Cosmetic Surgery of the intimate

Surgery of the “Intimate” is of interest for both sexes.

Referring to women, the only gender we will talk about in this issue, many different fields of interest (labiaminoraplasty or ninphomeiosis, clitoral unhooding, hymenoplasty and much more) have began to be talked about in magazines, television and other media.

With the purpose of devoting our interest in this paper only to labiaminoraplasty or ninphomeiosis (but waiting for expected interest of readers for next other matters of the “surgery of the intimate”) we have revised the literature in the field which spread over many different options, arguing that many authors have already expressed their own ideas, and that nothing really new has broken out under the sun.

This has lead us to the wish of expressing our point of view on the technique we believe is the easiest and the successful one, and that the referred Plastic Surgeon in the title usually performs.

 

Introduction.

Hypertrophy of the labia minora is the disproportionate growth of the labia minora in relation to labia majora.

The terms usually adopted as labiaminora reduction , labiaminora rejuvenation, vaginal lip reduction,

labiaminoraplasty, have a new companion in the term of ninphomeiosis (where “nynpha” is the labia minora and “meiosis” means “reduction”).

Hodgkinson was the first to publish a description of “aesthetic” vaginal labiaminora‐plasty, and Davison was one of the authors whose revised technique we are talking about.

In fact, different techniques have been adopted, more often offering a simple longitudinal amputation of the complete free outer margin of labia minora (leaving an irregular outer inferior border of the labia minora) or a triangular amputation of the one‐third or two‐third lower part of labia minora (leaving only the superior part of the ninphas covering the clitoris in a very ugly appearance): both kinds of remnants are also complicated by a lowering of sensibility and, in worse cases, by paresthesia.

 

Frequency and etiology.

Frequency of labia‐minora hypertrophy is very difficult to establish and to estimate.

The number of labiaplasty procedures has been increasing in recent years along with the number of physician offering this service. We think this is an evolving field in plastic and gynecologic surgery.

About etiology, some women are born with protruding labia minora as those coming from some Turkish regions, some others experience it later in life as after mechanical irritation or lymphatic stasis or chronic irritation. Anyway, at present, no universally accepted etiology is recognized.

 

Grading.

Labia minora are usually measured between their base and their free edge, at the middle of every labia minora itself.

Grading of the hypertrophy of labia minora have been classified on their measured size by some authors, but this lead to unsettled measures very difficult to compare owing to individual variations.

Other authors refer to “clinical appearance” of the hypertrophy in a very simple and reproducible manner, as follow:

‐ No hypertrophy: labia minora are concealed within the free edge of the labia majora or may reach the free edge of labia majora.

‐ Moderate hypertrophy: labia minora extend themselves 1‐3 cm beyond the free edge of the labia majora.

‐ Severe hypertrophy: labia minora extend more than 3 cm beyond the free edge of the labia majora.

 

Indications.

Labia‐minora‐plasty is indicated in women referring difficulty in hygiene, discomfort with tight clothing, pain when riding bicycle, labia catching in zippers, and when labia minora are perceived as “too visible”.

The goal is to obtain a more aesthetic appearance of the external genitalia without adding scars or distorting them.

Our technique, also modulated from the experience of different authors, is a more refined variation of the simple “bull’s eye – technique”, as explained in the rest of the paper.

 

Anatomy.

The external female genitalia are referred as the vulva. The vulva includes labia majora, labia minora (or ninphas), clitoris and openings of urethra and vagina.

About relevant anatomy, labia minora consist of two fold of skin covering connective tissue with little or no adipose tissue. Right labia minora joins the left labia minora anteriorly and superiorly, toward the clitoris, where everyone of the two skin folds divides in two parts: one covering the clitoris to form the prepuce and the other forming the frenulum beneath it.

Posteriorly, the two labia minora join together forming the fourchette near the vestibulum of the vaginal opening, and mainly ending into the labia majora of each side.

Labia minora are very rich in nerve endings and very sensitive to touch.

 

Contraindications.

No contraindications exist.

A mandatory limitation is, of course, the minimum requirement of eighteen years of age, for the informed consent to be given.

 

Techniques.

Different surgical treatments are available.

