“What the Women Want”. an Overview on Labiaplasty: Function and Beauty Researched with an Aesthetic Gynecological Procedure

Lembo F, et l., J Reprod Med Gynecol Obstet 2020, 5: 053 DOI: 10.24966/RMGO-2574/100053 HSOA Journal of Reproductive Medicine, Gynaecology & Obstetrics

Review Article

psychological evaluations (multidisciplinary approach), discuss “What the Women Want”. realistic expectations, and personalize the technique of surgery. Although labiaplasty was described as a safe procedure with a high An Overview on Labiaplasty: satisfaction rate, current study includes few patients with short follow- up. Further clinical studies should be performed to: validate current Function and Beauty practices, define optimal management of patients and investigate long-term outcomes. Researched with an Aesthetic Keywords: Cosmetic genital surgery; Labial hypertrophy; Labia minora; Labiaplasty Gynecological Procedure Introduction Fedele Lembo*, Liberato Roberto Cecchino, Domenico Parisi and Aurelio Portincasa The surgical reduction of labia minora, defined labiaplasty, was Plastic and Reconstructive Surgery Department, Ospedali Riuniti-OORR, first described in literature by Hodgkinson and Hait in 1984 [1]. About University of Foggia, Foggia, Italy 56% of Plastic Surgeons perform labiaplasty worldwide and, over the years, this procedure has become more popular. In 2018 a total of 132.664 procedures (1.3% of total) were performed worldwide, with an increase of 25% vs 201 [2]. In 2018 Brazil was the Country Abstract in which there are recorded the higher number of procedures, about Labiaplasty is the most commonly performed female cosmetic 18.476; in USA 13.668, and in Italy 4.800 [2]. According to data genital surgery procedure. Women sought labiaplasty for aesthetic of American Society of Plastic Surgeons, 11.218 procedures were reason and/or for functional impairment. Despite increasing numbers performed in 2019, up 9 percent from 2018 [3]. of procedures performed, there is a lack of consensus of standards of nomenclature, of care and of outcomes. The aim of this study was So, labiaplasty is the most commonly performed FCGS (female to clarify the current notions and the management of these women. cosmetic genital surgery) procedure. This increase was secondary A systematic literature review of the last 5 years (2015-2020) was to amplified exposure to female nudity in the media and internet, performed using the PubMed database. The search returned 111 which cause a definition of an ideal look of female genitalia, that, articles; after applying inclusion criteria to identify studies evaluating however, differs between Countries [4,5]. Women sought labiaplasty classification of labia minora hypertrophy, surgical techniques, for aesthetic reason and/or for functional impairment such as complications and outcomes, 50 articles were selected (11 reviews, 3 clinical trials, 36 prospective and retrospective studies). In this brief irritation, pain or physical and psychological discomfort, especially review the authors clarify that no consensus exists in the literature in adolescent patients [6-8]. In fact, hypertrophy of labia minora can regarding the classifications of labia minora hypertrophy. Overall, cause self-esteem reduction, insecurity when wearing tight clothing 7 different techniques have been reported, and patient satisfaction (for job or sport), dryness, irritation, tearing, chronic urinary tract rates ranged from 95 to 100 percent. The most common complication infections, dyspareunia and discomfort during sexual intercourse described was wound dehiscence (around 5%). [9,10]. The analysis of literature clearly shows that the counselling Although these surgical procedures are debated for ethical aspects, is fundamental and women’s motivations for treatment should be carefully explored. A complete medical, sexual, psychological about 95% of patients are satisfied with outcomes on quality of life and gynecological history should be obtained in all patients and self-perception [11,12]. There is no consensus regarding the before surgery. To achieve the best outcomes in both functionality use of criteria to define a diagnosis of labial hypertrophy, and it has and appearance with minimal complication rates and greatest been proposed that surgery should be pursued with the presence of patient satisfaction, trained surgeons must inform patients about any chronic symptomatology. Various classifications and surgical normal variations and about the potential risks of surgery, perform techniques exist, with no consensus regarding their use. The lack of standards of nomenclature, of care and of outcomes have caused *Corresponding author: Fedele Lembo, Plastic and Reconstructive Surgery questions about the level of safety and efficacy of these procedures Department, Ospedali Riuniti-OORR, University of Foggia, Foggia, 71100, Italy, Tel: +39 0881733803; E-mail: [email protected] [13]. The aim of this study was to clarify the current notions and the management of these women. Citation: Lembo F, Cecchino LR, Parisi D, Portincasa A (2020) “What the Wom- en Want”. An Overview on Labiaplasty: Function and Beauty Researched with Materials and Methods an Aesthetic Gynecological Procedure. J Reprod Med Gynecol Obstet 5: 053. A systematic literature review of the last 5 years (2015-2020) Received: July 15, 2020; Accepted: July 25, 2020; Published: August 01, 2020 was performed using the PubMed database with the following search Copyright: © 2020 Lembo F, et al. This is an open-access article distributed algorithm: ((labiaplasty) OR (labial hypertrophy)) AND ((etiology) under the terms of the Creative Commons Attribution License, which permits OR (epidemiology) OR (classification) OR (treatment)). The primary unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. literature search returned 111 articles. The authors independently Citation: Lembo F, Cecchino LR, Parisi D, Portincasa A (2020) “What the Women Want”. An Overview on Labiaplasty: Function and Beauty Researched with an Aesthetic Gynecological Procedure. J Reprod Med Gynecol Obstet 5: 053.

