The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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94 Aesthetic Abdominal Surgery in Men: BodyBanking with
Autologous Fat Contouring and Silicone Six-Pack Implant
Augmentation
Jordan D. Frey and Douglas S. Steinbrech
Abstract
The highly defined, athletic abdominal musculature, or ´six-
pack,” is highly sought after in the male population. This phy-
sique can now be achieved surgically through autologous as well
as implant-based techniques. In our BodyBanking technique,
selective abdominal liposuction is performed to strategically
place depressions outlining the existing rectus abdominis,
abdominal obliques, serratus anterior, and inguinal furrow, with
subsequent fat grafting over the rectus and serratus musculature.
Alternatively, a sleek, contoured abdominal appearance can be
achieved through insertion of implants in the rectus abdominis
subfascial muscular pocket, providing an anatomically accurate
“silicone six-packµ augmentation. Thus modifiable and natu-
ral-appearing muscular enhancement in patients lacking muscle
bulk can be achieved through these unique techniques, which
can be individualized according to patient desire and anatomy.
Keywords
liposuction, contouring, fat grafting, abdomen, BodyBanking,
massive weight loss, lipectomy, lipocyte extraction, CATCH
(Compensatory Adipo-Trophic Cellular Hypertrophy), ectomor-
phic, mesomorphic, endomorphic, MuscleShadowing, silicone
six-pack, abdominal, abs, rectus abdominis, muscles, silicone,
implant, contour
94.1 Introduction
The rectus musculature extends from the level of the xiphoid
to the pubis and is typically divided into three to four segments
by tendinous inscriptions. Ideal male abdominal anatomy has
remained relatively constant throughout history, especially with
regard to the ideal male abdomen. This is as evidenced by the
findings of males with defined rectus abdominis musculature
on ancient Greek urns as it is by the statue of David in Florence.
Even in modern times, a sculpted male midsection is a sign of
athleticism, youth, and strength.
Many men of varying ages present desiring enhancement or
rejuvenation of their abdomen. The majority of these patients are
health-conscious and have devoted time and effort toward achiev-
ing the ideal abdomen through diet and exercise. The ideal body
fat percentage at which clear definition of the rectus abdominis
will be attained is not known. However, anecdotal evidence sug-
gests that this may occur near 8 to 15% body fat, with appropriate
muscle bulk. Of note, Centers for Disease Control and Prevention
data demonstrate that mean body fat percentage in the United
States ranges from 22.9% in men aged 16 to 19 to 30.9% in men
over 60. Thus a sculpted abdominal contour is difficult to achieve
in even the most devoted patients, especially in the aging male.
Surgical techniques for enhancing the male abdomen include
both autologous and implant-based methods. Power-assisted
suction lipectomy of the abdomen can selectively outline the
abdominal musculature by creating depressions at the outlines of
the rectus abdominis, abdominal obliques, serratus anterior, and
inguinal furrow while also removing excess adipose tissue. This is
particularly effective when performed in a superficial and deep
plane; however, this is most technically demanding with a steeper
learning curve. Results with this method are greatly enhanced
through the technique of BodyBanking, in which autologous fat
is selectively injected over the rectus abdominis and serratus
musculature. Alternatively, six to eight silicone gel implants
may be placed after precise pocket dissection, typically using a
hidden umbilical incision, in an implant-based “silicone six-pack”
technique to enhance abdominal contours. Each technique pos-
sesses unique advantages in achieving an ideal and natural male
abdominal aesthetic and can be tailored to the individual patient’s
goals, desires, and anatomy.
94.2 Indications and
Contraindications
The ideal patients for autologous BodyBanking are men with
mild to moderate excess adipose tissue around the trunk who do
not have pronounced muscular development of the abdominal
wall musculature. Patients with severe excess adiposity are not
good candidates, as this is primarily a contouring procedure
rather than a fat reduction procedure. Such patients are better
served with localized or circumferential liposuction as dictated
by exam, and possibly BodyBanking as a staged procedure.
Conversely, ideal candidates for six-pack implants are generally
lean young men with insufficient adipose for BodyBanking to the
abs. These are typically active patients with good muscle tone
who have had difficulty achieving a sculpted abdominal appear-
ance. Patients with this body type will have a flat abdominal
contour with a greater amount of adiposity overlying the inferior,
suprapubic portion of the rectus musculature compared with
the superior portion. Further, the superior portion of the rectus,
which inserts into the xiphoid and costal cartilage, may be more
prominent due to the adjacent bony support.
There are a subset of patients with complete disarray to the
fascial inscription architecture which the senior author (DSS) has
deemed “spaghetti abs.” Patients who have a “spaghetti” abdomen
may not be suitable candidates for subfascial abdominal six-pack
silicone implant augmentation, as subfascial implant placement

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94 Aesthetic Abdominal Surgery in Men
will follow the abnormal course of the native rectus musculature.
These patients are therefore better candidates for autologous
BodyBanking, in which contour can be placed to follow the ideal
rectus anatomy, or implant placement in a suprafascial, subcuta-
neous plane, which can be performed carefully but is not ideal.
Fig. 94.1 represents patients with spaghetti abs. These patients
present to your office with very little abdominal definition despite
a very lean physique featuring minimal abdominal fat. Their rectus
abdominis configuration is characterized by very disorganized
attachments of the rectus fascia to the linea alba, semilunaris,
and transverse inscription, leading to the term spaghetti abs as
analogous to the disordered array of tendons seen in the classic
“spaghetti wrist injury.”
Fig. 94.2 represents the contrast in patients for BodyBanking
versus silicone abdominal implants. Fig. 94.2a,b represents a
more mesoendomorphic candidate with good muscle tone and a
moderate layer of fat, which is ideal for abdominal sculpting of
the linea alba, semilunaris, transverse inscription, and superior
obliques with the addition of BodyBanking lipocyte to highlight
the rectus abdominis and superior obliques. In contrast, Fig.
94.2c,d represents a lean, ectomorphic patient who is an excellent
candidate for silicone augmentation within the fascial pocket of
the rectus abdominis.
94.3 Pertinent Anatomy
The rectus abdominis is a paired muscle extending from the
xiphoid and costal cartilages of the fifth to seventh ribs superi-
orly to the pubis inferiorly. The anterior rectus sheath runs along
the entire course of the muscle while the posterior rectus sheath
runs superiorly to the level of the arcuate line inferiorly. Its blood
supply arises from the bilateral superior and inferior epigastric
arteries, while its innervation is via segmental thoracolumbar
spinal nerves meeting the muscle on its posterolateral surface.
Three to four tendinous inscriptions divide the muscle into three
to four muscular sections on each side, yielding an aesthetic
and sculpted appearance when visible. These inscriptions are
generally at the level of the xiphoid and umbilicus and halfway
between these two landmarks. The midline, straplike rectus
abdominis muscles are flanked by the three-layered muscular
oblique construct consisting of, from superficial to deep, the
Fig. 94.1 (a,b) Patients with “spaghetti abs.” These patients present to your office with very little abdominal definition despite a very lean physique
featuring minimal abdominal fat. Their rectus abdominis configuration is characterized by very disorganized attachments of the rectus fascia to the
linea alba, semilunaris, and transverse inscription, leading to the term spaghetti abs as analogous to the disordered array of tendons seen in the classic
“spaghetti wrist injury.”

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external oblique, internal oblique, and transversus abdominis
muscles (Fig. 94.3).
With this deep anatomy in mind, the surface topography of the
ideal male abdomen can be conceptualized as a series of relative
depressions over areas of muscle insertions along with a series of
elevations over well-developed musculature. Depressions include
the vertical linea alba between the paired rectus muscles, the linea
semilunaris at the lateral edge of the rectus muscles where the
oblique complex inserts into the rectus sheath, and the horizontal
inscriptions in the rectus muscles. Further, an inferior aesthetic
depression is formed as the inferolateral edge of the oblique
muscles rolls over the inguinal ligament and produces a V-shaped
taper running from the iliac crest to the pubis. Elevations include
the rectus abdominis bulges between inscriptions as well as the
serratus muscle bulk over the inferior rib cage, which is often
lacking but can produce a very muscular and athletic appearance
when enhanced.
Superficially, abdominal subcutaneous fat is divided into deep and
superficial layers relative to Scarpa’s fascia. The superficial fat above
Scarpa’s fascia is more dense and vascular relative to the sub-Scarpa’s
fat. Removing the deep fat has less risk of contour deformities but
obviously will also yield less definition as the dense subcutaneous
fat will obscure the fine muscle contours. Thus selective contouring
via liposuction of the superficial fat layer is recommended in addi-
tion to resection of the deep layer of adipose tissue.
94.4 Preoperative Assessment
• Perform a complete history and physical. Patients presenting
for this procedure are generally healthy and do not require
extensive preoperative clearance for surgical intervention.
• Examine the abdominal wall for scars, incisions, hernias, or
asymmetries of the abdominal musculature.
• Assess the protrusion of the abdominal wall. This can be
assessed by asking the patient to flex the abdomen and noting
if the amount of abdominal wall fat changes (intra-abdominal
adiposity will appear less significant with the abdominal wall
flexed). The patient must be counseled that no amount of
liposuction will address intra-abdominal fat.
• Inspect abdominal skin quality; the presence of significant
skin laxity or striae may compromise the aesthetic outcome.
These patients will benefit from adjunctive skin excision.
• Assess for the presence of rectus diastasis, which may result
in a widened appearance when fat is grafted or implants are
placed over the rectus musculature.
Fig. 94.3 The important structures of the abdominal wall anatomy,
which will be emphasized in surgical enhancement of the male abdo-
men: the linea alba centrally, the linea semilunaris laterally, along with
the transverse inscriptions and the upper and lower external obliques
as well as the serratus anterior.
Fig. 94.2 Figures represent the contrast in patients for BodyBanking
versus silicone abdominal implants. (a,b) A more mesoendomorphic
candidate with good muscle tone and a moderate layer of fat, which is
ideal for abdominal sculpting of the linea alba, semilunaris, transverse
inscription, and superior obliques with the addition of BodyBanking
lipocyte to highlight the rectus abdominis and superior obliques. (c,d)
In contrast, a lean, ectomorphic patient who is an excellent candidate
for silicone augmentation within the fascial pocket of the rectus
abdominis.

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94 Aesthetic Abdominal Surgery in Men
• Mark the linea alba and linea semilunaris bilaterally with the
patient flexing. If there is insufficient muscle bulk to palpate
the borders of the rectus, use symmetric approximations of
the ideal contour.
• Assess the position of the inscriptions in the rectus abdominis
when the rectus is flexed, and mark them appropriately. The
inscriptions are commonly asymmetrical, and marking them
according the patient’s own anatomy will produce a more
natural result than attempting to achieve some idealized
geometric pattern. This must be discussed with the patient.
• Perform a pinch test of the abdominal fat to assess subcutane-
ous fat layer thickness. This will determine if the patient will
need both contouring and generalized liposuction in the deep
fat layers, as opposed to contouring alone.
• Discuss the overall plan for the procedure with the patient
during the preoperative visit. Show before and after photos,
highlighting less or more aggressive contouring outcomes to
better assess the patient’s goals. Showing photos of possible
complications will help educate the patient regarding risks.
94.5 Preoperative Planning,
Including Markings
The techniques described herein can be performed under general
anesthesia, local anesthesia with sedation, or local anesthesia
alone provided via the tumescence solution, depending on the
patient’s and surgeon’s preference.
Prior to marking, preoperative photographs and a video are
taken of the patient’s abdomen in repose as well as with the rectus
abdominis muscles flexed. The muscular sections of the rectus
abdominis, whose positions correspond with the proposed areas
for fat grafting or implant placement and whose outline will guide
liposuction contouring, are noted and marked with the abdominal
muscles in repose as well as when flexed and extended.
For BodyBanking procedures, three stab incisions are placed in
the suprapubic area within the underwear line—one centrally and
two laterally. Four incisions are marked inside the umbilicus for
access to the linea alba and the transverse inscriptions. Incisions
are made under the nipples bilaterally to access the upper rectus/
costal margin insertion and the most superior inscription. For
access to the second and third inscriptions, a single incision can
be placed lateral to the rectus muscle at the level of each inscrip-
tion. Finally, one incision is made at the top of the gluteal cleft for
posterior back and flank liposuction (Fig. 94.4).
For implant-based augmentation, a vertical 3.5 cm incision is
marked in the natural crease of the linea alba centrally between
the superior (first) and second set of muscular sections of the
rectus abdominis, and a circumferential incision is marked
around the native umbilicus (Fig. 94.5). Corresponding proposed
pockets for subfascial dissection for ultimate implant placement
with documented dimensions are then drawn.
A final set of preoperative patient photographs and videos with
markings are taken. When BodyBanking, the patient is prepped
circumferentially in the standing position before lying on the ster-
ile operating table prior to induction of anesthesia. For silicone
six-pack procedures, the patient may lay on the operating table
with only the abdomen being prepped, unless adjunctive pro-
cedures on other body areas are being performed. The arms are
abducted on arm boards at 90° from the body. The room should
Fig. 94.4 Incision marks for BodyBanking using umbilical, infranipple,
and two lower incisions, which fall below the patient’s swimming
suit and underwear lines. The senior author (DSS) uses the specially
designed swan neck cannulas to avoid using lateral incisions, enabling
a “scarless abs” result.
Fig. 94.5 The muscular sections of the rectus abdominis, whose
outlines correspond to areas for liposuction and whose convexity
corresponds to the proposed areas for implant placement, are noted
and marked with the abdominal muscles in repose as well as when
flexed and extended.

