Current Perspectives in Labiaplasty: A Review of Physical, Aesthetic and Psychosocial Aspects
Igor Leonardo Padovesi Mota*, Beatriz Grassetti Martins da Costa, Marcos Latarini Peres,
Ollivia Frederigue Ferreira, Paulo Cezar de Oliveira Junior, Barbara Bevilacqua Zeiger

*Correspondence to: Igor Leonardo Padovesi Mota. MD. Instituto de Cirurgia Íntima. São Paulo, Alameda dos Aicás 104, São Paulo – SP, Brazil, CEP 04086-000.

Copyright   

© 2024 Igor Leonardo Padovesi Mota. This is an open access article distributed under the Creative Commons Attribution  License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 02 February 2024

Published: 28 February 2024

Introduction

Labiaplasty, also known as nymphoplasty, is a surgical procedure that involves reducing or remodeling the labia minora. This surgery is performed with the aim of improving the aesthetics of the female genital region or relieving physical discomforts caused by large or asymmetrical labia minora. The labia minora are usually considered hypertrophic when the distance between the base and the edge is greater than 1 centimeter, and hypertrophy may or may not extend to the clitoral hood. The etiology of hypertrophy of the labia minora or stretching of the labia minora is multifactorial and can be congenital or acquired due to a chronic local inflammatory process, extreme weight gain and endogenous or exogenous hormonal action (use of androgens). Labiaplasty is a cosmetic procedure that removes of excess of the labia minora aiming to have an harmonic aspect of the vulva. This is a procedure performed mainly by gynecologists and plastic surgeons, with a significant increase in demand in recent years. Brazil is a world leader in numbers of the so-called labioplasty, nymphoplasty, or surgery to reduce the labia minora.

Keywords: labiaplasty, labia minora hypertrophy, cosmetic vulval surgery.

Motivations to Perform a Labiaplasty

The motivations to perform a cosmetic surgey such as labiaplasty may vary among women. Some of the common reasons why a woman may choose to perform this procedure include physical discomfort (irritation or friction when performing everyday activities such as exercising, wearing tighter clothes or bikinis; discomfort during sexual intercourse; difficulty for sanitizing the vulva) and psychological discomfort, given that the embarrassment with the appearance of the vulva may significantly affect a woman’s self-esteem. The patient seeking labiaplasty should be carefully assessed by the professional, aiming to address her physical and psychological concerns rather than adhering to beauty standards.

Development and Evolution

Vulvar surgery that is mostly cosmetic-driven, such as labiaplasty, represents a relatively recent field of research and medical practice. The first case report was described in 1978.

In recent decades, cosmetic vulvar surgery has emerged as a growing field, gaining greater popularity and becoming a widespread practice worldwide. The potential causes for such a shift may include increased access to the internet and social media, heightened exposure to diverse bodies and various types of vulva through pornography, and greater awareness of this procedure, which many women were previously unaware of.

The practice of cosmetic genital surgery has motivated ethical and regulatory debates. Medical organizations and professional societies have established guidelines for responsible practice. However, publications in this field of knowledge are still scarce, and further studies are needed regarding the efficacy, safety, and physical as well as psychological implications for women undergoing labiaplasty.

Preoperative, Procedure, and Postoperative

During the preoperative evaluation, the surgeon should conduct a thorough assessment of the patient and discuss in detail her motivations and expectations. The procedure can be performed under local anesthesia with or without sedation, either in the operating room or outpatient clinic, depending on patient preference and convenience, as well as the surgeon’s expertise. Pen marking on the skin is mandatory, in order to promote a satisfactory aesthetic result and avoid excessive removal of tissue. Careful incisions are made on the labia minora, often including the clitoral hood, and excess tissue is removed. Various surgical techniques are described, all with the aim of removing excess skin while preserving the function and sensitivity of the region.

It is crucial to keep in mind that labia minora are not perfectly symmetrical and possibly play a role in the defense mechanism against the invasion of bacteria and fungi, preventing vulvovaginitis. Various labiaplasty techniques exist, varying according to the anatomy and complaint of each patient, and the expertise of the surgeon with each technique. Excision of excess skin is not restricted solely to the labia minora; it can extend to the clitoral hood and the perineum, often requiring removal. The procedure aims to improve patient satisfaction by addressing both aesthetic concerns and functional implications that lead to impaired quality of life.

