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So Many Surgical Techniques, But Which Is Best For You?
Surgical Techniques Vary, Depending On Individual Case—Here’s What You Need to Know—And the Questions to Ask.
Reviewed by Michael Goodman, M.D., FACS and by Bernard Stern, M.D., FACS
November 18, 2016
So You Think Picking A Surgeon Isn’t A Big Deal? Think again.
There’s a lot of chatter on the Internet about labiaplasty and vaginoplasty. Things like who is better than whom . . . which procedure is better than another. To say the least, it’s very confusing.
So, where do you find an expert labiaplasty surgeon who has mastered a surgical technique, or one who knows many techniques? This is critically important because once tissue is removed (excised) it can rarely, if at all, be replaced if something isn’t done correctly—so employing the proper technique is paramount. Choosing the wrong surgeon, one who doesn’t utilize the best technique, can take a bad situation . . . and make it the worst decision of your life—potentially destroying your current and future relationships. Don’t merely rely on a pretty website or someone who is local (the “I don’t want to travel,” syndrome). You could be playing “Russian Roulette” with your genitals if you don’t deal with an expert who knows the procedures.
Confused? Don’t Know Which Technique Is Best For Your Situation?
You’ve made the decision to proceed with your Labiaplasty surgery. You’ve researched the medical journals, read the news reports, studied testimonials, and analyzed pre and post-operative photos. So many terms, so many different techniques to consider.
But, really just how important is knowing the surgical technique that your surgeon might use? The answer is “not really that important.” Your real concern should be that your surgeon is knowledgeable in many different techniques, so they can determine the best one to use in your specific case. They can assess your situation and will use the best method.
To a large extent, there are numerous surgical techniques—usually developed by surgeons who’ve had years of experience. They all involve the reduction and re-sculpting of the labia minora and in some cases the labia majora—and while it’s not critical for you to know one technique from another, it would be helpful to at least learn which technique might give you the best result after discussions with your surgeon(s).
It begins with understanding one’s individual situation. In some instances, women with large labia, or labial hypertrophy (labia minora or labia majora) can experience pain during intercourse, or feel discomfort during everyday activities—such as wearing clothing that restricts movement or is tight-fitting. (See also Definitions of Female Genital Cosmetic Surgery.)
Other women may feel unattractive, or have a symmetry problem . . . one side of the labia minora considerably smaller or larger than the other side. Interestingly enough, it is very common to find that the labia majora is often quite asymmetric and is not generally considered problematic in this manner, unless a patient specifically has an issue with pain, aesthetic appearance, or hygiene issues. Lastly, some women may wish to enhance their sexual experiences by removing some of the skin that covers the clitoris. All of these problems can be caused by genetics, sexual intercourse or difficulties in childbirth. For more detailed information, read our Labiaplasty Questions and Answers. Your LPS surgeon will discuss the techniques applicable to you if you ask them. You should.
Labiaplasty techniques vary greatly. Some apply to labiaplasty minora reduction . . . others apply to labiaplasty majora reduction/sculpting. Other techniques are specific to Reduction of Clitoral Hood (RCH). Also, it’s very important to note that there are considerable differences and indications between labiaplasty labia minora (LP-m) techniques, and labiaplasty labia majora (LP-M) techniques. The vast majority of labiaplasty surgery is performed for labia minora issues as mentioned prior, usually on younger women. In more rare instances, labiaplasty of the majora, (LP-M) specifically among middle age or older women, or in cases where significant weight loss may have occurred may be recommended. Issues relating to majora reduction can range from discomfort with clothing/fitting, due to hypertrophic (enlarged) labia majora, to infection of vaginal regions due to the excess tissue making it difficult to administer proper cleansing and hygiene. As the vast majority of labiaplasty procedures are on the minora structures, we will not address what is termed “majoraplasty” procedures, which can greatly vary depending on application.
Labiaplasty minora procedures (LP-m) include two fundamental techniques, (#1-2, below) and a few variations of these. Most cases can be addressed successfully using either Linear Resection, or V-wedge and the majority of cases are usually handled using either of these techniques.