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XII Body Contouring
be warmed and the patient should be covered with a sterile drape
during induction to maintain normothermia.
94.6 2SerDWiYe 7eFKniTue IRr
Autologous BodyBanking
Abdominal Contouring
The areas to be treated are injected with tumescent solution
of 0.9% saline with 0.1% lidocaine and 1:1,000,000 epinephrine.
Ten minutes should be allowed for optimal vasoconstriction and
analgesia.
Deep layer liposuction is first performed to remove any overall
excess of subcutaneous fat. After adequate deep liposuction is
performed, setting the foundation for the remainder of the pro-
cedure, fine, ´etchingµ liposuction of the superficial layer is done.
Superficial liposuction is performed in the linea alba, linea semi-
lunaris, the V-taper of Adonis’s belt, the horizontal inscriptions
across the rectus muscles, and the serratus insertions superolat-
erally. Care must be taken in superficial liposuction to avoid con-
tour abnormalities, and a smaller cannula size is recommended
until one is comfortable with this procedure. Once the abdomen
and anterior flanks have been treated, the patient is placed prone
and tumescence solution is injected into the posterior flanks and
back. As no contouring needs to be done in these areas, deep or
superficial liposuction may be performed, as long as consistency
is maintained (Fig. 94.6).
All harvested fat is maintained in a sterile container and may be
processed according to surgeon preference as no method has yet
been shown to be consistently superior. For simplicity and ease
of use, we prefer using a metal strainer and gravity separation of
the fat. The processed fat is placed into 20 mL syringes while the
patient is again placed supine. The abdomen is reprepped and
redraped, and the fat grafting sites are remarked as needed. An
18-gauge needle is used to create access ports to the fat grafting
sites over the six-pack and serratus muscles based on preopera-
tive markings. Processed fat is injected via a 1.2 Tulip fat-grafting
cannula (Tulip Medical Products). As in any fat grafting procedure,
it is important to place the graft in small aliquots using multiple
passes for the best take (Fig. 94.7).
In the senior author’s series, the average amounts of lipoaspi-
rate removed were as follows: lower abdomen, 272 mL; muscular
inscriptions, 136 mL; lateral anterior abdomen, 313 mL; bilateral
flanks, 537 mL; upper back, 228 mL. The average amounts of fat
graft placed in the six-pack mounds were 42 mL in each of the
lower mounds, 58 mL in each of the middle mounds, and 55 mL in
Fig. 94.6 (a) The senior author (DSS) uses the specially designed swan neck cannulas to avoid using lateral incisions enabling a “scarless abs” result.
(b) Umbilical access to the third transverse abdominal inscription. (c) Umbilical access to the fourth transverse abdominal inscription. (d) Umbilical
access to the third transverse abdominal inscription. (e) Umbilical access to the third transverse abdominal inscription. (f) Nipple crease access to
the first transverse abdominal inscription. (g) Nipple crease access to the second abdominal inscription. (h) Areolar access to the second abdominal
inscription. (i) Nipple crease access to the second transverse abdominal inscription.

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94 Aesthetic Abdominal Surgery in Men
each of the upper mounds. An average of 31 mL was grafted into
each serratus mound.
The liposuction port sites near the fat-grafted areas (umbilicus,
inscription access sites) are closed with 5–0 nylon. The suprapubic
and gluteal incisions are left open to drain (Fig. 94.8).
94.7 2SerDWiYe 7eFKniTue IRr
Silicone Six-Pack Abdominal
Augmentation
The proposed incisions and pockets are infiltrated with a dilute
lidocaine with epinephrine solution for hemostasis, pain control,
and hydrodissection. The previously marked incisions are then
made, and dissection proceeds bilaterally in a subcutaneous
plane to expose the medial edges of the rectus abdominis fascia.
A 1-cm vertical incision is marked and incised at the medial edge
of the first rectus abdominis muscle pocket. The subfascial plane
is entered through this incision, and the implant pocket is gently
dissected using a tonsil clamp. During this initial dissection,
any medial rectus abdominis perforators must be controlled
to maintain a bloodless field with optimal vision. Progressively
larger urethral sounds are then used to expand the pocket to the
correct size for a ´hand-in-gloveµ fit of the implant, with care
taken to avoid overdissection (Fig. 94.9). A small, lighted retrac-
tor can be used to enhance visualization and obtain hemostasis.
The pocket is rinsed with triple antibiotic solution (cefazolin,
gentamicin, bacitracin), and a MuscleGel implant is then carefully
inserted into the dissected pocket. The implant should fit exactly
into the pocket and, if necessary, can be trimmed and customized
to improve the implant fit, profile, and contour. The implant must
then be secured in its ideal position by placing an absorbable
suture between the anterior surface of the implant and the
Fig. 94.7 The surgeon makes a stab incision using an 18-gauge
needle and then uses a 2-mm abdominal fat-grafting cannula in the
subcutaneous plane.
Fig. 94.8 (a,c,e) A 32-year-old, 5 feet, 11 inches tall, 220-lb., endome-
somorphic man interested in greater definition and projection of his
abdominal musculature. Given his preoperative lack of definition and
availability of adipose tissue for grafting, he was an ideal candidate for
BodyBanking and not a good candidate for silicone six-pack implant-
based augmentation. He underwent BodyBanking with fat extraction
from his flanks, abdomen, and lower chest with autologous fat transfer
to the rectus musculature and upper chest. Suction lipectomy of the
lower chest area was performed last, with this fat being discarded.
(b,d,f) Postoperative results at 35 months demonstrate more defini-
tion to the abdominal area and obliques (serratus stripe), with subtle
improvement to the chest area.

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XII Body Contouring
overlying fascia of the implant pocket. The fascial pocket is closed
using a running 4–0 absorbable suture, and the preceding steps
are repeated for each subsequent abdominal implant to be placed.
Skin incisions are closed in a layered fashion and dressed with
skin adhesive and wound closure strips (Fig. 94.10).
Regardless of the technique employed, dressings will help
to maintain and optimize abdominal contour postoperatively.
Postoperatively, we use strips of Reston foam (3M) placed bilat-
erally to outline the rectus musculature—longitudinally along
the linea alba, extending obliquely in a superolateral direction
from the pubis, along the linea semilunaris laterally, and across
the costal margins and xiphoid superiorly. Transverse foam strips
then isolate and outline the rectus mounds created either with fat
grafting or implants. A larger foam piece is then placed over this
construct as well as over the abdominal wall lateral to the rectus
muscles. All patients are then placed in an abdominal binder or a
surgical garment.
94.8 Ancillary Procedures
In combined implant and autologous cases, after all implants
are placed, adjunctive abdominal liposuction, with or without
fat grafting, can be gently performed to refine, blend, and/
or augment the result. Great care is taken not to damage the
implants or disturb the implant pockets with the cannulas. In
select patients, these techniques may be combined with an
abdominoplasty procedure or other body contouring procedures
to enhance the result. However, these patients must be assessed
to have sufficient skin and tissue quality of the abdomen to
support implants if an implant-based technique is selected. In
implant- and autologous-based cases combined with excisional
techniques, great care must be taken to ensure that the implants
or autologous fat is placed in correct position and that this posi-
tion is maintained throughout the healing process.
94.9 Postoperative Care
The binder or garment is worn continuously, except for bath-
ing, until the first follow-up visit at 3 to 5 days after surgery,
at which time it is removed. After the first postoperative visit,
progressively less compression is required, and the patient may
be allowed to change garments or apply less compression with
the binder. Sponge baths are acceptable until the first postop-
erative visit, after which time showering is allowed. Baths and
swimming are permitted after 3 weeks.
Explicit instructions should be given to avoid any twisting or
bending motion, with patients being advised to logroll as much
as possible while the foam bolsters are in place. This is important
to reduce the risk of skin damage from the adherent foam and
compression dressings. Any unnecessary massage of the abdomi-
nal area is avoided to minimize the risk of graft alteration or loss
as well as implant malposition. Patients should not work out or
strain any abdominal musculature for 3 weeks postoperatively.
94.10 Outcomes 5eVuOWV
94.10.1 BodyBanking with Liposuction
and Autologous Fat Grafting
This technique carries an excellent safety profile with overall
outcomes that are very good. This technique carries a similar
complication profile to any liposuction or fat grafting procedure,
which includes largely asymmetry, contour deformity, fat graft
take, and possible need for revision surgery.
Asymmetry and contour irregularities are the result of
nonuniform liposuction or fat-grafting techniques, especially
in the superficial plane, and occur in the range of 6.7. :hen
encountered and adequate time for healing has been allowed,
the treatment is revision liposuction or fat grafting, depending
on the deformity encountered. Seroma formation, which is more
common in obese patients, is the most common complication, at
approximately 13%, and is treated with ultrasound-guided aspira-
tion and closed suction drainage, if persistent. The senior author
has noted a significant decrease in seroma rate after employing
passive drainage via Penrose drains. While seroma can be more
common, hematoma is very rare with a tumescent technique as
described here. If present and clinically significant, the hematoma
should be evacuated surgically to avoid the risk of seroma or
chronic pseudocyst formation. Likewise, skin necrosis with nonul-
trasound or laser-assisted liposuction is rare but can occur due
to overly aggressive superficial liposuction. :hen encountered,
the area of skin necrosis should be managed as any other, either
expectantly with local wound care if superficial or surgically if
large and full-thickness. Infection is rare at approximately 2.2%.
Perhaps the most significant potential complications of this
technique are lidocaine toxicity, venous thromboembolism, and
fat embolism. Careful calculation of the maximal safe dose of lido-
caine is mandatory. While safe doses up to 55 mg/kg have been
reported, it is advisable to stay below this threshold. Neurotoxicity
occurs before cardiac toxicity and arrhythmias, and it manifests
first as perioral tingling, numbness, or dizziness. Maximal plasma
Fig. 94.9 A subfascial implant pocket is created after a small vertical
incision is made in the medial rectus fascia. Initial dissection is under-
taken with a tonsil clamp before passing progressively larger urethral
sounds to complete precise pocket creation.