A study conducted in France, analyzing the experience of 163 women undergoing labiaplasty, concluded that reducing hypertrophy of the labia minora resulted in aesthetic improvement in 91% of patients and relief of discomfort in 96%. Surgeons considered the results satisfactory in 96% of cases, emphasizing patient satisfaction as the primary goal. Complications, such as wound dehiscence (observed in 7% of cases) and temporary dyspareunia, were noted but did not significantly impact overall satisfaction. The high rates of procedure satisfaction support its indications, emphasizing the importance of careful patient selection. The study advocates labia minora reduction for cases involving aesthetic or functional concerns. The described technique, which preserves the free pigmented edges and adapts flap size based on symptoms, yielded positive anatomical results. Additionally, the article highlights the importance of adjusting flap size based on the patient’s symptoms. 

Ethical and Legal Issues

Female aesthetic surgery raises ethical debates that encompass issues related to patient autonomy, beauty standards, risks and benefits, and the motivations behind these procedures. The decision to undergo cosmetic surgery is deeply personal, and ethics dictate the importance of ensuring that patients have full autonomy and the ability to make informed decisions. Surgeons must provide clear and objective information, enabling patients to make knowledgeable choices. The influence of society and the media significantly contributes to shaping a distorted perception of beauty, presenting important ethical issues within the context of aesthetic surgery. This underscores the necessity of considering how such procedures can both reinforce and challenge current aesthetic standards. Faced with these complex ethical issues, health professionals bear the responsibility of critically addressing this phenomenon, adopting sensitive and thoughtful approaches that account for the psychological, social, and ethical impacts involved. This reflection is essential to promote an ethical and informed medical practice, aware of the ethical challenges inherent in aesthetic surgery within a complex sociocultural context.

Like any medical procedure, cosmetic surgery may pose risks or complications. Therefore surgeons have a crucial responsibility to provide comprehensive information to patients about inherent risks and possible complications, respecting patient autonomy and informed consent. An ethical approach should always include a balance between the pursuit of aesthetic improvement and ensuring the safety and well-being of patients. The importance of objectively, honestly, and realistically explaining expectations becomes paramount in disclosing information, ensuring that potential patients are fully informed about the risks involved and closer to more realistic results.

Currently, there is no consensus on the aesthetic standards and the cases for which labia minora hypertrophy surgery should be indicated. These ethical discussions are fundamental to ensure that aesthetic surgery is performed responsibly, respecting the well-being and autonomy of patients. Health professionals, medical societies, and legislators continue to debate and develop ethical guidelines to guide the practice of cosmetic surgery.

Legal guidelines for cosmetic gynecology procedures vary considerably worldwide. In general, regulations impose strict requirements on surgeons, mandating proper registration and certification to ensure their qualifications. Obtaining informed written consent is an essential aspect, ensuring that patients are fully informed about proposed procedures, including risks and benefits, before making a decision.

Advertising related to cosmetic surgery is subject to specific ethical requirements, must be accurate and avoid misleading promises. Imposing a minimum age for procedures aims at ensure the ability of patients to make informed decisions. Postoperative responsibility, including proper follow-up and treatment of possible complications, is an essential commitment of surgeons, as well as proper documentation of procedures, including pictures. Moreover, protecting patient confidentiality is a primary concern.

Complications

Like any surgical procedure, labiaplasty carries inherent risks and potential complications. Haematomas, bleeding, edema, local infections, and dehiscence are the most common complications associated with labiaplasty and can be partially mitigated through proper surgical technique, hygiene and appropriate post-opperative care. Changes in sensitivity in the vulva after labiaplasty are uncommon but have been reported, ranging from increased to decreased sensitivity.

Some assymmetry in the labia minora may persist after surgery and should be addressed before the procedure. Some patients may experience prolonged postoperative discomfort or pain. Unsatisfactory results, divergent from patient expectations, can lead to dissatisfaction. Anesthetic complications, such as systemic reactions or toxicity from high concentrations of anesthetics, are important considerations. Serious complications, such as excessive removal causing amputation of the labia minora may result from lack of expertise and adequate anatomical knowledge by the professional, often due to excessive excision of tissues. This review emphazises the importance of a cautious and informed approach when considering labiaplasty, recognizing both the physical and aesthetic benefits and the inherent risks of the procedure.

Images 1, 2, 3 and 4: examples of labiaplasty with clitoral hood reduction.

