CASE-BASED LEARNING
Labiaplasty
Shaireen Aleem
Elisabeth Jane Adams
Abstract
Labiaplasty is the surgical term for labia minora reduction. Increasingly
women are presenting to the primary and secondary care complaining of
physical discomfort and cosmetic appearance of their labia. Demand for
this procedure is becoming common amongst very young women who
appear to have developed a concern regarding their labia since their early
adolescent years. This review considers different scenarios in which
women present with complaints with regards to their labia in the form of
both discomfort and appearance. It discusses management of such cases.
It uses these scenarios to illustrate the importance of accurate assessment
and more importantly thorough counselling of patients with regards to
what the operative procedure entails and what are the potential complica-
tions. There will be further discussion about different techniques of surgery
and post operative complication and longterm impact on patients.
Keywords labial hypertrophy; labial reduction; labial surgery;
labiaplasty
Introduction
In recent years female cosmetic genital surgery has become
increasingly popular and, as a result, the number of labial reduc-
tions being performed within the NHS have doubled. Increasing
demand for this could be a reflection of the modern media’s influ-
ence, through television programs, websites and magazines, on
women perceptions of normality. What is perceived by some
women as large labia can be a false interpretation of the normal
range and diversity of female genitals. Increasing awareness of the
fact that surgery is available has further contributed to demand.
Overall it reflects a significant cultural change which gynecologists
need to be aware of because in economically affluent nations the
request for female genital cosmetic surgery is becoming as main-
stream as other cosmetic procedures.
The majority of labiaplasties are performed on patients
between the ages of 16 and 35 years. Though women presenting
with complaints are usually young, now women in their mid 50’s
and older are increasingly complaining of noticing changes in
their perinium in the form of enlarging labia minora and or lax
labia majora.
When deciding on the need for surgical intervention the
surgeon must take into account medical, ethical and psychosexual
Shaireen Aleem MBBS MRCOG Consultant Obstetrics and Gynaecology,
Southport and Ormskirk Hospital NHS Trust, Ormskirk District General
Hospital, Ormskirk, Lancashire, UK.
Elisabeth Jane Adams MBChir MD MA FRCOG Consultant Urogynaecologist,
Liverpool Womens Hospital, Crown Street, Liverpool, UK.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 22:2
aspects. Complaints can be functional, aesthetic and psycholog-
ical. Common functional symptoms include chronic irritation,
problems with personal hygiene, interference with sexual inter-
course and other activities such as cycling and horse riding.
Labiaplasty is offered mainly by Gynaecologists and Plastic
Surgeons. There is no evidence of one surgical technique being
better than the other. Methods include longitudinal trimming of
the edges of the labia, and wedge resection where a V- or
W-shaped portion of the labia is excised and then sutured. These
procedures can be performed using laser or harmonic scalpel for
dissection. De-epithelialization techniques also remove a wedge
of skin, but aim to preserve the interstitial tissue.
Complication rates can be upto 30%. Recognized complica-
tions include bleeding, infection, wound breakdown, scar tissue
formation, hole in the labia and reduced sexual function. Re-
operation rates vary between 2.9% and 7%; indications for re-
operation included wound dehiscence and also not infrequently
dissatisfaction with appearance. Follow up period can range from
1 to 3 months.
There is an urgent need for good quality research within this
field, to examine women’s concerns about their genitals, and
comparative trials of the different surgical techniques.
Scenario 1: A 25-year-old women presents to the clinic with
complaints about the appearance of both her labia which she
feels are enlarged and are causing her discomfort on wearing
underwear and tight trousers. She is married and has two
children.
Dissatisfaction with genital appearance and vulval discomfort
caused by genital protrusion (labia minora protruding beyond the
labia majora) is the most common complaint and indication for
surgery. When taking history try and identify the indications used
to justify surgery in addition to appearance and measurement of
the labia. Psychological and sexual difficulties can also be
complaints, including poor self-esteem, comments from a partner
and teasing by peer groups. Sexual difficulties could include
physical such as labia catching or rubbing during intercourse
causing pain or even psychological such as not wanting to be seen.
An examination should be carried out by an experienced
gynaecologist. It is important to exclude other medical conditions
such as psoriasis, eczema and lichen sclerosis because they could
potentially be one of the reasons for discomfort in this area.
The width and length of the labia should be measured and
compared against published normal values. However there is
a wide range of variation in normal labial dimensions and
therefore it is difficult to have a clear and consistent threshold for
treatment based solely on size.
Therefore a patient centred approach is of utmost importance in
these cases taking into account their concerns with regards to both
the symptoms described by the patient and the labial measurements.
In our practice the standard approach is that if on physical
examination after spreading the labia minora with minimal
traction, the widest part of the free edge lies at the level of the
adductor longus muscle and if patient has symptoms then
surgical intervention could be considered. Other recommenda-
tions in the literature include a distance of greater than 40 mm
between the base and the free edge of the labium.