1) Sculpted Linear (or curvilinear) Resection—
Generally a straight line incision (or, if an arc shape, often referred to as a curvilinear incision) along the hypertrophic outer edge of the labia minora using either laser, scissors, incising needle, or radio frequency (RF). This technique is generally suited to best remove excess tissue on either side of the labia minora, and produces a nice sculpted line of remaining labial tissue that can be closed with a “sub-cuticular” (absorbable, under-the-skin) or “interrupted” (separate through-and-through) suture line. It is the procedure used most often by surgeons performing labiaplasty minora. Care must be taken to not suture too tightly, as doing so would result in bunching and a labial edge appearing much like the outside edge of a scallop shell (scalloping). This technique removes the edges of the labia minora, and hence results in an outward appearing semi-circle of resected tissue, akin to a more “normal” labial appearance, also removing any pigmentation inconsistencies that might have occurred naturally prior to surgery, and a “leveled” appearance (versus a bulging labia minora beyond the labia majora) when compared to the labia majora. This technique is employed generally by lesser experienced surgeons because of the reduced learning time to become proficient. Surgeons must use conservative application of this technique; to excise too much tissue (an amputation) can result in both unnatural final vulva appearance, and pain during intercourse caused by either too much tension on the clitoral glans tissue, or chafing if too much “mucosa” (the sensitive skin just inside the lips) has been pulled outside by removing too much tissue.
2) V-Wedge Resection/Modified V-Wedge Resection—
This technique employs a more dramatic surgical technique whereby a v-shaped wedge of tissue on the outer edge of the hypertrophic labia is excised. Much like a geometric cone-shape, the wedge is smaller at the base of the labia, and larger at the outer edge of the labia. Another way to visualize this would be the section of a round clock from twelve o’clock, to three o’clock (in some instances the wedge can be smaller, or larger, depending on the individual case) with the inner point or apex of the wedge being at the center of the clock. The edges of the incision, (superior edge—upper, and inferior edge—lower edge) are then closed together and sutured, thus removing excess labial tissue and preserving the remaining outer, existing natural edge of the labia. This technique yields a very good result and reduces the effects of nerve damage to the external edges of the labia, as they are outside the area of excision, and usually reduces any chance of blood supply loss/constriction to surrounding tissue. Additionally, as no “new” labial edge is created, many women consider the post-operative appearance to be more “natural.” The downside of this technique is that it requires considerably more surgical skill to mesh the outer remaining edges of the labia, together, and requires a skillful eye to determine on the initial tissue markings just how much tissue will retract, when excised—thus if not executed correctly, there is a chance of tissue coming apart/separation at the sutures (dehiscence), and/or pain if drawn too tightly. In experienced hands, a “Y” modification of this procedure may be performed, neatly reducing the size of redundant clitoral hood tissue, if desired.
Z-plasty Technique (variation of Modified V Wedge above)—
The Z-plasty technique is utilized as a modification of the V-wedge incision, to allow for an additional excised area adjacent to the V-wedge . . . hence the term being applied as a “Z” shaped incision with an additional excised tissue area as described. Sometimes, depending one individual case, where more labial tissue is present in perimeter regions of the vulva, a Z-plasty, or even a further modification of the incision (“W” shape incision) to address these outlying areas, is beneficial. Typically this technique is used when there is excessive labial tissue at the perimeter junctions where the labia inserts at the prepuce (clitoral hood) and perineum (area between rectum and vaginal orifice).
Superior-inferior pedicle flap Technique—
Another modification of the V-wedge Technique whereby an incision much like a more open “V” incision is made, in this case from the higher extending point of the labia (superior aspect), to a lower extended point of the labia (inferior aspect), and the higher exposed incision area is drawn down to the lower area and sutured together.
3) Stem-Iris Scissors Technique—
A technique utilizing skill sets and instrumentation specific to a process whereby care is taken to not alter labial tissue by stretching it unnecessarily during mark-up and surgery, thereby yielding unintended results. In this case, Iris or similar scissors are used because of their delicate design, and detailed attention is paid to anesthesia, hemostasis and tissue planes. The instruments, commonly used in Ophthalmology and eye surgery, are so delicate they enhance the surgeon’s ability to achieve natural-appearing results. A complicated series of ancillary “mini-techniques” that will affect final outcome, this procedure is performed by only a select few experienced surgeons who have developed an “eye” for what will yield specifically good results—after extensive experience. Generally, proper patient selection is key, as are computer images that usually aid the surgeon in determining best approach. Anesthesia is administered inside of intended incision lines and particular attention is given to bleeding and stopping such flow immediately—stasis of small capillary “bleeders,” that can alter tissue in a negative manner—stretching it and yielding an undesirable result from too much tissue being removed. This technique is a modification of linear resection.
4) De-epithelialization Technique—
Used by only a small number of very, very experienced surgeons, this technique preserves the natural rugosity (being folded or wrinkled) of the labial minora edge completely. With this method, an incision of elliptical shape is made in the inner wall of the labia through to the exterior side, and this “eye-shaped” area is removed. The remaining edges are then sutured together. The greatest problem with this technique is that it might result in severing of the neuro-vascular connections to the upper, remaining labial edge, causing feeling loss and possible restricted blood supply to the labial edges. If not done properly, results can undesirable or very bad.
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