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94 Aesthetic Abdominal Surgery in Men
lidocaine levels occur at 13 to 18 hours after infiltration; thus
patients must be counseled as to warning signs that warrant an
emergency room visit.
The risk of venous thromboembolism is low with this procedure
given its outpatient nature and generally healthy patient popula-
tion. However, preoperative risk stratification is advised according
to the recently published guidelines. Risk of fat embolism is like-
wise minimal with abdominal fat grafting given the lack of a large
vascular plexus, such as with gluteal fat grafting. Regardless, care
should be taken to minimize risk, such as retrograde fat injection
and care to stay in the correct planes during infiltration.
94.10.2 Silicone Six-Pack Abdominal
Implant Placement
With similarly overall safe and satisfactory results, the most
common postoperative issues with implant-based abdominal
enhancement include transient bruising, swelling, and pain, all of
which can be managed conservatively. More significant compli-
cations include asymmetry, displacement, infection, hematoma,
and seroma. While minor asymmetry lends itself to a more nat-
ural result, risk of significant asymmetry is minimized by careful
patient assessment preoperatively, paired with meticulous intra-
operative implant selection and crafting. Revision and implant
exchange may be necessary if asymmetry is persistent. Mild and
early infection may be managed closely with oral antibiotics;
however, progressive infection requires intravenous antibiotics
with implant removal possible if unresponsive. Hematoma is
rare when care is taken to achieve meticulous hemostasis but
mandates return to the operating room for exploration when
encountered. Seroma is likewise a rare occurrence after implant
placement with precise pocket dissection and postoperative
compression. Careful aspiration of these collections is required
in significant cases.
94.11 Concluding Thoughts
The highly defined, athletic abdominal musculature, or six-pack,
is highly sought after in the male population and can be obtained
through autologous as well as implant-based techniques. With
the BodyBanking technique, selective abdominal liposuction is
performed to strategically place depressions outlining the exist-
ing rectus abdominis, abdominal obliques, serratus anterior, and
inguinal furrow with subsequent fat grafting over the rectus
and serratus musculature. Alternatively, a contoured abdominal
appearance can be achieved through an implant-based technique
via insertion of implants in the rectus abdominis subfascial
pocket, providing an anatomically accurate silicone six-pack
augmentation. Each technique possesses unique advantages in
achieving an ideal male abdominal aesthetic and can be tailored
to the individual patient’s goals, desires, and anatomy. Careful
attention to anatomy and surgical technique with each proce-
dure is essential to achieve an ideal outcome.
Fig. 94.10 (a,c,e) A 27-year-old lean, ectomorphic man who presented
with a request for more projection and definition to his abdominal
musculature, specifically desiring an “eight-pack.” Four subfascial
implants were inserted via the “upper-four” incision hidden in the
midline shadows. The “lower-four” were introduced by the deep
umbilical incision. (b,d,f) Postoperative photos at 23 months.

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XII Body Contouring
Clinical Caveats
Pearls
• Meticulous attention should be given to the accuracy of the
markings; the outlines of the musculature can be very diffi-
cult to delineate after tumescing the tissue planes with the
patient relaxed.
• Lower-profile implants should be used superiorly in the costal
region, where implants will ultimately be placed on top of
the ribs, where there is more structural support for implant
projection. Higher-profile implants may be required in the
midabdomen, where the abdominal viscera do not provide a
stable base for implant projection.
• Liposuction of the suprapubic fat pad can significantly
enhance a patient’s result—plan to treat the suprapubic area
in concert with the abdomen.
• While fat graft take is variable and has been correlated to age,
only minimal overcorrection, is required in our experience.
Pitfalls
• Creating a six-pack abdomen in a patient with visceral adi-
posity or a protuberant abdomen will create an unnatural
appearance. These patients are better served with weight
loss or more generalized liposuction for fat removal, rather
than contouring.
• Patients with excess skin laxity or a history of massive weight
loss are poor candidates for BodyBanking or silicone six-pack
procedures and require skin excision prior to any abdominal
contouring procedure.
• The appearance of overly narrow rectus musculature is very
difficult, if not impossible, to correct. Therefore, err on the
side of defining the lateral rectus border too laterally, which
can be easily corrected, if unsure of the location of the linea
semilunaris.
• Care should be taken with liposuction of the horizontal
inscription at the level of the umbilicus. A seated position will
create a natural crease in this location; additional liposuction
in the same line can create an exaggerated appearance that
may be hard to correct.
• With implant-based techniques, the pocket should not
be overdissected, especially laterally. This will ensure a
“hand-in-glove” fit with appropriate and anatomical implant
placement.
Suggested Reading
[1] Alvarez-Alvarez FA, Gonzalez-Gutierrez HO, Ploneda-Valencia CF. Safe gluteal
fat graft avoiding a vascular or nervous injury: an anatomical study in cadavers.
Aesthet Surg J 2019;39(2):174–184
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95 Male Massive-Weight-Loss Chest Excision
1483
95 Male Massive-Weight-Loss Chest Excision
Omar E. Beidas and Jeffrey Gusenoff
Abstract
In an era of self- or bariatric-driven weight loss, excess tissue of
the chest is a significant problem for males after massive weight
loss. These patients require a unique approach to correct the
chest deformity. The anatomical changes after weight loss are
rarely limited to the chest, and patients often present desiring
multiple combined or staged procedures to contour the body.
While a plethora of less invasive approaches are viable options
for normal weight patients, this chapter focuses on the two
techniques that will be most commonly used in this population:
pedicled reconstruction or free-nipple grafting. This chapter
details the preoperative planning, intraoperative steps, and
postoperative care for each of these procedures.
Keywords
body contouring, chest, free-nipple graft, gynecomastia, male,
massive weight loss, pedicle, pseudogynecomastia
95.1 Introduction
There has been a steady rise in the male massive-weight-loss
(MWL) surgical population because of two factors. First, the
increase in weight loss patients—whether through surgery, diet
and exercise, or pharmacological drugs—has caused an increase in
patients presenting to the plastic surgeon’s office related to issues
with excess skin that cannot be removed by nonsurgical means.
The second reason is the rising acceptance of plastic surgery for
males and the subsequent increase in aesthetic procedures in
men. Since 2000, there has been a greater than 30% growth in the
number of males undergoing chest contouring procedures.
Following MWL, the male is often left with a chest that has a gyne-
comastoid appearance without true features of the disorder, termed
pseudogynecomastia. This is an important distinction to make, as
gynecomastia refers to breast enlargement secondary to glandular
hypertrophy, while pseudogynecomastia is breast enlargement due
to fatty proliferation. There are many ways in which to contour the
male chest, such as liposuction or gland excision, but MWL patients
often require excisional procedures, as less invasive techniques are
insufficient to treat the severe deformity. For patients with mild
skin laxity and nipple malposition, a periareolar donut mastopexy
approach can be applied, but may result in significant pleating and
may require permanent purse-string sutures to prevent areolar
spread over time. Most patients present with high-grade pseud-
ogynecomastia, and less aggressive techniques result in residual
skin laxity that leaves patients dissatisfied. As a largely cosmetic
operation, it is imperative for the surgeon to achieve an optimal
result the first time.
95.2 Indications and
Contraindications
Male patients who present for body contouring must be suit-
able candidates for surgery. A weight loss history is obtained
to determine the method of weight loss, the time of weight
loss onset, and whether the weight is stable (i.e., no more
than a 10-lb. weight fluctuation over a 3-month period).
Comorbidities should be addressed at the initial consult
and reviewed at the preoperative visit. Medical clearances
are obtained and referrals made to specialists as deemed
appropriate.
Contraindications include patients with significant comorbid-
ities that are nonoptimized or unable to be optimized. Smokers
should not undergo chest contouring procedures, as these
patients are at increased risk of wound healing complications.
Hypertension should be controlled as men are often at increased
risk for hematoma in body contouring procedures. The surgeon
is cautioned against operating on patients who have unrealistic
or unreasonable expectations. Relative contraindications to chest
contouring are patients with existing scars that violate tissue
planes which require undermining during the chest contouring
procedure.
95.3 Pertinent Anatomy
The chest wall is composed of several layers, beginning super-
ficially with the skin, subcutaneous tissue, muscle, and bony
exoskeleton, all serving to protect the intrathoracic contents.
Various combinations of subcutaneous thickness exist, and each
patient’s unique anatomy will guide the best operative approach
for that patient. MWL causes unpredictable changes in the soft
tissue characteristics of the male chest as well as downward
descent caused by tissue laxity.
Ideally, the male inframammary fold (IMF) is positioned
at or slightly below the lower border of the pectoralis major
muscle. The proper location for the nipple is at the intersection
of the fourth intercostal space and the lateral border of the
pectoralis major muscle. Alternatively, others have found that
it may be positioned 20 cm from the sternal notch and 18 cm
from the midclavicular point. The nipple should be centered
over an areola with an oval shape, measuring 27 mm along the
long axis and 20 mm along the short axis. The nipple–areola
complex (NAC) is oriented in an oblique fashion with the long
axis extending from a superomedial to inferolateral direction,
or perpendicular to the fibers of the underlying pectoralis major
muscle. The nipple should lie approximately 5 to 6 cm above
the IMF.

1484
XII Body Contouring
95.4 Preoperative Assessment
Preoperative planning begins at the first consultation, at which
time the surgeon will begin to think about the appropriate oper-
ative procedure. The plan is formulated and discussed with the
patient during the visit to give a broad overview of expectations
and limitations. Perioperative and postoperative timelines are
briefly reviewed. It is recommended that the surgeon and patient
meet at least twice before the procedure date. In this manner,
the patient has ample opportunity to develop and ask questions
prior to surgery. The patient may call the clinic to schedule a
follow-up visit should he require additional face-to-face time
with the surgical team or, alternatively, choose a surgical date
and preoperative visit.
At the preoperative visit, an informed consent discussion is
held, the patient asks questions, and consent forms are signed.
Consent includes procedure-specific complications, such as
bleeding; infection; scar; delayed wound healing; seroma; injury
to, malposition, or loss of the NAC; change in sensation; recurrent
skin laxity; blood clots to the legs or lungs; and death. Preoperative
instructions are reviewed and orders for necessary labs, studies,
and medical clearances are provided. Blood thinner medications
are held per surgeon preference and specialist recommendations.
Caprini 2005 scores are calculated to determine the appropriate
deep venous thrombosis prophylaxis regimen. Adequate preop-
erative blood glucose control is essential to decrease the risk of
postoperative hyperglycemia. Gynecomastia surgery alone is
often performed as an outpatient procedure.
95.5 Preoperative Planning,
Including Markings
The physical exam begins with an assessment of the patient’s
chest and anatomical features. Measurements such as sternal
notch to nipple (SN–N), nipple to nipple (N–N), and nipple to
IMF (N–IMF) distances are helpful in guiding treatment. Of
utmost importance is excluding the presence of gynecomastia,
as this may have implications for workup and treatment of such
patients. The physical exam is sufficient to detect the difference:
patients with true gynecomastia will have a firm disc of tissue
in the retroareolar region, whereas patients with pseudogyne-
comastia will not. In MWL patients, most—if not all—the excess
subcutaneous tissue is fatty in nature with significant excess
skin, falling into the category of pseudogynecomastia.
Given the high prevalence of hematoma after male chest
contouring procedures, it is important to optimize patients
preoperatively to minimize the risk of occurrence. Risk factors
for development of hematoma in chest procedures include male
gender, smoking, and hypertension. Multiple studies have shown
a direct correlation between perioperative blood pressure and
hematoma formation in chest procedures.
95.5.1 &ODVViÀFDWiRn SyVWem
In 1973, Simon et al proposed a classification system for gyne-
comastia that is still in use today, with increasing severity
from grade I to IV. In grade I, there is a slight protrusion of the
chest limited to the areolar region, sometimes associated with
increased areolar diameter. Males with grade II show hypertro-
phy of all parts of the breast, with the NAC above the level of the
IMF. Progressing to grade III, the chest shows more significant
hypertrophy of tissues with the NAC at the level of or slightly
below the IMF. In the most severe grade IV deformity, there is
excess skin and significant ptosis, with the 1AC more than 1 cm
below the level of the IMF.
Others have tried to modify this classification system, but most
do not consider the lateral chest and upper abdominal tissue laxity
present in the weight loss patient. A separate classification system
was developed for this deformity based on the degree of ptosis,
lateral chest roll, and upper abdominal laxity and is summarized
in Table 95.1. In this scheme, grade 1 is defined as minimal excess
of skin and fat. The lack of excess tissue laterally subdivides this
this group into 1a as opposed to its presence, which upgrades it to
a 1b. Grade 2 is present in male chests with a NAC and IMF below
the ideal IMF, the presence of a lateral roll, and minimal upper
abdominal laxity, whereas grade 3 patients have significant upper
abdominal laxity.
95.5.2 Choice of Procedure
Procedures fall under the category of liposuction, excision, or a
combination of both. Since male MWL patients mostly present
with grades 2 and 3 pseudogynecomastia, liposuction is gener-
ally inadequate to treat the chest deformity, making excisional
procedures necessary for appropriate management. Therefore,
the main decision to make preoperatively is to choose among the
methods for removing the excess tissue, which differ based on
the vascularity of the NAC. Two main techniques are described: a
nipple as a skin graft or based on a pedicle.
The surgeon assesses the location of the nipple in relation to the
chest wall, as this generally predicates the procedure needed to
relocate the nipple to its appropriate position. This determination
is made based on the distance between the nipple and the natural
IMF. If a pedicle reduction is used, the pedicle must be tucked
subcutaneously in the chest, and it becomes difficult to give the
chest a smooth, aesthetic appearance if there is a long pedicle. An
N-IMF distance greater than 5 cm is an indication that there will
be a significant amount of tissue bulk if the nipple is preserved on
Table 95.1 Pseudogynecomastia classification system using
parameters present in massive weight loss (MWL) patients along with
treatment recommendations
Grade
Description
Treatment
1
Minimal excess skin and fat, minimal
alteration of NAC, normal IMF
Based on
subclassification
1a
No lateral skin roll
Liposuction
1b
Lateral skill roll
Liposuction, direct
excision of roll
2
NAC and IMF below the ideal IMF, lateral
chest roll
Pedicled nipple
reconstruction
3
NAC and IMF below the ideal IMF, lateral
chest roll, significant upper abdominal
laxity
Free-nipple graft
reconstruction
Abbreviations: IMF, inframammary fold; NAC, nipple–areola complex.
Source: Data from Gusenoff JA, Coon D, Rubin JP. Pseudogynecomastia after
massive weight loss: detectability of technique, patient satisfaction, and
classification. Plast Reconst Surg. 2008;122(5):1301–1311.