There are various surgical techniques described within the
literature none of which have been validated by good quality
50 Ó 2011 Elsevier Ltd. All rights reserved.
 CASE-BASED LEARNING

research. Therefore it is hard to advocate one technique over the

other and usually the technique in which the surgeon has the W-shaped resection
most experience is also the best in his or her hands. These
methods include labial trimming or amputation (longitudinal
resection), where the labia are trimmed and then over sewn, and
Prepuce
wedge resection where a V (Figure 1) or W (Figure 2) shaped of clitoris
portion of labium is excised and then sutured. Another tech-
Clitoris
nique, de-epithelialization involves removal of a wedge of skin,
but aims to preserve the interstitial tissue. Further variations
have been described to prevent post operative scarring and or
stenosis of the introitus, such as “Z plasty”.
There are some theoretical advantages and disadvantages of Urethra
different techniques. The wedge resection preserves the natural
outline of the labia, hence the pigmentation of the free edge of Running
the labium is better preserved. De-epithelialized labiaplasty ‘W’ shape
preserves the neurovascular supply of the free edge of the labium resection
and for the very enlarged labia probably the W-shape labial
resection also called the zigzag technique may be preferred to Vaginal
prevent complications based on scar contraction. orifice
Routine pre-operative single dose antibiotic at time of anaes-
thetic induction can be considered, however the evidence is that Labia
with routine antibiotics there is a drop in the overall infection minora
Hymen
rate but not in the complication rates such as wound breakdown.
Complication rates can be as high as 30%. These include bleeding,
infection, wound breakdown, scar tissue formation, hole in the labia
and reduced sexual function either due to nerve pain or reduced
sensation due to nerve damage causing numbness. Re-operation Figure 2
rates vary between 2.9% and 7%; indications for re-operation
included wound dehiscence and dissatisfaction with appearance. days. 45% describe physical inconvenience, discomfort and
Recovery to normal activities is usually up to 3 weeks. superficial dyspareunia between 3 and 90 days. Analgesia and
Following labiaplasty 60% of patients experience pain for 1e60 cold packs help with pain.
To reduce the risk of complications it is recommended is to
avoid the following for at least 3 weeks, swimming, cycling,
V-shaped resection horse riding and intercourse.
Follow up is extremely important and is usually at 3 months.
Non-attendance for follow up should not be assumed to repre-
Prepuce sent success. Patients may not have attended because they may
of clitoris have complications and fears with regards to repeat surgery.

Scenario 2: A 16-year-old girl accompanied by her mother

presents to the hospital very concerned with regards to the
appearance of her left labia as her best friend pointed out to
her that it was abnormally enlarged. She has seen her GP who
Urethra
has referred her with a letter stating she has a pendulous right
labia. She and her mother are now requesting surgery for this.
Wedge In this scenario thorough and accurate history of symptoms
resections and assessment of the Gillick competence of the patient is
crucial. It is important that patient is able to give consent and is
capable of expressing her own free will. In younger adolescent
Vaginal women, influence by their peer groups and parental concerns can
orifice affect their judgement. Therefore some of these cases may have
to be counselled in collaboration with a psychologist. This
Labia procedure should not be carried out in women younger than 18
minora
Hymen years of age because the shape of their external genitalia is still
changing during puberty.
Always consider second opinion in more difficult cases.
Try and seek out what are the exact reasons for which patient
wants the surgery. The most common reason is dissatisfaction
Figure 1 with the appearance of the labia.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 22:2 51 Ó 2011 Elsevier Ltd. All rights reserved.
 CASE-BASED LEARNING
The patient’s perceptions of abnormality may have been
reinforced by her GP’s comments and the referral to an expert.
This should be discussed and diffused.
Reinforce and highlight that there will be developmental
changes in hormones, fat and pubic hair distribution. This will alter
the appearance of her vulva. Explain that a great interpersonal
variability in the shape and appearance of the external genitalia
exists (according to one paper the width varied from 7 mm to 50
mm). Advise them to see the sculpture by Jamie McCartney of 400
womens labial casts http://www.brightonbodycasting.com/
design-a-vagina.php. It highlights the range of normality.
They may not realize that hormonal changes during puberty
result in growth of genitals in such a way that the inner labia
mostly become longer than the outer labia. Therefore in some
cases patients may interpret the results of these normal physio-
logical changes as abnormal and may feel insecure, uncomfortable
and bothered by the shape of their genitals. Changing cultural
trends, (shaving or waxing of the pubic hair) and watching TV
programmes, looking at internet pictures or reading in magazines
about cosmetic genital surgery is common these days. This results
in women becoming more aware of their protruding labia, which
in vast majority of the cases is probably anatomically normal.
