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Labia Majora Augmentation With Hyaluronic Acid Filler: Technique and Results
Labia Majora Augmentation With Hyaluronic Acid Filler: Technique and Results
Genital Rejuvenation
Abstract
Background: External female genitalia lose elasticity and volume with age. In the literature several techniques address the redundancy of the labia
minora, but only few reports describe the augmentation of labia majora with fat grafting. At present, no studies describe the augmentation of the labia
majora with hyaluronic acid.
Level of Evidence: 4
Cosmetic surgery of the female external genitalia has gained reflects blood supply, thus explaining the pale appearance of
increasing popularity over the past decade. The American external genitalia in advanced age.
Society for Aesthetic Plastic Surgery reported a total of 8,745 Indeed, following the loss of follicular activity, the external
labiaplasty procedures performed in 2015, with a dramatic genitalia and labia majora lose subcutaneous fat while connec-
increase (more than 15%) compared to the previous year.1 tive tissue relaxes and becomes less elastic.3 Macroscopically,
Commonly these procedures address the morphological the labia majora decrease their tone and volume, while the
and structural modifications which arise as the effects of labia minora increase in size.4
aging. Tissues become more prone to inflammation; typical of
A clear example of aging of the female external genitalia aging is post-menopausal atrophic vulvovaginitis, characterized
is provided by the thickness of the vulvar epithelium, which
reaches its peak during reproductive years and decreases Dr Fasola is a microsurgeon in private practice in Milan, Italy.
with age. At a cellular level, estrogen induces nuclear modifi- Dr Gazzola is a Resident, Department of Plastic Surgery, Università
cations among the superficial epithelial cells during each degli Studi di Milano, Milan, Italy.
menstrual cycle, thus influencing the thickness of the whole
Corresponding Author:
epithelium.2 Dr Riccardo Gazzola, Plastic Surgery Department, IRCCS Istituto
Similarly, vascularization reaches a peak during pregnan- Ortopedico Galeazzi, Via Galeazzi 4, 20161 Milan, Italy.
cy, while it rapidly decreases after menopause. Coloration E-mail: riccardogazzola@gmail.com
2 Aesthetic Surgery Journal
by reduced lubrication,5 skin hydration, friction and permeabil- The patient must be informed about possible complica-
ity.6 Progressive muscle fiber hypotrophy follows similarly in tions, although the literature is lacking concerning compli-
other tissues.7 cations of HA on external female genitalia.
The number of procedures that aim to rejuvenate the Generic complications of HA infiltration include herpes
female genitalia is rising.8,9 The vast majority of these pro- simplex and herpes zoster reactivation after filler injection.
cedures address the cutaneous excess of the labia minora, This issue should be prevented with an adequate prophy-
with wedge resections,9,10 edge resections, Z-plasties, or lactic therapy.18 Furthermore, when intravascular infiltra-
modified resections.11 tion of hyaluronic acid is administered, cutaneous necrosis
Rejuvenation of the labia majora is able to improve the and distant embolization could occur.19,20 On the other
aesthetic aspect of the external genitalia, producing a more hand, the risk of infection is low and could be minimized
youthful appearance, while augmentation of the mons by accurate disinfection of the area.21 However there are no
pubis could improve discomfort during intercourse reduc- data in the literature concerning the infective risk for HA in-
ing trauma along the pubic bone.11,12 filtration in this region.
Few reports describe labia majora augmentation with fat Erythema, edema and bruising may be observed immedi-
grafting.4,13 De Lorenzi et al describe the use of hyaluronic ately after infiltration, which resolve spontaneously. Allergies
acid injections to correct irregularities of the mons pubis, are rare but could occur within hours from injection, although
labia minora or labia majora.14 However, the literature late allergic reactions, granulomas and chronic inflammations
lacks studies that investigate the effectiveness and compli- are described.21
Stage I - Mild (Early) Mild hypotrophy. Distribution of adipose None to mild cutaneous hypotrophy. Thin Usually asymptomatic. Possible
tissue is usually symmetrical. wrinkles may be visible. consequence of weight loss.
Stage II - Moderate Moderate hypotrophy. Possible asymmetric Moderate cutaneous laxity, Dryness, dispareunia, soreness could be
distribution of adipose tissue. dermatochalasis. Wrinkles are visible. observed.
Stage III - Severe Severe hypotrophy. Frequent asymmetric Severe dermatochalasis and deep wrinkles. Usually associated to symptoms like
distribution of adipose tissue. dryness, dispareunia, soreness.
molecule and the volume reached in living tissues is greater herpes zoster infection, active herpes zoster infection in
than the injected one. Infiltration of an excessive volume other sites, local dermatitis, vulvar squamous papillomas,
could lead to ischemic complications, granulomas, and mycosis, bacterial infections, autoimmune diseases, and
raise the risk of infection. history of adverse reactions to hyaluronic acid fillers.
Topical antimicrobial and antimycotic treatment with Demographic data, menopause, and pharmacologic treat-
phenethyl alcohol is regularly administered for one week.24 ments were recorded. Hypotrophy was preoperatively staged
Antibiotic prophylaxis with amoxicillin clavulanate is ad- according to our classification into three grades (mild, mod-
Figure 4. A 63-year-old woman affected by moderate hypotrophy of labia majora. The patient received 19 mg/mL hyaluronic acid,
1 mL per part. At 6 months later a second treatment with 19 mg/mL hyaluronic acid was carried out (1 mL per part). (A) A preoper-
ative photograph and the result at 12 months (B) from the first treatment are shown.