95 Male Massive-Weight-Loss Chest Excision
1485
a pedicle. Therefore, in most instances, if a patient has an N-IMF
length of more than 5 cm, it is best to perform a direct IMF exci-
sion and move the NAC as a free-nipple graft.
95.5.3 Markings
The first step involves marking the midline chest over the
sternum and the location of the presumed IMF horizontally.
Next, a line is dropped from each hemichest 6 cm lateral to the
midline (midclavicle), usually dropping medial to the NAC. The
appropriate new nipple position is located using landmarks,
placing it at the intersection of the fourth intercostal space and
the lateral border of the pectoralis major muscle. To help keep
from placing the nipple in an overly medialized position, one can
mark the chest meridian as would be done in a breast reduction
and use this as a reference line. The markings then differ based
on whether the NAC will be raised on a pedicle or as a free graft.
Using a ruler, the NAC is marked intraoperatively at 27 mm.
%rRDd-%DVed ,nIeriRr 3ediFOe 7eFKniTue
The NAC is based on a wide-based pedicle emanating from the
IMF. An elliptical pattern is drawn with the base at the previ-
ously marked IMF and encompassing the NAC superiorly, basing
it on an inferior pedicle. At each of the medial and lateral ends of
the ellipse, a Burow’s triangle is drawn that will require excision
to be able to close the incision primarily, while maintaining a
broad-based pedicle of approximately 10 cm. More tissue above
the NAC can be removed as needed based on skin laxity and the
pinch test. It is imperative to keep this flap broad-based and very
thin, to allow it to be tunneled under the upper skin flap and not
result in excessive fullness of the chest (Fig. 95.1).
)ree-1iSSOe GrDIW 7eFKniTue
The extent of excess vertical tissue is determined, and a hori-
zontal pattern of excision is drawn using the previously marked
IMF. A pinch test is used to determine the height of resection
and marked as an ellipse. The resection in MWL patients must
often be carried posteriorly to remove the excess axillary tissue
or, if needed, can be blended into other incisions, such as that of
a brachioplasty or upper body lift. The markings are verified to
ensure that the new N-IMF distance, or the distance from the
nipple to the ideal IMF location, is 5 to 6 cm (Fig. 95.2).
95.6 2SerDWiYe 7eFKniTue
The patient is seen in the preoperative area and consents are
reviewed. Markings, if not made previously, are made and
discussed with the patient. The team brings the patient back to
the operating room, where intermittent pneumatic compression
should be placed prior to induction of anesthesia. The skin is
clipped, prepared, and draped using sterile technique.
95.6.1 Broad-Based Inferior
3ediFOe 7eFKniTueV
The pedicled nipple technique begins with de-epithelializing
the region between the NAC and the pedicle. Next, the Burow’s
triangles are excised down to the chest wall, akin to the medial
and lateral pillars in a female breast reduction. The NAC is then
raised on the central pedicle with a 1 cm thickness coursing
inferiorly to its base. Next, the superior chest skin and subcuta-
neous tissue is raised off the chest wall toward the clavicle. Once
this is complete, the chest flap is thinned by removing a swath
of tissue of similar shape and thickness as the inferior pedicle,
as far as is necessary to position the NAC in its predetermined
new location (Fig. 95.3a,b). This excised tissue must bear similar
characteristics to the pedicle since the pedicle will sit in its place,
so excessive pedicle fullness should be avoided. The area is irri-
gated and hemostasis ensured. The pedicle is then tucked under
the chest flap, and the IMF incision is temporary closed with
staples to secure the base of the incision, holding the pedicle in
place (Fig. 95.3c).
The new 1AC position is verified by sitting the patient up and
checking that the SN–N and midline–N distances are equidistant
from one side to the other. The patient is then placed back in the
supine position, and the NAC cutout is made with the plunger
from a 10 mL syringe (Fig. 95.4a,b). Full-thickness excision allows
Fig. 95.1 A 30-year-old man who lost 130 lbs. with diet and exercise
over a 7-year period. He desired contouring of arms, chest, abdomen,
and thighs. His first stage consisted of gynecomastia correction, lower
body lift, and thighplasty. (a,b) He is a suitable candidate for pedicled
reconstruction technique given his short nipple to inframammary fold
distance. (c,d) Markings for a broad-based inferior pedicle technique,
showing the ellipse that encompasses the nipple–areola complex on an
inferior pedicle and flanking Burow’s triangles that will be excised full
thickness. (e,f) Results 6 weeks postoperatively show a very aesthetic
result. Scars are slightly red but will fade with time.

1486
XII Body Contouring
this opening to expand to the desired 27-mm-wide areola (Fig.
95.4c,d). The surgeon should be careful to place the nondominant
hand under this skin flap to protect the underlying chest pedicle.
The NAC is grasped with forceps and brought out to its new
location.
A drain is placed and secured in each hemichest. The incisions
are closed with 3–0 absorbable suture in the deep dermis, and a
3–0 or 4–0 absorbable suture in the subcuticular layer. Prior to
placing the dressing, the vascularity of the NACs is checked to
ensure their viability. While rare, should there be poor or ques-
tionable vascularity or venous congestion of a NAC, consideration
should be given to converting to a free-nipple graft. This decision
is best made prior to cutting out the NAC opening so that the
graft can be sewn onto a de-epithelialized surface and not into a
full-thickness defect.
95.6.2 )ree-1iSSOe GrDIW 7eFKniTue
The first step in the free-nipple graft technique involves harvest-
ing the NAC as a full-thickness skin graft. The NACs are thinned
using sharp-curved Iris scissors to optimize take of the grafts.
Each side is preserved in a wet gauze on the back table. After this
is complete, the procedure can move on to the excision of the
excess chest tissue.
The area of planned resection is infiltrated with a dilute solu-
tion of 1:100,000 epinephrine in normal saline. This step may
be performed at the start of the procedure to allow time for the
epinephrine to take effect. The superior incision (anchor line) is
made with a scalpel, and dissection proceeds toward the chest
wall musculature with electrocautery. The area to be resected is
undermined along the chest wall fascia until the desired resection
Fig. 95.2 A 36-year-old man presented after Roux-en-Y gastric bypass with a weight loss of 233 pounds. (a–c) Preoperative anteroposterior, oblique,
and lateral views. (d–f) Preoperative markings. (g–i) Postoperative results at 4 months. There is some widening of the right lateral chest scar due to a
superficial wound dehiscence that healed with local wound care.

95 Male Massive-Weight-Loss Chest Excision
1487
is reached. This may require undermining the abdominal skin.
Using penetrating towel clamps, the estimated area of resection
is continuously checked to avoid undermining beyond the area of
planned resection. The skin is then resected. The wound is irri-
gated and hemostasis is obtained, and the incision is temporarily
closed with penetrating towel clamps. These are replaced with
2–0 absorbable suture in the superficial fascia system layer. A
drain is placed exiting laterally on the chest wall prior to closure.
The deep dermis is closed with 3–0 absorbable suture, and a 3–0
or 4–0 absorbable suture is used in the subcuticular layer.
After the IMF incision is closed, the patient is sat up, and the NAC
position is verified before committing to the location. Symmetry
is assessed using a ruler or suture on a clamp to measure the
SN–N and midline–N distances on each side. The area of planned
1AC position is marked on the chest, and a final visual check is
made from the foot of the operating room table before making
the incision. The cutout for the NAC is then made, measured at
approximately 20 mm to allow for stretch of the tissue; this size
can be drawn using the plunger of a 10 mL syringe. A circular
pattern is de-epithelialized with the instrument of choice, and
each nipple is sewn in place with a 4–0 chromic suture. A bolster
is fashioned using Xeroform, cotton balls, and mineral oil, then
secured with 4–0 nylon suture over the full-thickness skin graft.
95.6.3 2WKer 7eFKniTueV
Another approach was introduced by Thienot et al, who used a
posteroinferior pedicle to treat grade 3 pseudogynecomastia.
Some surgeons use a combination approach with liposuction and
reduction mastectomy for grades 3 and 4 pseudogynecomastia.
An alternative technique described by Hurwitz is termed the
boomerang technique, given the shape of the excision on the
chest wall. Both these methods are similar to the traditional
technique in that the NAC is based on an inferior pedicle.
Fig. 95.4 (a) After temporarily closing the inframammary incision, the
nipple–areola complex (NAC) is measured at 17 to 18 mm using the
plunger end of a 10 mL syringe. (b) The patient is sat up intraopera-
tively to assess the position and symmetry of the NACs. (c) The NAC
cutout is excised full thickness to allow for NAC inset and will stretch
to a final diameter of 27 mm. (d) Final appearance after completing
both sides.
Fig. 95.3 (a) After the pedicle has been defined and the superior flap is developed, this latter flap is thinned to allow for pedicle inset by minimizing
bulkiness. In this picture, the excess is grasped with Allis clamps, and electrocautery is used to remove the tissue. (b) The appearance of the tissue
after all resection is complete. The thickness of the inferior pedicle flap should be similar to that of the removed tissue from the superior flap. (c)
The inferior pedicle will be tucked under the superior skin flap, the linear incision will be closed, and the nipple–areola complex will be brought out
through a cutout on the skin flap.

1488
XII Body Contouring
Finckenstein et al described a technique applicable to milder
deformities, 1a or 1b, involving liposuction of the chest combined
with an obliquely orientated excision along the midaxillary line.
This method treats both the medialization of the nipples and
ptotic chest tissue by lifting the chest superiorly and laterally. The
scar is well hidden by the arm when at the patient’s side.
Readers should use the reading list to access respective technique
papers for chest-contouring procedures involving other methods.
95.6.4 Dressing
Incisions are sealed with skin glue to provide a watertight clo-
sure. Regardless of the method of excision, a compression gar-
ment is applied to the patient’s torso after the procedure. This is
fashioned by placing a soft pad or dressing over each hemichest
and wrapping with a 6-inch Ace wrap.
95.7 Ancillary Procedures
Correction of male gynecomastia in the MWL patient may be
combined with complementary procedures. Most commonly,
chest contouring is simultaneously performed with lower truncal
contouring, either a panniculectomy/abdominoplasty or a lower
body lift. Patients may choose to perform upper body contouring,
combining the gynecomastia procedure with a brachioplasty or
upper body lift, leaving the lower body for a separate stage.
95.8 Postoperative Care
Depending on whether other concurrent procedures are being
performed, patients may be discharged home or admitted over-
night for closer monitoring. If admitted, patients are examined
the following morning and if doing well are discharged home.
Patients are instructed to leave the initial postoperative dress-
ing intact until their first clinic visit, which should be within a
week of surgery. Drains, if used, are removed once the output
is less than 30 mL per day for 2 consecutive days. Patients are
instructed to avoid strenuous activity or lifting, pushing, or
pulling any items heavier than 5 kg for a total of 6 weeks. Driving
may resume if the procedure does not interfere with the patient’s
ability to drive once he is no longer taking narcotic medications.
95.9 Outcomes
Male chest contouring after MWL is associated with very high
satisfaction rates. Patient satisfaction scores after pseudogyne-
comastia correction were 3.8 out of 5, with all patients stating
that they would undergo surgery again. From the perspective of
plastic surgeons, pedicled reconstructive techniques were more
aesthetically pleasing than free-nipple graft options.
95.10 Results
It is well documented that males undergoing body contouring
after weight loss have a higher incidence of hematomas. After
gynecomastia correction, hematoma rates range from 3 to 6%,
not an insignificant percentage. Given the high occurrence of
hematoma in this population, it behooves surgeons to optimize
patients preoperatively. While drains may not prevent hemato-
mas, they may limit physical activity by the patient.
Many differences exist between pedicled and free-nipple graft
techniques. NAC sensation is preserved, albeit sometimes decreased,
with pedicled techniques. Some studies report dysesthesias with
pedicled nipple reconstruction. In contrast, free-nipple graft
techniques leave the NAC insensate due to the grafting nature of
the procedure, although some patients do report sensation to pres-
sure. The appearance of the 1AC also differs based on the method
used, with pedicled techniques more likely to cause puckering or
dimpling and with free-nipple graft techniques having a stuck-on
appearance. With any technique, there is a risk of pigment change
of the NAC, although this is more common after free-nipple grafts.
95.11 Concluding Thoughts
The goal in contouring the male M:L chest is to obtain a flat
chest with a properly located nipple and defined IMF. Several
techniques exist to achieve this end, and it is up to the surgeon
to choose the appropriate method.
Clinical Caveats
• Pseudogynecomastia has a separate grading system that
should be used when referencing the male massive-weight-
loss patient.
• Patients with nipple to inframammary fold distances ≤ 5 cm
are generally good candidates for chest contouring with a
pedicled nipple technique.
• Patients with nipple to inframammary fold distances > 5 cm,
or with significant upper abdominal skin laxity, should be
strongly considered for a free-nipple graft technique
Suggested Reading
[1] Abdelrahman I, Steinvall I, Mossaad B, Sjoberg F, Elmasry M. Evaluation of
glandular liposculpture as a single treatment for grades I and II gynaecomastia.
Aesthetic Plast Surg 2018;42(5):1222–1230
[2] American Society of Plastic Surgeons. 2017 Plastic Surgery Statistics Report.

