Background: Hypertrophy of the labia minora is of concern to a subset of adolescents and adult women. The posterior wedge resection is a new labiaplasty technique with an anatomic approach to yield the optimal aesthetic outcome and yet continue the functional achievement of prior techniques.
Objective: The authors describe the results of their posterior wedge resection technique in a retrospective series of patients.
Methods: A retrospective chart review was performed of 22 consecutive patients who underwent posterior wedge resection labiaplasty between February 2009 and February 2012. Complications and aesthetic outcomes were reviewed.
Results: The average age of the patients in this study was 35 years (median, 33 years). Follow-up ranged from 2 weeks to 1.5 years. Two minor complications occurred without further sequelae. At follow-up, none of the patients reported any paresthesias, pain, or problems with penetrating vaginal intercourse.
Conclusions: An increasing number of labiaplasties are being performed for aesthetic and functional concerns. The posterior wedge resection enables the surgeon to perform labiaplasty easily, safely, and effectively, ensuring symmetry and maintenance of the natural pigment, color, and texture of the defining free edge of the labia minora.
Level of Evidence: 4
Hypertrophy of the labia minora is of concern to a subset of adolescents and adult women. As a result of greater public awareness about problems with hyperplastic labia minora, an increasing number of women are seeking treatment not only for aesthetic concerns but also for functional and/or psychological reasons. A multitude of reduction techniques have been developed to alleviate noticeable projection of the labia minora beyond the boundaries of the labia majora.
Although practitioners from different specialties have performed labia minora reduction surgery, the plastic surgical and gynecological literature dominates its evolution.
Unless other concomitant procedures are being performed, the majority of labiaplasties are performed in the office setting under local anesthesia. Most of these procedures are a variation of 1 of 4 techniques: (1) deepithelialization, (2) edge excision, (3) inferior wedge resection, or (4) central wedge nymphectomy. In fact, Ellsworth et al1 devised an algorithmic approach to these labiaplasty methods. With all of these approaches, overall patient satisfaction remains high, but plastic surgeons are constantly exploring ways to improve and build upon prior techniques; the patient seeking plastic surgery also desires perfection in the result. In this study, we describe an anatomic approach to labiaplasty that we believe yields the optimal aesthetic outcome while maintaining the functional achievements of prior techniques.
For this study, we retrospectively reviewed the charts of 22 patients who underwent posterior wedge resection labiaplasty between February 2009 and February 2012. Patients who presented with concerns about labia minora hypertrophy were examined, evaluated, and counseled by the senior author (N.N.M.); these 22 patients met criteria based on degree of hypertrophy and associated aesthetic and/or functional impairment and were therefore offered surgery to correct the deformity. After informed consent, patients gave permission for preoperative and postoperative photographs for their medical records; additionally, permission was granted for use of pictures to aid in teaching, publication, or for website display, as long as identifying demographics were removed from the photographs. Preoperative and postoperative photographs were taken in our photo studio. Intraoperative and immediate postoperative pictures were taken in the operating room.
To begin the surgical procedure, all patients were placed in a lithotomy position. Unless other concomitant procedures were being performed, most patients were given a local anesthetic (1% Lidocaine with 1:100 000 epinephrine); antianxiolytic medicines and monitored anesthesia care were provided in conjunction for select candidates.
After positioning and anesthetizing the labia minora, sterile prep and drape were performed. Intraoperatively, marks were made to outline the boundaries of the posterior wedge to be resected. Markings were first made along the lateral border of the labia minora, to preserve the natural pigment and tissue. The marking continued from inferior to superior and proceeded medially down to the base of the labia minora, approximately 1 cm from the frenulum. The marking was then continued posteriorly to the posterior fourchette but stopped prior to reaching the midline. Parallel markings were made on the mucosal side (Figures 1 and 2).
Multiple 5-0 nylon sutures were placed for traction. If asymmetry existed between the left and right labia minora, measurements were made with a ruler, and a wider wedge was calculated for resection on the side with greater hypertrophy. Sharp scissors were used to cut the labia minora in a full-thickness flap, starting at the lateral aspects. Markings were then followed for the posterior wedge resection. Approximately 1 cm of the posterior fourchette was left intact, to create a more natural appearance. These steps (Figure 1C) helped to obtain symmetry and achieve good outcomes with easy reproducibility.