Images 5 and 6: examples of labiaplasty with clitoral hood reduction (frontal view)

Conclusion

It is crucial to consider that each patient has individual motivations and expectations, and before undergoing a labiaplasty, a thorough evaluation must be performed by a plastic surgeon or gynecologist who is experienced in cosmetic gynecology procedures. The decision for surgery should be made only after considering personal motivations, medical issues, and a detailed consultation with a specialist. Choosing an experienced and qualified surgeon, adhering to postoperative instructions, and attending follow-up appointments are critical steps to ensure proper recovery and minimize risks.

In summary, this review aimed to provide a comprehensive overview of the medical, aesthetic, and psychosocial aspects associated with this procedure. The current evidence indicates a growing demand for labiaplasty in recent years, driven by multiple motivations including physical discomfort, embarrassment, sexual dissatisfaction, aesthetic concerns, and the pursuit of improved quality of life.

While significant benefits such as enhanced self-esteem and psychological well-being have been largely reported, it is imperative to acknowledge the potential risks and complications associated with this procedure, as well as create realistic expectations before the decision for surgery. Further studies in this field are urgently needed to keep up with the growing demand for such surgery in recent years.

References

1.AMERICAN SOCIETY OF PLASTIC SURGEONS. Labiaplasty. [Internet]. 2020. Available from: https://www.plasticsurgery.org/cosmetic-procedures/vaginal-rejuvenation/labiaplasty. Accessed November 3, 2023.

2.JEFFCOATE N. Hypertrophy of the labia minora "Spaniel ear nymphae." In: Principles of gynaecology. 4th ed. London: Butterworths; 1975. p. 151.

3.ROSEN R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26(2):191-208.

4.WARE JE JR, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care. 1992;30(6):473-483.

5.BEAUCHAMP TL, Childress JF. Principles of Biomedical Ethics. Oxford University Press; 2019.

6.AGARWAL S, Kim JJ. Ethical considerations in female genital plastic and cosmetic surgery. Int Urogynecol J. 2014;25(12):1637-1641.

7.SARWER DB, Crerand CE. Body image and cosmetic medical treatments. Body Image. 2005;2(1):95-104.

8.ISAPS (International Society of Aesthetic Plastic Surgery). Code of Ethics. [Internet]. 2022. Available from: https://www.isaps.org/wp-content/uploads/2018/10/Code-of-Ethics.pdf. Accessed November 3, 2023.

9.MOYAL-BARRACCO M, Bouchard J. Labiaplasty: plastic surgery of the labia minora. In: Aesthetic and Reconstructive Surgery of the Labia Minora. Springer; 2007. p. 1-10.

10.OSTRZENSKI A. Labia minora reduction: experience in 100 consecutive cases. Plast Reconstr Surg. 1997;100(2):479-489.

11.MUNHOZ AM, Filassi JR, Ricci MD. Aesthetic labia minora reduction with inferior wedge resection and superior pedicle flap reconstruction. Aesthet Plast Surg. 2012;36(3):638-643.

12.SHARP G, Coleman N, Hovsepian R. Perioperative complications of labia minora reduction. Aesthet Surg J. 2010;30(3):409-414.

13.BUCKNOR A, Chen AD, Egeler S, Bletsis P, Johnson AR, Myette K, Lin SJ, Hamori CA. Labiaplasty: Indications and Predictors of Postoperative Sequelae in 451 Consecutive Cases. Aesthet Surg J. 2018;38(6):644-653.

14.LISTA F, Mistry BD, Singh Y, Ahmad J. The Safety of Aesthetic Labiaplasty: A Plastic Surgery Experience. Aesthet Surg J. 2015;35(6):689-695.

15.IGLESIA CB, Yurteri-Kaplan L, Alinsod R. Female genital cosmetic surgery: a review of techniques and outcomes. Int Urogynecol J. 2013;24(12):1997-2009.

16.HONOR L, O'Hara K. Benign Enlargement of the Labia Minora: Report of Two Cases. Vol 8. 1978.

17.GARCIA B, Scheib S, Hallner B, Thompson N, Schiavo J, Peacock L. Cosmetic gynecology - a systematic review and call for standardized outcome measures. Int Urogynecol J. 2020 Oct;31(10):1979-1995.

18.ROHDEN, F. A Divulgação Da Cirurgia íntima No Brasil: Normas De Gênero, Dilemas E Responsabilidades No Campo Da Cirurgia Plástica Estética. Cad. Sau?de Pu?blica 2021; 37(12).

19.INTERNATIONAL SOCIETY OF AESTHETIC PLASTIC SURGERY. ISAPS international survey on aesthetic/cosmetic procedures performed in 2019.