gery-statistics-report-2017.pdf. Accessed May 15, 2018
[3] American Society of Plastic Surgeons. 1ew statistics reflect the changing
face of plastic surgery.
new-statistics-reflect-the-changing-face-of-plastic-surgery. Accessed May 15, 2018
[4] Beckenstein MS, Windle BH, Stroup RT Jr. Anatomical parameters for nipple
position and areolar diameter in males. Ann Plast Surg 1996;36(1):33–36
[5] Beer GM, Budi S, Seifert B, Morgenthaler :, Infanger M, Meyer VE. Configura-
tion and localization of the nipple-areola complex in men. Plast Reconstr Surg
2001;108(7):1947–1952, discussion 1953
[6] Braunstein GD. Clinical practice. Gynecomastia. N Engl J Med
2007;357(12):1229–1237
[7] Chong T, Coon D, Toy J, Purnell C, Michaels J, Rubin JP. Body contouring in the
male weight loss population: assessing gender as a factor in outcomes. Plast
Reconstr Surg 2012;130(2):325e–330e
[8] Cordova A, Moschella F. Algorithm for clinical evaluation and surgical treatment
of gynaecomastia. J Plast Reconstr Aesthet Surg 2008;61(1):41–49
[9] El-Khatib HA. A single stage liposuction and dermopexy for grade 3b and grade 4
pseudogynecomastia after massive weight loss: an observational study. Int J Surg
2007;5(3):155–161

95 Male Massive-Weight-Loss Chest Excision
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[10] Farkas -P, .enkel -M, Hatef DA, et al. The effect of blood pressure on hematoma
formation with perioperative Lovenox in excisional body contouring surgery.
Aesthet Surg J 2007;27(6):589–593
[11] Finckenstein JG, Wolf H. Chest lifting. Aesthetic Plast Surg 2006;30(3):286–293
[12] Gusenoff -A, Coon D, Rubin -P. Pseudogynecomastia after massive weight loss:
detectability of technique, patient satisfaction, and classification. Plast Reconstr
Surg 2008;122(5):1301–1311
[13] Hurwitz DJ. Boomerang pattern correction of gynecomastia. Plast Reconstr Surg
2015;135(2):433–436
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Plast Surg 2016;40(2):245–255
[15] Hussien M, Lee S, Malyon A, Norrie J, Webster M. The impact of intraoperative
hypotension on the development of wound haematoma after breast reduction.
Br J Plast Surg 2001;54(6):517–522
[16] Ibrahiem SM. Severe gynecomastia: New technique using superior pedicle NAC
flap through a circumareolar approach. Ann Plast Surg 2016;76(6):645–651
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[18] Keskin M, Sutcu M, Cigsar B, Karacaoglan N. Necessity of suction drains in gyne-
comastia surgery. Aesthet Surg J 2014;34(4):538–544
[19] Maetz B, Bodin F, Abbou R, Wilk A, Bruant-Rodier C. Management of weight loss
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[20] Mladick RA, Hunstad JP, Pitman GH, Vogt PA. Male body contouring. Aesthet Surg
J 2006;26(3):307–316
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necomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr
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Surg 1974;27(1):39–41

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96 Thighplasty
Karan Chopra and Jeffrey M. Kenkel
Abstract
Excisional surgery of the thigh has been performed since the
1960s and pioneered by the likes of Ivo Pitanguy, MD, and Ted
Lockwood, MD. With the introduction of bariatric procedures
and the significant weight loss associated with these procedures,
newer, more aggressive techniques have been required to
adequately assess the changes in skin and fat seen. This chapter
highlights the authors’ preferred techniques, with a focus on
efficacy and safety.
Keywords
thighplasty, vertical thighplasty, Lockwood thighplasty, medial
thighplasty, horizontal thighplasty
96.1 Introduction
Body contouring operations such as thighplasty are being per-
formed in higher numbers, mirroring the increase in bariatric
surgery over the last decade. According to the American Society
for Aesthetic Plastic Surgery, thighplasty was among the top
20 most commonly performed operations over the last several
years.
While the traditional thighplasty technique was reported over
50 years ago, the technique has undergone many changes over
the last few decades. The increased volume of these operations
has led to improved anatomical understanding and advances in
surgical technique.
This chapter reviews our experience in managing excess skin
and fat of the medial thigh. It reviews methods to decrease com-
plications while optimizing aesthetic outcomes and longevity of
the surgical results.
96.2 Indications and
Contraindications
Proper selection of surgical candidates is one of the most import-
ant considerations in plastic surgery. During the thighplasty con-
sultation, a thorough history is reviewed and a detailed exam and
analysis are performed. Moreover, a thorough discussion must
take place regarding the anticipated recovery and procedural
risks, and patient expectations must be discussed at length.
The patients can be broadly separated into two groups. The
first group of patients describe excess fullness of the medial thigh
following weight changes associated with pregnancy or aging. The
second group tends to be massive-weight-loss patients.
The non–weight loss patient describes ptosis of the proximally
based medial thigh tissues, most often presenting between the
ages of 35 and 45. Other areas of adiposity may be described.
However, the quality of the thigh skin prevents these patients from
achieving an optimal outcome with liposuction alone. Weight loss
patients present with circumferential thigh redundancy as well
as skin laxity and lipodystrophy in other areas of the trunk and
extremities.
Ideal candidates for thighplasty should have weight stability
for a minimum of 3 months. They have excess skin and a mod-
erate degree of lipodystrophy. The excess skin can be lateral or
anteromedial and may extend down to and below the knees to the
calves. Patients with significant comorbidities, including weight
instability, poorly controlled diabetes mellitus with a hemoglobin
A1c value greater than 7.0, nicotine use, immunocompromise, and
other cardiopulmonary manifestations may not be candidates for
thighplasty. This procedure carries with it a higher risk for sur-
gical dehiscence, seroma/lymphocele, and long-term edema, and
the patient’s general health can certainly impact these risks.
96.3 Pertinent Anatomy
The medial thigh has anatomical characteristics that contribute
to the tendency for this area to be a harbinger of body ptosis
secondary to aging or weight fluctuations. An understanding of
these unique anatomical characteristics enables the surgeon to
successfully manage, excise, and recontour the skin of the inner
thigh.
The medial thigh has a relatively thin dermal component, which
is distinct from adjacent areas, such as the lateral thigh or lower
abdomen. Deeper are two layers of adipose tissue separated by a
superficial fascial layer. This fascial layer is thin and often poorly
defined. The deep layer of the superficial perineal fascia is known
as Colles’ fascia and was described by Lockwood. Colles’ fascia is
deep to the subcutaneous plane of the perineal region and is strong
and anatomically distinct. Colles’ fascia contributes to and defines
the perineal thigh crease. Intraoperatively, Colles’ fascia is identi-
fied by dissection proximally along the adductor muscles up to the
ischiopubic ramus and lateral to the vulvar soft tissues (Fig. 96.1).
Knowledge of the femoral triangle and avoidance of inadvertent
iatrogenic injury is important for prevention of ischemic, venous,
or lymphatic dysfunction postoperatively (Fig. 96.2). The femoral
triangle is located in the upper third of the thigh and several vital
structures pass through it: the lateral cutaneous nerve of the
thigh, the femoral nerve, the femoral artery, the femoral vein, and
the deep inguinal lymph nodes. Its boundaries are superiorly the
inguinal ligament, medially the medial border of the adductor
longus muscle, and laterally the medial border of the sartorius
muscle (Fig. 96.3).
96.4 Preoperative Assessment
Two important factors in the patient presenting for thigh lift are
the degree and extent of skin laxity and lipodystrophy. Non–
weight loss patients may have proximally based skin laxity asso-
ciated with lipodystrophy, prohibiting liposuction as a primary

96 Thighplasty
1491
means to contour the area (Fig. 96.4). As a general rule, most
weight loss patients have redundancy extending beyond the
proximal third of the thigh, limiting the improvement they can
achieve with more traditional techniques (Fig. 96.5). Traditional,
horizontally based techniques in weight loss patients can create
disharmony between the proximal and distal thigh (Fig. 96.6).
96.5 Preoperative Planning,
Including Markings
Body contouring patient markings can be arduous and involved.
Therefore, it is our preference to eliminate using valuable operat-
ing day time in the preoperative holding area; instead, we mark
the patients in the office 1 day prior to surgery. This allows accu-
rate marking without undue time constraints. This also allows
for standardized photography for medical records, preoperative
planning, and outcome assessment.
96.5.1 Classic Medial Thigh Lift
It is important to realize that a classic (Lockwood) medial
thighplasty creates an unnatural marriage between the rigid
Colles’ fascia and the poorly defined Scarpa’s fascia of the thigh.
There is a delicate and fragile balance between taking enough
skin off for a satisfactory result and not creating an overly tight
closure, which predisposes the patient to an unacceptably high
dehiscence rate as well as other complications. This also has to
be balanced with intraoperative positioning.
The patient should be marked in the standing position with
feet shoulder width apart. This positioning allows the surgeon to
appreciate medial and posterior skin requiring surgical excision
and simulates the skin’s intraoperative positioning. Moreover,
the location of lipodystrophy is palpated and marked for lipo-
suction. The femoral triangle should be marked and avoided
intraoperatively.
The markings begin with a line marked from the ischium pro-
ceeding along the inner surface of the buttock fold both medially
and inferiorly to the labia majora. Skin pinch determines the need
for a vertical component based on the degree of thigh laxity. It
is best to mark the proximal excision line under no tension and
minimal abduction as this tends to displace the proposed incision
inferiorly, making it more visible. If the skin laxity extends beyond
the upper third of the thigh, then a vertical component should
Fig. 96.2 The lymphatic system.
Fig. 96.1 Different characteristics of the superficial fascial system depending on body area. (a) Dense and (b) loose connective tissue layers.
a
b