If complaints are of sexual dysfunction then it is important to
highlight that reducing the labia may not improve sexual func-
tion unless it is specifically related to the labia rubbing or
catching during intercourse. If there are any psychosexual issues
they must be addressed and appropriate counselling should be
arranged. Make sure that patient does not suffer from depression,
anxiety or body dysmorphic disorder which can be common in
teenagers. They should completely understand what the proce-
dure entails and be fully aware of the risks and complications of
the surgery. Counselling must include the risks of haemorrhage
or infection which can result in premature breakdown of the
sutures causing a poor cosmetic result. Also the risk of re-
operation because of complications should be stated. Ideally
they should be given a written patient information leaflet.
However ultimately in this case surgery should not be per-
formed due to the risk of additional operations later on because
of the growth of the other labia due to normal development.
Scenario 3: A 50-year-old lady presents with complaints
regarding the appearance of her bilateral labia majora and
labia minora especially since childbirth and menopause. She
feels that her labia minora are excessively large and cause
discomfort especially when she cycles. She also feels her labia
majora and perineum appear very lax.
Over recent years there are a growing number of older women in
there 50’s and more presenting with these complaints. This may
again be due to the influence of the media. There are main pro-
grammes promoting the “makeover” which increasingly involve
cosmetic surgery. Also the changing trends in waxing or shaving off
all of the pubic hair is probably causing women to then regard the
labia as more prominent. Another factor is that with ageing there
are changes in the collagen, fat and hair distribution in the skin.
This affects the vulva and labia majora, and may cause the loss of
fullness and laxity of this area. This can make the labia minora
appear enlarged in comparison to the labia majora. Other reasons
for changes in the appearance of this area and or possible discom-
fort could be post childbirth, menopause and weight loss.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 22:2
Patient should be taken very seriously and listened to carefully.
Explore other reasons that could have caused these concerns in the
patient such as psychosexual problems, relationship breakdown
or divorce, and physiological changes associated with the meno-
pause. Psychosexual issues can be common in this age group and
counselling plays a very important role and should be considered
as a nonsurgical option in these cases.
Ensure the conventional conservative advice is also given
such as in this particular case another type of bike seat, or
wearing less tight underwear. For all patients there should be
a low threshold for referral for psychosexual counselling.
Treatment options can include topical or systemic HRT. This
may alleviate the discomfort symptoms in this area. With regards
to the complaints of the labia minora the surgical options would
be labiaplasty. For the labia majora a referral to plastics may
need to be considered as labia majora remodelling is offered by
some surgeons. This is usually done by injecting fat taken from
other areas in the body such as the abdomen, hips or thighs into
the vulva and or the labia majora (microfat grafting techniques).
Collagen has also been used in this area.
Like the other scenarios in this review, counsel the patients
thoroughly with regards to surgery and other treatment options.
Give them time to think about this and consider surgery as last
resort only if it is indicated.
Scenario 4: A 31-year-old lady wishes a re-operation of her
right labia minora following bilateral labial reduction
6 months ago as she has developed a small hole in her right
labia she finds it extremely unsightly and is still suffering
with discomfort on that side.
Re-operation should be considered extremely carefully
whether it is due to complications or dissatisfaction regarding
appearance. If following counselling and examination it is
thought to be appropriate to re-operate one should have a low
threshold for referral to a plastic surgeon.
Re-operation rates vary between 2.9% and 7%. The main
problem in these cases is a poor blood supply, ischaemic changes
associated with the previously operation site. This significantly
increases the failure rate for re-operations. This includes failure of
achieving the desired appearance, repairing the hole in the labia
minora as well as a high risk of wound dehiscence and scar formation
resulting in significant sexual dysfunction. Therefore preoperative
counselling with regards to this is extremely important to aid the
patient to make the right and well informed decision for themselves.
Surgically the edges of the affected area are incised and
refreshed and over sewn. In more severe cases there are reports
of plastic surgeons using skin grafts to repair the defect.
Conclusion
The demand for labial reduction surgery is constantly increasing.
Healthcare funds are becoming limited and in the current
financial and NHS atmosphere labiaplasty might be seen as
luxury rather than a necessity. It could be argued it places an
unnecessary burden on the already scarce healthcare funds. In
many units this procedure is no longer provided by the NHS.
The vast majority of women seeking surgery have normal labia.
More than 50% of these women do so because they perceive their
labia enlarged and wish to make them smaller to improve
52 Ó 2011 Elsevier Ltd. All rights reserved.
 CASE-BASED LEARNING
appearance. Therefore clear guidance is needed for clinicians to
enable them to best to care for women seeking surgery. Clinicians
need to be able to negotiate their way through the potential mine-
field of those women seeking labiaplasty whose primary problem is
with body dysmorphy, psychosexual problems, external negative
influences that may not benefit from surgery and those with purely
physical symptoms which may improve with surgery.