1 mL). Among the second group (severe hypotrophy), 3 pa- All patients returned for the planned 12-month follow-up
tients underwent a second infiltration with 19 mg/mL HA visit. A significant improvement (P < .0001) in GAIS score
filler (maximum 1 mL) (Table 2). was observed both in the scores provided by the patients and
6 Aesthetic Surgery Journal
Table 2. Summary of Hyaluronic Acid Filler Infiltration for Labia Majora Table 3. Global Aesthetic Improvement Scale (GAIS) Preoperatively and
Atrophy 12 Months Postoperatively
First Treatment Second Treatment at 6 Months Preoperative – GAIS Average 12 Months – GAIS Average
(Range) (Range)
No. of patients (HA filler concentration)
Patient Doctor Patient Doctor
Stage I 11 (19 mg/mL) –
Stage II 20 (19 mg/mL) 1 (19 mg/mL) Stage I-II 6.16 (4-9) 6.90 (5-9) 8.97 (6-10) 8.77 (6-10)
Stage III 23 (21 mg/mL) 3 (19 mg/mL) Stage III 4.04 (2-6) 4.74 (2-6) 8.35 (6-10) 8.17 (6-10)
Total 54 4 All 5.26 (2-9) 5.98 (2-9) 8.70 (6-10) 8.52 (6-10)
by the doctor (Table 3 and Figures 6 and 7). The GAIS score In our case series we did not observe granulomas, ischemic
improved from an average of 5.26 by the patients (range, 2-9) complications, and other complications. Transient hyperemia
and 5.98 by the doctors (range, 2-9) to an average of 8.7 by the was observed in half of the patients after treatment lasting
patients (range, 6-10) and 8.52 by the doctors (range, 6-10). A usually 30 minutes. One patient, treated with the needle tech-
greater relative improvement was observed in patients affected nique, reported edema for 5 days. Mild ecchymosis were ob-
by stage III hypotrophy (patient score + 106.45%, doctor served in two patients treated with the needle. A small amount
score 72.36%) (Table 4). In this group the preoperative mean of product accumulation, appearing as a small bump, was ob-
GAIS was 4.04 by the patients (range, 2-6) and 4.74 by the served in the patients after HA injection with the needle. A
doctors (range, 2-6). Postoperatively, GAIS measured respec- light massage of the area was sufficient to correct the defect.
tively 8.35 (range 6-10) and 8.17 (range, 6-10).
Interestingly, the t-test revealed that the scores provided
DISCUSSION
by the doctor was significantly higher than those provided
by patients in the preoperative (P < .0001) and signifi- The demand for cosmetic procedures of female genitalia is
cantly lower in the postoperative (P < .011). increasing. Labiaplasty, vaginoplasty and clitoral hood re-
Improvement of dyspareunia was not observed (in fact duction are widespread and have excellent outcomes. In par-
vaginal introitus was not infiltrated). Nonetheless some ticular, labiaplasty demonstrates excellent results in 96.6%
patients reported improvements in hydration. of patients, enhancing sexual satisfaction in 64.7%.29
Fasola and Gazzola 7
Figure 6. Patient evaluation of the treatment on the Global Figure 7. Doctor evaluation of the treatment on the Global
Aesthetic Improvement Scale (GAIS), preoperatively and 12 Aesthetic Improvement Scale (GAIS) preoperatively and 12
months postoperatively. months postoperatively.
Labiaplasty addresses the redundancy, laxity and hyper- Table 4. Observed Variation in Global Aesthetic Improvement Scale (GAIS)
15. FIGO Committee for the Ethical Aspects of Human Applications. In: Pomin V ed. Hyaluronan - Biological and
Reproduction and Women’s Health. Ethical consider- Medical Implications. New York: Nova Publishers; 2014.
ations regarding requests and offering of cosmetic genital 28. Rosenbaum PR. Observational Studies. 2nd ed, New York:
surgery. Int J Gynaecol Obstet. 2015;128:85-86. Springer-Verlag; 2002.
16. Krissi H, Ben-Shitrit G, Aviram A, et al. Anatomical diver- 29. Goodman MP, Placik OJ, Benson RH 3rd, et al. A large
sity of the female external genitalia and its association multicenter outcome study of female genital plastic
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2016;196:44-47. 30. Karabagli Y, Kocman EA, Velipasaoglu M, et al. Labia
17. Shaw D, Lefebvre G, Bouchard C, et al. Female genital cos- Majora Augmentation with De-epithelialized Labial Rim
metic surgery. J Obstet Gynaecol Can. 2013;35:1108-1114. (Minora) Flaps as an Auxiliary Procedure for Labia
18. Gazzola R, Pasini L, Cavallini M. Herpes virus outbreaks Minora Reduction. Aesthetic Plast Surg. 2015;39:289-293.
after dermal hyaluronic acid filler injections. Aesthet Surg 31. Oredsson S, Plate G, Qvarfordt P. The effect of mannitol on
J. 2012;32:770-772. reperfusion injury and postischaemic compartment pres-
19. El-Khalawany M, Fawzy S, Saied A, et al. Dermal filler com- sure in skeletal muscle. Eur J Vasc Surg. 1994;8:326-331.
plications: a clinicopathologic study with a spectrum of his- 32. Zager RA, Mahan J, Merola AJ. Effects of mannitol on the
tologic reaction patterns. Ann Diagn Pathol. 2015;19:10-15. postischemic kidney. Biochemical, functional, and mor-
20. Cavallini M, Gazzola R, Metalla M, Vaienti L. The role of hy- phologic assessments. Lab Invest. 1985;53:433-442.
aluronidase in the treatment of complications from hyaluron- 33. England MD, Cavarocchi NC, O’Brien JF, et al. Influence
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