The easiest and commonly used technique is the amputation of the hypertrophic portion of the labia minora, placing a clamp across the area of labia minora to be resected and cutting away the outer part, often leaving an irregular outer edge and potentially being complicated by neuromas or numbness or paresthesias.

(An example, from literature, of the immediate and late results of the amputation technique)

Another technique is a wedge resection (plus or not the addition of a Z‐plasty depending on the individual situation) that may be done in the central portion of the labia minora or in the inferior portion of them, leaving in this way an always intact outer border of labia but, also by this technique, being at risk of neuromas or numbness anyway.

The de‐epithelization technique, first described by Choi, is a safe method to reduce width of labia minora leaving their outer free edge intact. A variation of this last technique is the complete and throughout exeresis of the central part of labia minora making a complete window through their thickness (the so called “bull’s eye – technique”). In both cases the suture, which comes after, obtains a reduction in width of the labia.

Many other techniques are available, also by laser instruments.

Our technique is a step‐by‐step technique, i.e. mainly a de‐epithelization technique that may (or preferably not) be followed by a resection of the outer free border of labia minora.

Our idea is, of course, to fit the technique to the single specific patient, in order to plan the best way for giving a stable and good result without any drawback.

The images are exhaustive for the understanding of the technique.

Our technique is very simple and can be performed both under general anesthesia, as with the patient depicted, or under local anesthesia plus i.v. sedation.

The technique may of course be performed in one side only, as in the case of labia minora asymmetry.

 

Results.

In the images we desire to make well understood that a throughout excision of a “window” of labia minora full thickness (“bull’s eye – technique”) is not necessary, and the aim to maintain intact their free border may be achieved with a more careful de‐epithelization of their inner and outer part (which only needs some more time).

Results are clear.

 

Discussion.

A technique has been exposed we perceive as simple and successful. A technique which mainly fits specific situations and resolves them.

The goal is to obtain a more aesthetic appearance of the external genitalia without adding scars and without distorting them, and with the aim not to leave numbness or parhestesias or pain.

As previously said, our patients are women referring difficulty in hygiene, discomfort with tight clothing, pain when riding bicycle, labia catching in zippers, and when labia minora are perceived as “too visible”.

Satisfaction of patients is overwhelming.

 

Bibliography.

1. Hodgkinson DJ, Hait G. Aesthetic vaginal labioplasty. Plast Reconstr Surg. Sep 1984;74(3):414-6..

2. Alter GJ. A new technique for aesthetic labia minora reduction. Ann Plast Surg. Mar 1998;40(3):287-90.

3. Alter GJ. Central wedge nymphectomy with a 90-degree Z-plasty for aesthetic reduction of the labia minora. Plast Reconstr Surg. Jun 2005;115(7):2144-5; author reply 2145. 

4. Rouzier R, Louis-Sylvestre C, Paniel BJ, Haddad B. Hypertrophy of labia minora: experience with 163 reductions. Am J Obstet Gynecol. Jan 2000;182(1 Pt 1):35-40. ].

5. Choi HY, Kim KT. A new method for aesthetic reduction of labia minora (the deepithelialized reduction of labioplasty). Plast Reconstr Surg. Jan 2000;105(1):419-22; discussion 423-4. .

6. Munhoz AM, Filassi JR, Ricci MD, Aldrighi C, Correia LD, Aldrighi JM, et al. Aesthetic labia minora reduction with inferior wedge resection and superior pedicle flap reconstruction. Plast Reconstr Surg. Oct 2006;118(5):1237-47; discussion 1248-50. http://www.medscape.com/medline/abstract/17016196.

7. Maas SM, Hage JJ. Functional and aesthetic labia minora reduction. Plast Reconstr Surg. Apr 2000;105(4):1453-6. http://www.medscape.com/medline/abstract/10744241.

8. Giraldo F, González C, de Haro F. Central wedge nymphectomy with a 90-degree Z-plasty for aesthetic reduction of the labia minora. Plast Reconstr Surg. May 2004;113(6):1820-5; discussion 1826-7. .

9. Girling VR, Salisbury M, Ersek RA. Vaginal labioplasty. Plast Reconstr Surg. May 2005;115(6):1792-3