1492
XII Body Contouring
be approximately 5 to 10 cm. The caudal extent of the ellipse is
determined with a lift and place technique.
96.5.2 Vertical Medial Thigh Lift
:eight loss patients often require a different type of incision
than that already described. Vertical incisions use more favor-
able vectors, which decreases tension on the perineal structures
as no vertical elevation and suspension is required. All the
tension is medially and horizontally oriented. This distributes
the tension along the entire, medially oriented vertical incision.
The length of the incision is proportionate to the degree of skin
laxity present. As mentioned, in many patients this will require
an incision that extends down to and below the knee. There is
no vertical elevation or pull and therefore a decreased risk of
recurrent ptosis or traction deformity on the labia majora.
Similar to the classic medial thigh lift, the patient should be
marked in the standing position to allow evaluation of the tissue
ptosis and laxity prior to the patient being positioned supine in
the operating room, which alters the appearance of tissue laxity.
Areas of lipodystrophy are marked and are frequently circumfer-
ential in nature. Important areas to target include the fat around
the knee and the proximal and posteriorly located fat. When not
decompressed, these areas may result in persistent fullness and
an unsatisfactory postoperative appearance. Next, the location of
the desired final medial closure is marked from the knee to the
groin crease. First, the anterior skin is displaced posteriorly, and
the transposed incision is marked. This creates the anteriormost
aspect of the proposed excisional pattern. A bottleneck is created
proximally and anteriorly to account for the decreased mobility
of the proximal thigh due to the attachments of the inguinal liga-
ment to the overlying tissues. This helps ensure that the final scar
is less noticeable and posteriorly oriented. The posterior skin is
mobilized and transposed in a similar manner. The standing cuta-
neous cone deformity (dog-ear) created by the proximal ellipse
is removed superiorly and superficial to the inguinal crease. This
excisional pattern eliminates the need for any vertical elevation of
the thigh skin and thus removes tension from the perineal region
(Fig. 96.7).
96.6 2SerDWiYe 7eFKniTue
96.6.1 Patient Positioning
The patient is positioned in the supine position with the use of
spreader bars for maintaining leg abduction and allowing the
surgeon adequate access to the medial thighs. This is ergonom-
ically more favorable and may reduce cervical spine strain. All
Fig. 96.3 Anatomy of the thigh and lower leg. (a) Anterior and (b) posterior view.
a
b

96 Thighplasty
1493
pressure points are well padded, a urinary catheter is inserted,
and sequential compression devices are placed (Fig. 96.8).
There is a delicate balance between abduction of the thighs for
surgical exposure and how much skin can be removed. The more
abducted, the less skin one can remove.
96.6.2 Classical Thigh Lift
The patient is prepped in the standard fashion from the hips to
just distal to the knees. Liposuction is commonly indicated and
performed first. Excision begins with performing the proximal
incision first, remaining superficial to preserve lymphatics, and
care is taken to avoid the femoral triangle. Dissection proceeds
caudally to the lower, marked incision on top of the deep fascia.
The tension is assessed, and if acceptable, one may commit to
the lower incision and resect the skin between the two marks.
If unclear, isolated vertical incisions may be performed down to
the level of the caudalmost mark. It is imperative to recognize
that Colles’ fascia is 1 to 2 cm beneath and superior to the upper
incision, necessitating 1 to 2 cm of extra skin on the lowermost
mark (Fig. 96.9). Colles’ fascia is identified with lateral traction.
Blunt digital dissection can be performed using a dry gauze
sponge to allow atraumatic exposure of the Colles’ fascia.
If extensive dissection is performed, one can consider drains.
Because there is frequently minimal dead space, we often do not
drain these patients. It is often helpful to approximate the tissues
Fig. 96.5 Traditional weight loss patient with skin laxity from her groin
down to and below her knees.
Fig. 96.6 A patient following massive weight loss and traditional
Lockwood thighplasty. Note the disharmony between the proximal
and distal thigh.
Fig. 96.4 This non–weight loss patient desires contouring of her inner
thighs. Liposuction alone would likely result in further skin laxity and a
poor outcome.
Fig. 96.7 Patient marked for vertically oriented thighplasty.

1494
XII Body Contouring
and tailor tack with staples to help with closure planning. One
has to recognize that the lower incision is longer and that the
additional length needs to be accounted for in the closure. Three-
point sutures are then placed from Scarpa’s to Colles’ fascia. There
is considerable tension in this layer of the closure, but this should
result in the two skin edges being well approximated with little or
no tension. A 2–0 polydioxanone suture is used as the anchoring
stitch. Deep dermal sutures are performed with 3–0 polydiox-
anone, and the final layer is a running subcuticular with 4–0
absorbable, barbed suture. A meshed tape secured with a topical
glue is used as a dressing. The patient is placed in compression.
If the patient tends to perspire, then moisture may accumulate
in the perineal area. This can result in skin maceration and even
fungal infections. A topical powder with or without ketoconazole
may be used to help prevent this (Fig. 96.8).
96.6.3 Vertical Thigh Lift
The patient is positioned as described for the classical thigh-
plasty (Fig. 96.9). The anterior and medial thigh and knee are
infiltrated with our standard wetting solution. If needed, areas
of the lateral thigh can be addressed as well. Patients rarely
Fig. 96.8 (a,b) A 51-year-old woman who sustained a 100-lb. weight loss (c) shown here 9 months following a lower body lift and classic Lockwood
thighplasty.

96 Thighplasty
1495
require a two-staged approach, because there is benefit from the
discontinuous undermining with liposuction and the potential
disadvantage of having a scar plane present at a secondary pro-
cedure. It is important to focus the liposuction posteriorly and
proximally, because this fat is more lobular, and its persistence
may result in a postoperative deformity. Debulking of the knee
area with liposuction is preferred over direct excision, as it
tends to preserve lymphatics in an area at risk for lymphocele
development.
Following liposuction, the anterior incision is made through
Scapa’s fascia. The dissection begins just deep to the superficial
fascia. The saphenous vein should be identified and preserved.
The surrounding fat is rich in lymphatics and is also preserved.
The dissection continues posteriorly and is facilitated by the
prior liposuction. Branches of the saphenous vein are ligated
using cautery or ligating clips. Once the predetermined posterior
mark is reached the proposed posterior incision is confirmed and
tailor-tacked anteriorly. The area is irrigated, and hemostasis is
confirmed. A 15 French closed suction drain is placed through a
separate incision (often the proximal anterior thigh access site
for liposuction). Excision should proceed from distal to proximal,
tailor-tacking the skin in 10- to 15-cm segments. Following resec-
tion, the two skin edges are immediately approximated. As the
resection proceeds proximally toward the anterior extension, the
dissection should proceed superficially to preserve the underlying
lymphatics and neurovascular structures.
A number of different closure techniques have been imple-
mented over the years. Our current preference is to approximate
Scarpa’s fascia with interrupted 0 polyglactin braided suture. The
dermis is then closed with interrupted 3–0 polydioxanone and
the final layer is completed with a 4–0 polydioxanone barbed
subcuticular suture. A meshed tape secured with a topical glue
is used as a dressing. The patient is placed in compression (Video
96.1).
96.7 Ancillary Procedures
When not being performed as an isolated procedure, thighplasty
is most commonly performed in patients following weight loss at
the second stage in conjunction with a flank excision. Our pref-
erence is to avoid performing this procedure with an abdomino-
plasty as the vectors of pull tend to counteract each other. Finally,
we prefer to avoid operating on the upper and lower extremities
at the same time, allowing one pair of unoperated extremities to
aid in mobility during the recovery period. There are exceptions
to every “rule.” These areas may be considered in patients who
have a lower body mass index and have isolated needs.
96.8 Postoperative Care
The patients are observed overnight in an accredited facility
with 24-hour nursing. An indwelling urinary catheter is main-
tained until the following morning. A rapid recovery program
is implemented using intraoperative liposomal bupivacaine.
Principles of multimodal pain control are followed with the use
of COX-2 inhibitors and gabapentin, with opioids being reserved
for breakthrough pain. Chemical thromboprophylaxis and calf
or foot compression devices are maintained. The patients are
ambulated several times that evening and prepared for discharge
the following day in most cases.
Patients should be thoroughly educated about postoperative
expectations and self-care. Compression, mobilization, and
nutrition are stressed. Drains are emptied at home every 8 hours
and removed when output is less than 30 mL for at least 2 days
consecutively. This is usually around 10 to 14 days after surgery.
Compression garments should be worn as often as comfortable
for 6 to 8 weeks postoperatively for edema reduction and oblit-
eration of dead space. Care should be taken to avoid excessive
or asymmetric external pressure, which may lead to ischemia or
asymmetric contours. We also recommend feet and calf compres-
sion as the patients develop dependent edema.
96.9 Complications and
Management
96.9.1 Postoperative Dissatisfaction
There may be many reasons for a dissatisfied patient in the
postoperative period. These may include recurrent skin laxity,
residual localized adiposity, and asymmetry. Managing a
dissatisfied patient requires additional time and reassurance
during visits. Many of these problems should be monitored for
at least 6 months before performing a revision because many
of these initial issues do resolve without surgical intervention.
When revision is required, oftentimes only a minor procedure
is required, but if extensive recurrent skin laxity has occurred,
then a full revision of the previous operation may be required.
96.9.2 :Rund 'eKiVFenFe
Delayed Wound Healing
Thighplasty incisions are at risk for dehiscence because of
motion, pressure with sitting, the degree of tension on the clo-
sure, all combined with the otherwise moist and bacteria-rich
Fig. 96.9 Patient positioned for thighplasty with legs abducted and
supported by spreader bars.

1496
XII Body Contouring
atmosphere of the groin. Small wounds can be adequately man-
aged with local wound care, such as packing. Larger dehisced
wounds, or those with necrosis or signs of infection, may require
operative débridement or the use of negative-pressure wound
therapy.
96.9.3 /ymSKRFeOe/ymSKedemD
Patients following vertically oriented thighplasty are predis-
posed to an increased risk of seroma or lymphocele in the knee
region. This is seen in up to 20% of our patients following this
procedure. It presents as localized swelling in the knee region.
Aspiration results in clear or yellow fluid. Compression and
diuretics are considered. If this fails aspiration and compression
therapy two to three times then marsupialization is performed
and the wound is allowed to heal by secondary intention.
Lymphedema may occur after thighplasty as a combined result
of alterations in lymphatic flow from surgery, postoperative
immobilization, and fluid overload. Management should begin
with ruling out deep vein thrombosis. If deep vein thrombosis is
ruled out by history, physical exam, or ultrasound, then conserva-
tive measures for dependent edema should include elevation and
compression wraps from foot to groin. These patients may also
benefit from diuretics. Persistent dependent edema may persist
for up to 6 months. If it continues beyond 6 months, patients may
be referred to a lymphedema specialist for further evaluation and
management. Long-term edema is seen in up to 5% of our patients
following vertically oriented thighplasty.
96.9.4 Venous Thromboembolism
Deep vein thrombosis or pulmonary embolism is uncommon after
thighplasty but can have catastrophic outcomes. Fortunately,
the majority of thromboembolic events can be prevented with
appropriate prophylaxis. While there are presently no consensus
plastic surgery guidelines, surgeons should refer to the 2005
Caprini Score for appropriate risk stratification and management
guidance.
96.10 Results
Careful preoperative planning, a thorough understanding of the
anatomy, and meticulous surgical technique are essential to
obtaining optimal aesthetic results in thighplasty.
Fig. 96.10 demonstrates our results following a vertical thigh
lift in the setting of post-bariatric weight loss in a female patient.
Fig. 96.11 demonstrates our results following a vertical thigh
lift in a male patient with significant skin laxity and lipodystrophy
in the setting of post-bariatric weight loss. The images demon-
strate the preoperative deformity, preoperative markings, and the
final scar at 5-month follow-up.
96.11 Concluding Thoughts
Thighplasty is a useful procedure in both weight loss and non–
weight loss patients. There are two types of excisional patterns
utilized:
1. Classic horizontal excision (Lockwood)
2. Vertical excisional pattern
It is important to understand where the tension is placed with
each of the techniques to avoid the complications associated with
scar migration and tension on adjacent structures.
While the scars often heal well, the operation does carry with
it morbidity that should be appreciated and reviewed with the
patient.
Fig. 96.10 (a,c,e) A 66-year-old woman s/p 80-lb. weight loss
(b,d,f) shown here 7 months following vertically oriented thighplasty
(patient in video 96.1).