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reviewed article titles and abstracts to identify all studies that assessed deepithelialization, [46] direct excision, [47] W-shaped resection, labial hypertrophy classification, labiaplasty techniques and outcomes. [48] wedge resection, [49-53] composite reduction, [54-55] Z-plasty, Selected articles that met these inclusion criteria then underwent full [56] and laser labiaplasty [57,58], few studies have defined an text review. Information from commentaries/replies, conferences and algorithm for choosing the optimal surgical procedure according to published abstracts was excluded. After applying inclusion criteria, the degree of deformity. Patient-specific techniques chosen based of 111 articles returned, only 50 articles were selected as pertained to on the patient’s anatomy and applied with a realistic approach can vaginal labiaplasty (11 reviews, 3 clinical trials, 36 prospective and increase patient satisfaction and reduce complication rates. Overall, retrospective studies). All articles were in English language. the different techniques reported can be categorized into three groups: edge resection; wedge resection; and central resection. Discussion Edge resection Labial hypertrophy classification In this technique, the excess of labial tissue is removed by resecting The labia minora vary in length (7 mm to 5 cm), thickness, sym- the most protruding part. This excision can be performed either in a metry and protuberance. Women’s health care professionals play a line that follows the curve of the labia, in an S-shaped line, or in a fundamental role in helping patient to understand their normal ana- W-shaped resection. The S-shaped resection, or the double-W-shaped tomic variation [14-16]. Labial hypertrophy is most commonly con- incision or the Z-plasty is widely used technique to increase the length genital, but can be acquired also (androgenic hormones in infancy, of the scar and to reduce the effects of scar contraction [48-58]. topical estrogen, stretching or weight attachment, lymphedema, re- cidivate dermatitis, myelodysplastic diseases) [17]. There is no con- Wedge resection sensus on classification [18,19]. The most used classification system, Wedge resection is the most popular labiaplasty technique. It first described by Franco [20], divides 4 stages based on the distance includes various adaptations that have been made to improve aesthetic from the base of the labia minora to the most distal tip: results (such as preserving the shape and colour of the labia) or to -- Stage I: <2 cm prevent loss of sensation or necrosis. The location of the wedge can -- Stage II: 2-4 cm be adjusted to the most bulging part of the labia minora. The central -- Stage III: 4-6 cm wedge resection can be performed with or without first identifying and preserving the main labial artery [50]. -- Stage IV: >6 cm Giraldo et al., [56] perform a 90° Z-plasty in order to prevent Other classifications are: the Motakef classification that is based scar contraction. When reduction of the clitoral hood is also desired, on the protrusion of the labia minora that exceeds the size of the a central wedge can be combined with a “lateral anterior curved labia majora [21]; the Banwell classification that categorizes the excision of redundant lateral labium and excess lateral clitoral hood” labia according to the shape and morphologic variations [22]; and the [50]. The wedge can also be placed posteriorly in a posterior wedge Chang classification that propose 4 classes of labia protrusion based resection [49], or inferiorly with a superior pedicle flap. on size and location [23]. Less used classifications are described by Oranges [24] and by Mayer [25]. Central resection Preoperative consultation Central resection is used to maintain the original texture, contour, and pigmentation of the labial edge and includes