After hemostasis was obtained, 4-0 Vicryl (Ethicon, Somerville, New Jersey) sutures were placed to imbricate the base of the labia minora. A “tailor tack” approach was used to trim any remaining excess labial tissue, and the flap was closed in 3 layers, all with interrupted 4-0 Vicryl sutures (Figures 1D and 2B).
Antibiotic ointment was applied to the suture lines. Postoperative care involved washing the surgical area with soap and water, pat drying, and application of antibiotic ointment twice daily until the suture lines healed. Patients were placed on cephalexin for 7 days; if any patient was allergic to penicillin or cephalosporins, clindamycin was prescribed instead. Patients were instructed to avoid sexual intercourse for 6 weeks.
The average age of the 22 patients in our study was 35 years (median, 33 years; range, 19–57 years). Average length of follow-up was 3 months (range, 2 weeks to 1.5 years). Clinical results are shown in Figures 3 and 4.
Two complications occurred in this series: (1) a minor wound dehiscence from early sexual intercourse at 2 weeks that healed by secondary intention and (2) a hematoma that was noticed in the recovery room and evacuated immediately in the procedure room with no further sequelae. At follow-up, none of the patients reported any paresthesias or pain/problems with penetrating vaginal intercourse. Table 1 shows demographics, follow-up time, and complications for all patients in the series.
|Patient No.||Age, y||Follow-up Time, mo||Complications|
|Patient No.||Age, y||Follow-up Time, mo||Complications|
Our goal in performing the posterior wedge labiaplasty was to improve the aesthetic outcome after labia minora reduction with a more natural contour, preserving the normal pigment at the outer (more readily visible) surface. Prior labiaplasty techniques have yielded high levels of patient satisfaction and are, as stated earlier, primarily a variation of 1 of 4 techniques.1 Straight amputation was described in the 1970s by Capraro2 and Radman.3 While technically feasible and shown to have fewer wound-healing complications, the naturally thinner and darker pigment of the labial edge is replaced; in some patients, it has been reported that excision at the periphery creates a fragile and stiff suture line associated with local irritation and even discomfort while walking.1,4 Additionally, linear scars can contract over time; therefore, critics of this technique state that this phenomenon can cause the posterior fourchette to be advanced, resulting in partial obliteration of the vaginal introitus and even chronic pain with sexual intercourse.1,4 However, when dealing with extreme degrees of labia minora hypertrophy, edge amputation remains a useful and powerful technique. In addition, some women associate the darker, corrugated edge of the labia minora with an aged appearance and wish to have it removed, in which case amputation serves the intended purpose.1 This technique is also useful when the outer labial edge is thicker than the more proximal portion.
However, there are also women seeking labiaplasty who prefer that the natural aesthetics of the outer labia minora edge be maintained.1 To overcome some of the shortcomings of the straight-edge amputation, Maas and Hage4 modified the edge excision with a W-shaped resection and reapproximated in an interdigitated manner. While this technique may alleviate some of the concerns regarding linear scar contracture, the suture line remains at the periphery and the darker pigmentation of the labial edge is still lost. Additionally, in some patients, a “squiggly,” Z-shaped, bulky labia minora may result, rather than a thin, darker-pigmented natural outer surface.4,5
To preserve the natural color, contour, and texture of the edge of the labia minora, Choi and Kim6 devised the deepithelialization technique. This labiaplasty is performed by deepithelializing the central portion of the labia minora and reapproximating the raw surfaces. Because full-thickness tissue is not excised, this technique is most useful for very mild hypertrophy.1 In patients with larger labia minora, the technique's inability to dramatically reduce labial volume produces a thickened appearance when the raw edges are brought together, resulting in an inappropriately large labial base and poor aesthetic outcome.1
Various forms of an inferior wedge resection with superior pedicle flap reconstruction have been described to achieve a greater labiaplasty volume reduction while maintaining the outer contour, color, and texture of the labial edge.7,8 However, the inferior edge is the thinnest and least protruberant part of the labia minora. A bulging contour deformity may result as the more protruberant superior flap is brought down to reconstruct the defect from the inferior wedge resection.9 Additionally, this “pulled-down” appearance, when it occurs, can be shown to create an unnaturally sharp transition near the posterior fourchette.7,8
Alter10,11 described the central wedge nymphectomy to reduce the incidence of contour abnormalities associated with prior techniques. With this technique or Giraldo's Z-plasty modification of it,12 the most prominent central portion of the labia is removed without its morphologic alteration. With this approach, the natural texture and appearance of the free labia minora border are preserved. However, even proponents of the technique admit that when the central wedge is excised, the natural craniocaudal transition of pigment color is replaced with an abrupt color change where the anterior and posterior flaps are brought together.12