96 Thighplasty
1497
Fig. 96.11 (a–e) A 33-year-old man s/p 120-lb. weight loss who underwent thighplasty 5 months prior.

1498
XII Body Contouring
Clinical Caveats
• Thighplasty patients often present with surface anatom-
ical changes that are a combination of both skin laxity and
lipodystrophy.
• There is a trade-off in thighplasty between adequate resec-
tion of excess skin and tightness of closure, which predisposes
the patient to dehiscence and other complications.
• The femoral triangle should be marked and avoided
intraoperatively.
• Liposuction is often used during thighplasty to enhance the
final postoperative result by removing fat around the knee
and both proximal and posteriorly located fat.
• Compression garments should be worn as often as comfort-
able for 6 to 8 weeks postoperatively, for edema reduction
and obliteration of dead space.
• Appropriate risk stratification and early ambulation should be
implemented to reduce the risk of venous thromboembolic
complications after thighplasty.
Suggested Reading
[1] Constantine RS, Davis .E, .enkel -M. The effect of massive weight loss status,
amount of weight loss, and method of weight loss on body contouring outcomes.
Aesthet Surg J 2014;34(4):578–583 doi: 10.1177/1090820X14528208
[2] Cortez R, Lazcano E, Miller T, et al. Barbed sutures and wound complications in
plastic surgery: an analysis of outcomes. Aesthet Surg J 2015;35(2):178–188 doi:
10.1093/asj/sju012
[3] Cram A, Aly A. Thigh reduction in the massive weight loss patient. Clin Plast Surg
2008;35(1):165–172
[4] Fowler ME, Lockwood TE. Advances in thighplasty. Plast Surg Nurs
1988;8(4):146–149
[5] Gusenoff -A, Coon D, 1ayar H, .ling RE, Rubin -P. Medial thigh lift in the massive
weight loss population: outcomes and complications. Plast Reconstr Surg
2015;135(1):98–106 doi: 10.1097/PRS.0000000000000772
[6] Hatef DA, Kenkel JM, Nguyen MQ, et al. Thromboembolic risk assessment and the
efficacy of enoxaparin prophylaxis in excisional body contouring surgery. Plast
Reconstr Surg 2008;122(1):269–279 doi: 10.1097/PRS.0b013e3181773d4a
[7] Lewis JR Jr. Correction of ptosis of the thighs: the thigh lift. Plast Reconstr Surg
1966;37(6):494–498
[8] Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr
Surg 1988;82(2):299–304
[9] Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a
new concept. Plast Reconstr Surg 1991;87(6):1009–1018
[10] Mathes DW, Kenkel JM. Current concepts in medial thighplasty. Clin Plast Surg
2008;35(1):151–163. doi: S0094–1298(07)00144–7
[11] Michaels J, Coon D, Mulvey CL, Rubin JP. Venous thromboembolism prophylaxis
in the massive weight loss patient: relative risk of bleeding. Ann Plast Surg
2015;74(6):699–702 doi: 10.1097/SAP.0000000000000009
[12] Schwaiger K, Russe E, Heinrich K, et al. Thighplasty: improving aesthetics
through revival of the medial, horizontal procedure: a safe and scar-sav-
ing option. J Plast Reconstr Aesthet Surg 2018;71(4):585–589. doi: S1748–
6815(17)30407–2
[13] Xie SM, Small K, Stark R, Constantine RS, Farkas JP, Kenkel JM. Personal evolution
in thighplasty techniques for patients following massive weight loss. Aesthet Surg
J 2017;37(10):1124–1135 doi: 10.1093/asj/sjx060

Part XIII
Female Genital
Rejuvenation
XIII

(Trang không có chữ)

97 Applied Anatomy in Female Genital Rejuvenation
1501
97 Applied Anatomy in Female Genital Rejuvenation
Franziska Huettner and John G. Hunter
Abstract
Knowledge of the anatomy of the mons pubis, vulva, introitus,
vagina, and perineum is essential to properly diagnose and
appropriately treat aesthetic concerns of the female genitalia.
Keywords
mons pubis, vulva, introitus, vagina, clitoris, clitoral hood, labia
minora, labia majora, perineum
97.1 Introduction
The anatomy of the female external genitalia has been well
described (Fig. 97.1). Detailed knowledge of it is essential to
properly diagnose and treat aesthetic concerns of the female
genitalia by surgical and nonsurgical/minimally invasive means.
The external female genitalia (vulva or vulval complex) is
formed by the mons pubis, labia majora and minora, clitoris
with overlying clitoral hood, vulvar vestibule, hymen (in youth),
external ostia of the accessory glands (Bartholin’s glands, Skene’s
glands, vestibular glands), and perineum. The muscles of the
external genitalia include the superficial and deep transverse
perineal muscle, the ischiocavernosus muscle covering the crura
of the clitoris, and the bulbocavernosus muscle (Fig. 97.2).
The blood supply of the external genitalia is mainly from the
pudendal artery, with its branches to the urogenital and anal
triangles. The internal pudendal artery (branch of the internal
iliac artery) gives rise to the perineal and posterior labial artery,
the main blood supply of the labia minora and majora, as well
as the dorsal artery of the clitoris. The external pudendal artery
(branch of the femoral artery) gives two small branches for the
clitoral hood and two small collateral arteries that communicate
with the posterior system of the internal pudendal artery on the
lateral aspect of the labia minora. The mons pubis is supplied by
the inferior epigastric artery, a branch of the external iliac artery
(Fig. 97.3).
The innervation of the external genitalia is mainly by the
pudendal nerve (S2–S4 level) accompanied by the pudendal ves-
sels. The nerve divides into superficial (posterior labial nerve) and
deep perineal branches (dorsal nerve of the clitoris), providing
innervation to the labia and clitoris, respectively (Fig. 97.4).
While the anatomy of the internal female genitalia (introitus,
vagina) have been well described in the literature, the erogenous
zones, such as the so Graefenberg spot (“G-spot”), although
purportedly relevant for the female orgasm, remain poorly
understood.
The main blood supply of the vagina is through the vaginal
arteries (branches of the internal iliac and the uterine artery),
with the innervation through the uterovaginal nerve plexus as
well as the deep perineal nerve.
Fig. 97.1 Basic gross anatomy of the female external genitalia. (From
Hamori C. Female Cosmetic Genital Surgery. New York, NY: Thieme; 2017.)
Fig. 97.2 Gross anatomy of the clitoris and vaginal introitus. (From
Hamori C. Female Cosmetic Genital Surgery. New York, NY: Thieme; 2017.)

1502
XIII Female Genital Rejuvenation
97.2 Mons Pubis
The mons pubis, or mons veneris, is a convex triangular emi-
nence, largely composed of hormone-dependent, hair-bearing
skin and fibrofatty subcutaneous tissue, superficial to the pubic
symphysis (Fig. 97.5). The mons skin is covered by pubic hair
after puberty, which commonly becomes sparse in old age. The
subcutaneous adipose tissue of the mons is estrogen-sensitive,
resulting in increasing prominence with onset of puberty. The
mons pubis may also enlarge with weight gain or obesity. It
often becomes less prominent with the decrease in estrogen
production accompanying menopause. Pubic rami angle varia-
tion can also contribute to the degree of mons pubis prominence.
The prominence of the mons area, due either to increased fat
deposition or to the angle of the pubic rami, presents often as an
indication for surgical reduction of this area.
The mons pubis is innervated by the anterior labial nerve
branches of the ilioinguinal nerve (first lumbar nerve) bilaterally.
Blood supply to the mons pubis arises from the inferior epigastric
artery, a branch of the external iliac artery.
97.3 ([WernDO GeniWDOiD9uOYD
97.3.1 &OiWRriV&OiWRrDO +RRd
The clitoris (clitoral body) is composed of three erectile tissue
components, the glans, body, and crura. It is embryologically
derived from the genital tubercle and corresponds to the
male penis. The body consists of two fused corpora cavernosa
extending from the pubic arch above to the glans below (Fig.
97.2). The body and glans of the clitoris are covered by the
prepuce or “hood,” which splits into a frenulum on either side of
the introitus and attaches most commonly to the outer aspect of
the upper third of the labia minora. Sometimes the clitoral hood
itself has also been noted to be vestigial, with a lateral clitoral
double-fold arrangement fusing variably with the labia minora.
The clitoral hood varies greatly among individuals, by being
commonly asymmetrical and by either having a smooth or irreg-
ular folded surface. It extends anteriorly and superiorly to the
anterior labial commissure, lateral to the interlabial sulcus, and
represents inferiorly the free edge of the prepuce with extension
down to the junction with the labia minora (Fig. 97.6). The prepuce
(hood) acts as a protective cover over the glans. The glans may be
completely or partially covered. Adjacent to the crus (crura) are
the vestibular or clitoral bulbs, an aggregation of erectile tissue as
an internal part of the clitoris. The vestibular bulbs are located on
either site of the vaginal orifice and united to each other in front
by the pars intermedia. During sexual arousal the clitoris responds
to neurotransmitter-mediated smooth muscle relaxation, which
leads to an increase in clitoral length and diameter. The urethral
meatus can be found at the apex of the frenulum.
The clitoris and clitoral hood are innervated by the dorsal
nerve of the clitoris, which crosses the perineal membrane 2.4 to
3 cm lateral to the urethral meatus. It passes along the perineal
membrane for 1.8 to 2.2 cm to the ischiopubic ramus, where it
transitions to the anterolateral surface of the clitoral body, deep
to the Buck fascia (Fig. 97.4)
97.3.2 Labia Minora
The labia minora (“nymphs”) are two skin folds lacking hair
and subcutaneous fat, located medial to the labia majora and
lateral to the vestibule. Anteriorly, they fuse together to form the
prepuce and frenulum of the clitoris. From there they continue
posteriorly toward the perineal body and either remain separate,
Fig. 97.3 Arterial anatomy of the labia minora. (From Hamori C. Female
Cosmetic Genital Surgery. New York, NY: Thieme; 2017.)
Fig. 97.4 Superficial and deep nerves of the female perineum. (From
Hamori C. Female Cosmetic Genital Surgery. New York, NY: Thieme; 2017.)

97 Applied Anatomy in Female Genital Rejuvenation
1503
attaching to the perineum, or join to form the posterior four-
chette. Depending on where the labia attach to the perineum, the
´labial perineal takeoffµ can be described as either high, medium,
or low (closest to the perineum), with the latter often being
associated with a connected posterior fourchette. Anatomical
variations in size, pigmentation, and thickness among patients
as well as asymmetry between each labia minora are common.
The prominence of the most lateral part of the labia minora may
occur in the upper, middle, and lower third of the vaginal vault.
Protrusion of the labia minora beyond the labia majora is of aes-
thetical concern to many women; hence labia minora reduction
is by far the most commonly requested and performed female
genital aesthetic surgical procedure.
The labia minora differentiate embryologically from the uro-
genital fold and are equivalent to the ventral surface of the cav-
ernosa urethra and the corpus spongiosum of the urethra forming
the median raphe in males. They contain sensitive nerve fibers
and a delicate vasculature, which leads to engorgement during
sexual arousal. The medial surface of the labia minora exhibit
mucosal epithelium within the vulvar vestibule, while the lateral
surface contains squamous epithelium; both areas are divided by
the Hart’s line, which represents an important landmark for the
genital surgeon.
Two arterial sources supply the labia minora, anteriorly the
obturator and the funicular arteries, coming from the external
pudendal artery, while the posterior supply is dominated by the
internal pudendal arteries. Fine branches run perpendicular to the
long axis of the labia, with a confluence beneath the labial edge.
The posterior, or lower two-thirds of each labium, is supplied by
the internal pudendal, while the anterior or upper portion derives
from fine branches of the external pudendal artery, with thin
anastomotic connections in between.
Four main arteries have been described, one dominant central
artery (the “C” artery), traveling perpendicular to the long axis of
the labium with continuation of the course in anterior direction.
The remaining three arteries, two located posterior (first posterior
or “P1” and second posterior or “P2” artery) and one smaller artery
located anterior to the central dominant vessel (the anterior labial
artery or “A” artery), run perpendicular to the long axis of the
labium (Fig. 97.3).
Innervation is by perineal branches of the pudendal nerve,
the genital branch of the genitofemoral nerve, and the posterior
femoral cutaneous nerve.
97.3.3 Labia Majora
The labia majora (singular: labium majus), the outer lips, are
bilateral, longitudinal, hair-bearing, usually pigmented, skin and
subcutaneous fibrofatty and fascial tissue (equivalent to the scro-
tal dartos in males) structures that form the lateral boundaries of
the vulva (Fig. 97.7). They extend from the mons pubis anteriorly,
where they meet and form the anterior labial commissure, to
the perineum/rectum posteriorly, forming the posterior labial
commissure. They are separated medially from the labia minora
by the interlabial sulci, or interlabial fold, and laterally from the
medial thighs by the labiocrural folds. Embryologically, the labia
majora develop from labioscrotal swellings and are homologous
to the male scrotum (Fig. 97.8).
Fig. 97.5 Mons pubis anatomy.
Fig. 97.6 Female vulvar anatomy. (From Hamori C. Female Cosmetic
Genital Surgery. New York, NY: Thieme; 2017.)