Women presenting for labial surgery may have unrealistic
expectations of surgery, but at the same time these perceptions
and expectations are often long standing and seem to be based on
strong cultural norms.
The use of validated quality of life questionnaires can be very
helpful in making an overall assessment and plan of care in such
cases. A second opinion from a psychologist and/or another
gynecologist should be considered in difficult cases.
Complications are perceived by majority of patients and
unfortunately in some cases of surgeons as minor and acceptable.
However we cannot emphasize enough the importance of fully
informed consent. One way to achieve this in an effective and
consistent way would be to introduce patient information leaflets.
In cases where there is discrepancy between the seriousness of
the complaints and the physical examination, when patients
expectations do not meet the results obtained by surgery or there
are complaint of chronic vulvar pain one must refrain from
surgical intervention. Psychological and psychosexual assessment
and counselling plays an invaluable role in these circumstances.
Patients appear generally happy with outcomes. The majority of
patients undergoing genital plastic surgery report overall satisfac-
tion. However most of this is anecdotal evidence. Therefore there is
a need for research, for formal evaluation of physical and psycho-
logical symptoms and patient satisfaction following surgery. A
FURTHER READING
1 Liao L-M, Michala L, Creighton SM, et al. Labial surgery for well
women: a review of the literature. BJOG 2010; 117: 20e5.
2 Goodman MP. Female genital cosmetic and plastic surgery: a review.
J Sex Med 2011; 8: 1813e25. 2011 Jun; 8: 1813e25.
3 Crouch NS, Deans R, Michala L, Creighton SM. Clinical characteristics
of well women seeking labial reduction surgery: a prospective study.
BJOG 2011; 118: 1507e10.
4 Solanki NS, Tejero-Trujeque R, Stevens-King A, Malata CM. Aesthetic
and functional reduction of the labia minora using the Mass and Hage
technique. J Plast Reconstr Aesthet Surg 2010; 63: 1181e5.
5 Bramwell R, Morland C, Garden AS. Expectations and experience of
labial reduction: a qualitative study. BJOG 2007; 114: 1493e9.
Practice points
C Women requesting labiaplasty should be thoroughly and accu-
rately assessed (do they meet criteria of enlargement and surgery)
C Make sure patients are aware that this is a procedure with
a high complication rate
C Women should be given clear and realistic expectations of
what will be achieved with the operation in term of appearance
and function
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 22:2
C Psychosexual counselling plays an invaluable role
C Consider having local practical guidelines
C Use patient information leaflets, books, CD’s, photographs
showing the great variability in the normal labia minora and
also to explain what the operation and its complications are
C Attendance at training programmes courses such as psycho-
somatic gynaecology needed to increase knowledge of this
subject in gynaecologists
Short cases
Short case 1. A 24-year-old women had a unilateral right sided
labial reduction 3 months ago but she is still complaining of
dissatisfaction with regards to the appearance of her labia and is
in tears and requesting reoperation. On examination the labia
look completely normal.
(a) How would you advise her regarding further management?
(b) What other nonsurgical options would you discuss with her?
Avoid surgery especially if appearance of labia is normal. During
the examination involve the patient ask her to point out where she
feels the problem is and as was shown in this case on doing so,
the problem was not the labia minora but the crease/fold of skin
parallel to the clitoral hood. Reassure patient and explain it is
normal part of the anatomy. In difficult cases like these ask for
second opinion and consider referral to plastic surgeon.
When there is a clear discrepancy between physical findings and
symptoms it is crucial that psychological and psychosexual
counselling is offered. In some cases the patient may not wish to
accept this referral. In such circumstances you can offer to review
the patient in a couple of months it gives them a chance to think
about things (cooling off period) and the patient may come back
with a different view to things.
Short case 2. 28-year-old had bilateral labial reduction done 2
days ago and now presents to the emergency department with the
right labia swollen (about 3  3 cm) and painful. Two sutures
appear to be broken down.
(a) What would be your immediate management?
(b) How would you counsel patients regarding long-term
implications?
If there is no active bleeding then management should be
conservative. Patient has probably bled in the immediate post-
operative period which has now stopped and a haematoma has
developed. The fact that a couple of sutures have broken down
helps as the haematoma will drain. In other cases you may need to
remove a few sutures to aid the haematoma to drain. We would
recommend a course of broad spectrum antibiotics for 10 days.
In case of active bleeding or enlarging haematoma patient may have
to be taken back to theatre to stop source of bleeding. Pressure
dressings should be considered post-operatively in such cases.
Long term implications may include development of a bigger scar,
pain and patient may not achieve the desired result.
53 Ó 2011 Elsevier Ltd. All rights reserved.