 12 women (15.6%), requiring revision in 10 women (83.3%)
      • wound dehiscence in 12 women (15.6%), requiring revision in 9 women (75%)
      • other complications
        • hematoma requiring evacuation in 1 woman
        • dyspareunia in 1 woman
        • decreased sensation in 1 woman
    • no postoperative wound infection, necrosis, or significant scarring reported
    • Reference – Ann Plast Surg 2020 Jul;85(S1 Suppl 1):S68
  • infection in 1 woman, wound dehiscence in 1 woman, and no scar contracture, painful scar, or discomfort due to labial edge distortion reported in 74 women who had edge excision labiaplasty with or without clitoral hood molding and management of labia majora in case series (Aesthetic Plast Surg 2012 Oct;36(5):1078)

Prognosis

  • recurrence of labia minora hypertrophy after labiaplasty is very rare (J Low Genit Tract Dis 2011 Jan;15(1):69)
  • recurrence may be more likely if labiaplasty is done before labial development is complete rather than delayed until adulthood(1)
  • recurrence of asymmetrical labia minora enlargement protruding beyond labia majora causing vulvar pain and irritation in 54-year-old postmenopausal woman with obesity 2 years after surgical revision in case report (J Low Genit Tract Dis 2011 Jan;15(1):69)

Guidelines and Resources

Guidelines

United States Guidelines

United Kingdom Guidelines

  • Royal College of Obstetricians/British Society for Paediatric and Adolescent Gynaecology (RCOG/BritSPAG) joint statement on issues surrounding women and girls undergoing female genital cosmetic surgery can be found at RCOG 2013 Nov 15 PDF

Canadian Guidelines

European Guidelines

  • Dutch Association for Plastic Surgery/Dutch Society of Obstetrics and Gynecology (Nederlandse Vereniging voor Plastische Chirurgie/Nederlandse Vereniging voor Obstetrie en Gynaecologie [NVPC/NVOG]) protocol on counseling and treatment of women requesting reduction of labia minora can be found at NVPC 2008 PDF [Dutch]

Australian and New Zealand Guidelines

  • Royal Australian College of General Practitioners (RACGP) guideline on female genital cosmetic surgery can be found at RACGP 2015 Jul PDF

Review Articles

Patient Information

References

General References Used

The references listed below are used in this DynaMed topic primarily to support background information and for guidance where evidence summaries are not felt to be necessary. Most references are incorporated within the text along with the evidence summaries.

  1. Gulia C, Zangari A, Briganti V, Bateni ZH, Porrello A, Piergentili R. Labia minora hypertrophy: causes, impact on women’s health, and treatment options. Int Urogynecol J. 2017 Oct;28(10):1453-61.
  2. Özer M, Mortimore I, Jansma EP, Mullender MG. Labiaplasty: motivation, techniques, and ethics. Nat Rev Urol. 2018 Mar;15(3):175-89.
  3. Committee on Gynecologic Practice. Elective female genital cosmetic surgery: American College of Obstetricians and Gynecologists (ACOG) Committee Opinion, Number 795. Obstet Gynecol. 2020 Jan;135(1):e36-e42.
  4. Shaw D, Lefebvre G, Bouchard C, et al; Clinical Practice Gynaecology Committee, Ethics Committee. Female genital cosmetic surgery. J Obstet Gynaecol Can. 2013 Dec;35(12):1108-12.

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