de-epithelialization In 2016, 2017 and 2020 ACOG Committee (American College [46] and fenestration [59]. Choi et al., [46] described a de- of Obstetricians and Gynecologists) recommended that the women epithelialization technique using a triangle-shaped marking centred in should be informed about normal variations and physical changes, the labia minora. Ostrzenski et al., [59] marked the amount of tissue to that the patient’s physical and emotional development had to be be removed centrally in the labia minora in a ‘bicycle helmet’ shape. evaluated, and that consultation about non-surgical technique should Excision is performed, and the inner and outer surface of the labia be provided [26-29]. In fact, counselling is fundamental to ensure minora are sutured separately, without suturing the erectile tissue that women have reliable information about normal variations and between them. physiological changes in the external genitalia over the lifetime and about possible complication of surgery, especially in adolescents In current literature there isn’t any comparative analysis of all [30-34]. Many women desire the labia minora roughly symmetric, reported labiaplasty techniques to establish a standard operative non-exposed or invaginated under of the labia majora. Women’s planning. Ellsworth et al., [60] proposed this algorithmic approach: motivations for treatment should be carefully explored. A complete patients with Franco type I and type II may be treated most effectively medical, sexual, psychological and gynecological history should with the deepithelialization technique. Patients with Franco type III be obtained [35-38]. In fact, principal contraindications are: body or type IV may be more appropriate candidates for either the direct dysmorphic syndrome, enhancing sexual lives and orgasm [39]. excision or the wedge resection technique. However, future larger studies should validate this approach. Labiaplasty techniques Advantages and Disadvantages When performing a labiaplasty, the essential goals should include the reduction of the hypertrophied labia minora with maintenance of Each technique offers its own advantages and disadvantages the neurovascular supply, preservation of the introitus, optimal col- [61]. Although direct excision is a simple technique, yet it removes or/texture match, and minimal invasiveness [40-45]. Although many the natural contour, coloration, and texture of the free edge of the surgical techniques have been reported in the literature, (including labia minora and may lead to visible scar formation. In contrast,

Volume 5 • Issue 3 • 100053 J Reprod Med Gynecol Obstet ISSN: 2574-2574, Open Access Journal DOI: 10.24966/RMGO-2574/100053 Citation: Lembo F, Cecchino LR, Parisi D, Portincasa A (2020) “What the Women Want”. An Overview on Labiaplasty: Function and Beauty Researched with an Aesthetic Gynecological Procedure. J Reprod Med Gynecol Obstet 5: 053.

• Page 3 of 6 • deepithelialization may preserving the natural border of the labia the impact of labiaplasty on a woman’s self-image and quality of life, minora and its neurovascular supply, but it may be unsatisfactory and compare outcomes between various labiaplasty techniques. for wider labial width. Wedge resection retains the natural contour and coloration of the free edge of the labia minora; however, it may Conflicts of Interest create an abrupt contrast in the coloration where tissues are sutured. The authors declare that there is no conflict of interest regarding Composite reduction is a technique that addresses both labial the publication of this paper. protrusion and clitoral hooding with excellent aesthetic outcomes. However, the complication and reoperation rate for this technique is Funding Statement also the highest described in the literature (about 17 percent) [55]. No financing. References

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