The existing labiaplasty techniques have certain similarities but also have intricate differences. Our posterior wedge resection is no exception, and it is another example of the progression and refinement of technique that occurs as increasing numbers of patients seek these procedures. Our technique uses a superior-based pedicle, similar to the inferior wedge resection described by Rouzier et al7 and also later by Munhoz et al.8 However, the major part of our excision is posterior to the outer labium, between the outer and innermost labia minora. A pure inferior wedge includes the outer edge along the continuum of their markings; our technique is a posterior wedge because it preserves the most outer or anterior labia minora edge, especially at the most superior and inferior boundaries. Such subtleties give the results of our posterior wedge resection a thinner-appearing superior pedicle, but in fact, the preserved outer edge decreases the distance required to close the superior flap to the remnant labia minora base. We believe that this modification, in a select group of patients, may provide for decreased tension and a less bulky final appearance.
Anatomically, the central labium contains the most darkly pigmented, hypertrophic, protruding, convoluted, and irregular portion of the labium.11 Therefore, in specific circumstances, the posterior wedge resection may have the disadvantage (compared with the central wedge) of leaving this undesirable labial portion on the superior flap and transposing it more posteriorly. In contrast, a central wedge can be placed to remove the most objectionable portion of each labium.11 However, this infrequent circumstance can be overcome by modifying the posterior wedge resection to include more of the central labium within the resection. Modifications performed to improve previously proven techniques are not uncommon as we strive to enhance patient satisfaction and surgical outcome.11 Overall, the posterior wedge resection is easy to perform and reproduce, but outcomes with different techniques will also vary based on surgeon experience and patient volume.
Our patient population did not exhibit extreme degrees of hypertrophy, and thus, the posterior wedge resection was the most useful technique to satisfy their functional and aesthetic goals. This technique maintains the normal anatomical contour of the labia minora. Additionally, the thinner lateral edge of the labia minora is preserved, and sutures lines are placed in natural creases that are virtually invisible. The base width of the labia minora is reduced by imbrication sutures to match the thinner lateral edge widths of the labia minora. Asymmetry of the lateral edges of the labia minora is common, and trimming can be performed to improve the asymmetry. A superiorly based random flap is extremely reliable, and flap loss or even partial flap loss has not been observed. Clitoral hood reduction and labia majora reductions can be performed concurrently, if necessary.
The labiaplasty patient is unique compared with other aesthetic plastic surgery patients in that she is not as likely to follow up regularly in the office unless she has a significant concern; this tendency is most likely due to the private nature of labia minora hypertrophy. We were fortunate to convince many of our patients to present for postoperative photographs when they came to our practice for other cosmetic procedures.
The retrospective chart review showed that there were no major complaints noted during the routine postoperative phone calls performed by the senior author's office staff. In retrospect, the findings in our study could have been augmented with a patient satisfaction survey, but our findings would most likely have been similar to those in prior studies, which have shown overall patient satisfaction. Such a survey would be more useful in a prospective analysis at an institution with a consistent patient population where different labiaplasty techniques are used, to better understand patients' perspectives on the advantages and disadvantages of various techniques. Our best anecdotal evidence for high levels of patient satisfaction with posterior wedge resection labiaplasty is the exponential increase in patients who visit us to have this procedure performed, mainly due to word-of-mouth referrals.
Labiaplasties are being performed with increasing frequency for aesthetic and functional concerns. The posterior wedge resection presented here is a new technique that enables the surgeon to perform labiaplasty with ease, while ensuring symmetry and maintenance of the natural pigment, color, and texture of the defining free edge of the labia minora.
The authors thank Katie Schoenlaub (firstname.lastname@example.org) for her expertise and creation of medical illustrations for this article.
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
The authors received no financial support for the research, authorship, and publication of this article.