1504
XIII Female Genital Rejuvenation
The labia majora are mainly vascularized by branches of the
internal pudendal artery and vein, specifically the posterior labial
and perineal artery/vein. Innervation is by perineal branches of
the pudendal nerve, the genitofemoral nerve, and the posterior
femoral cutaneous nerve (Fig. 97.4).
Progressive atrophy and laxity of the majora commonly occur
after menopause. With aging, skin layer relaxation, stretching sec-
ondary to pregnancy and involution, weight gain or loss, the labial
skin can become redundant and protrude, requiring noninvasive
radiofrequency shrinkage or surgical reduction.
97.4 Perineum
The perineum is the area below the vagina and above the anus,
structured between the ischiopubic rami, ischial tuberosities,
sacrotuberous ligaments, and coccyx. It can be divided into the
urogenital triangle anteriorly and the anal triangle posteriorly
by a line between both ischial tuberosities. The urogenital tri-
angle is covered by the perineal membrane, a connective tissue
layer penetrated by the vagina, urethra, and remaining external
genitalia, and contains a superficial and a deep perineal space
separated through the perineal membrane (Fig. 97.4).
While both spaces contain fat, the Bartholin glands and erectile
bodies with their various muscles and fascias are in the superficial
space. The loss of the fatty tissue with aging, change in weight, or
estrogen loss, can lead to vulvar skin laxity and ptosis.
The vulvar vestibulum (vestibulum, Latin “entrance court”),
bordered by the labia minora, posterior fourchette, and hymenal
ring, represents the entryway from the vulva and perineum into
the vagina.
Fig. 97.8 (a,b) The labia majora are analogous to the scrotum. The labia minora become fused in males (perineal raphe). Wolffian ducts develop in
males, and Müllerian ducts develop in females. Differences develop at approximately 9 weeks’ gestation. In the female, a deep groove forms around
the phallus. The sides of it grow dorsalward as the labioscrotal folds, which ultimately form the labia majora in females. The labia minora, in contrast,
arise by the continued growth of the lips of the groove on the undersurface of the phallus; the rest of the phallus forms the clitoris. The immature
glans becomes the clitoral glans. In the male, the pelvic portion of the cloaca undergoes much greater development, pushing before it the phallic
portion. The labioscrotal folds extend around and between the pelvic portion and the anus and form a scrotal area. During the changes associated
with the descent of the testes, this scrotal area is drawn out to form the scrotal sacs. The penis is developed from the phallus. As in the female, the
urogenital membrane undergoes absorption, forming a channel on the undersurface of the phallus; this channel extends only as far forward as the
corona glandis. (From Hamori C. Female Cosmetic Genital Surgery. New York, NY: Thieme; 2017.)
Fig. 97.7 Labia majora anatomy.
a
b

97 Applied Anatomy in Female Genital Rejuvenation
1505
97.5 Internal Genitalia
97.5.1 Introitus
The vaginal opening is called the introitus of the vagina. The
Latin word introitus comes from intro (into, within) plus ire (to
go), thus “to go into.”
97.5.2 Vagina
The word vagina is a Latin word meaning “a sheath or scabbard,”
a scabbard into which one might slide and sheath a sword.
The vagina is a fibromuscular tube, with the side walls being
suspended by their attachments to the paravaginal lateral
connective tissue containing the vaginal blood supply. The
vagina is shaped like an H, with the upper ending creating two
fornices or vaults, an anterior and a deeper posterior one. The
squamous epithelium lining covers the elastic fibers and the
well- developed fibromuscular layer underneath. :hile there
are no glands located in the lamina propria, vaginal lubrication
is provided by the transudate of the blood vessels as well as
secretions of the Bartholin’s and Skene’s glands. The Bartholin’s
glands (greater vestibular glands) are in the superficial perineal
pouch on each side. They secrete mucus and participate in lubri-
cation during sexual intercourse. This function decreases with
advancing age. Skene’s glands are a pair of periurethral glands,
which lie inconsistently in the anterior vaginal wall beneath the
epithelium proximal to the urethral meatus.
The hymen is the thin fibrous tissue that partially covers the
vagina, leaving an opening for vaginal or menstrual discharge.
The size, shape, and degree of opening varies greatly among
individuals.
Blood supply of the vagina is via the right and left vaginal arter-
ies (branches of the internal iliac and/or the uterine artery), as
well as anastomotic branches of the uterine, inferior vesical, and
internal pudendal arteries.
While the innervation of the vagina predominantly arises from
the autonomic nervous system, parasympathetic and sympathetic
fibers from the uterovaginal nerve plexus (inferior hypogastric
plexus), the inferior fifth receives somatic innervation via the
deep perineal nerve, a branch of the pudendal nerve. There is
evidence of a sensitive area, located 1 to 2.5 cm posterior to the
urethra, typically 2 to 3 cm inside the introitus on the anterior
vaginal wall in the region of the bladder neck, which when stim-
ulated becomes engorged, enlarged, and sensitive, supporting an
orgasmic response—the so-called G-spot. Although purportedly
clinically relevant for the female orgasm, it remains poorly under-
stood, with some anatomists even claiming its nonexistence.
97.6 Concluding Thoughts
Surgeons desiring to establish expertise in surgical and nonsur-
gical genital female rejuvenation procedures must be thoroughly
familiar with the surgical anatomy of the female mons pubis,
vulva, clitoris, labia minora and majora, introitus, vagina, and
perineum.
Suggested Reading
[1] Georgiou CA, Benatar M, Dumas P, et al. A cadaveric study of the arterial blood
supply of the labia minora. Plast Reconstr Surg 2015;136(1):167–178
[2] Hamori CA. Aesthetic surgery of the female genitalia: labiaplasty and beyond.
Plast Reconstr Surg 2014;134(4):661–673
[3] Placik OJ, Devgan LL. Female genital and vaginal plastic surgery: an overview.
Plast Reconstr Surg 2019;144(2):284e–297e
[4] Sokol A, Shveiky D. Glob. libr. women’s med., (ISSN: 1756–2228) 2008; DOI
10.3843/GLOWM.10000
[5] Goodman MP. Female Genital Plastic and Cosmetic Surgery. Hoboken, NJ:
Wiley-Blackwell; 2016
[6] Hamori CA, Banwell PE. Alinsod R. Female Cosmetic Genital Surgery. Concepts,
&ODVVLfiFDWLRQ, DQG 7HFKQLTXHV. New York, NY: Thieme; 2017
[7] Hacker NF, Moore JG, Gambone JC. Essentials of Obstetrics and Gynecology, 4th ed.
Philadelphia, PA: WB Saunders; 2004

1506
XIII Female Genital Rejuvenation
98 Clinical Decision Making in Female Genital Rejuvenation
John G. Hunter
Abstract
Rejuvenation of the vulva or vagina is increasingly sought by
women dissatisfied with the appearance or size of their external
genitalia (labia minora, clitoral hood, labia majora, mons pubis)
or quality of life or functional concerns related to their vaginas
(laxity, decreased erotic sensation, urinary stress incontinence).
Patient selection, surgical and nonsurgical procedure indications,
and potential complications for rejuvenation/alteration of the
labia minora, clitoral hood, labia majora, mons pubis, vagina, and
perineum are offered. .ey considerations regarding anatomical
variations, technique selection, procedural risks, complications,
and revision are presented.
Keywords
female genital rejuvenation, female genital cosmetic surgery,
labiaplasty, labia minora reduction, labia majoraplasty, clitero-
plasty, mons pubis reduction, vaginoplasty, nonsurgical genital
rejuvenation
98.1 Presenting Complaints and
Concerns
Most women seeking alteration of their external genitalia,
perhaps 90%, request procedures on the labia minora. Although
minor functional complaints are common—irritation, pulling,
discomfort in clothing or during exercise or sexual intercourse—in
the author’s experience, the primary motivation is aesthetic: the
women do not like the appearance or are embarrassed by their
minora. The labia are too large, hang out past the labia majora,
bulge or pop out of panties and swimsuits, or are perceived as
unattractive. Labia minora asymmetry, with one lip being signifi-
cantly different in size or shape, is also a common motivator.
Alterations of the labia majora and mons pubis are less com-
monly sought. Labia majora concerns most commonly reported
are ptosis, majora ´deflation,µ and skin redundancy. The women
frequently report dissatisfaction with the “old” or “saggy” appear-
ance of their genitals. Functional complaints are rare. Although
sometimes seen in women in their 20s, the majora surgery patient
cohort tends to be older, as labia majora laxity and ptosis tend to
increase in incidence with advancing age. A minority of women
presenting with labia majora complaints, usually young women,
request augmentation of very flat majora.
Mons pubis alteration, virtually always reduction, is usually
desired by women embarrassed by bulging or sagging of the mons,
especially in form-fitting pants or swimsuits. Again, functional
concerns are rare.
Women desiring vaginal rejuvenation are usually motivated by
quality of life or functional, not aesthetic, issues. Perceived vaginal
laxity or looseness during sexual intercourse, decreased lubrica-
tion and erotic sensation, or functional problems, such as stress
incontinence, are commonly reported. Most women report issues
developing after vaginal childbirth or aging. Requests for vaginal
rejuvenation by younger, nulliparous women are uncommon.
98.2 Patient Evaluation
Although most women consulting for rejuvenation of their exter-
nal genitalia will present with labia minora concerns, many will be
unclear as to what anatomically is bothering them. They state that
they “don’t like” or are embarrassed by the appearance of their
external genitals, which are often described as being “too big” or
having ´too much stuff going on.µ A careful and complete history,
with the patient given adequate time to fully express her concerns,
desires, and expectations, is therefore essential. Regardless of the
stated focus or perceived area of concern, the entire external
genital area should be examined in the lithotomy position, and
if appropriate (labia majora) in the standing position. Mons pubis
patients can usually be examined standing only. Internal exam is
not necessary. Photographs must be taken and evaluated with the
patient in the postexamination discussion. Asymmetries should
be pointed out, along with clitoral hood redundancy/folds, majora
laxity, redundant labial tissue posterior to introitus, if present.
Although higher rates of body dysmorphia have been reported
by some in patients undergoing labiaplasty, in my experience,
the vast majority of women seeking surgery have reasonable
complaints, motivations, and expectations and are very satisfied
with their outcomes. Concern should be raised—and caution
exercised—when severe functional complaints, or unrealistic
expectations (e.g., resolution of sexual dysfunction) are offered.
Women desiring rejuvenation of the vagina or perineum
require complete gynecologic/pelvic examination, and assess-
ment for vaginal laxity and for bladder, rectum, and uterine
prolapse. Additional bladder function testing may be indicated. A
comprehensive history, thorough evaluation of anatomical issues
and procedure planning, and competent technical execution are
essential in achieving optimal outcomes.
98.3 Alteration of the Labia Minora
As indicated, surgical alteration of the labia minora is by far
the most common female external genital procedure sought
and performed today. The indications for surgery are usually
obvious: labia minora that protrude significantly past the labia
majora and are considered too large by the patient. Labia minora
shape and size offer unlimited variations. Surgical procedures
should be tailored to the patient’s unique anatomy.
Although many minora reduction procedures have been
described, they are largely iterations of three techniques: edge
excision (trim), wedge excision, and central excision/de-epitheliali-
zation. Globally, edge excision and wedge excision variants are most
widely performed. Although claims have been made asserting supe-
riority of one technique over another, there is no evidence-based

98 Clinical Decision Making in Female Genital Rejuvenation
1507
literature supporting the claim. The literature suggests that either
technique (and the multiple variants of each), competently per-
formed, will yield satisfactory results and high satisfaction rates for
most women. Technique choice is largely determined by surgeon
and patient preference. In my opinion, however, there are women
who are better served by one of these techniques over the other. The
decision, in my experience and practice, is based on whether the
labial edge should be preserved or removed to obtain the best aes-
thetic result. Women of color and others with pigmented skin often
have darkly pigmented clitoral hoods, labia majora, and minora
edges, but the minora become lighter or pink as they approach the
introitus. Excising the pigmented edges in this cohort can result in
unnatural-appearing labial edges. Wedge procedures, as described
by Alter and others, are preferable for these patients. Conversely, for
many women, the minora edges are a significant part of their dis-
satisfaction, and preserving them results in a suboptimal aesthetic
result. These women have thick, textured, hyperpigmented minora
edges, and benefit is derived from edge excision.
Edge excision techniques are considered technically simpler
than wedge techniques and may be used for minora of virtually
any size or shape. It is also generally simple to extend and excise
lateral clitoral hood folds, when present, without perpendicular
incision lines as occurs with the extended wedge technique. Edge
excision, if not carefully performed, can result in overzealous
resection and labial amputation or near amputation, a dreaded
complication. Edge scalloping is an occasional occurrence.
Prominent edge scars or scar contractures, although reiterated
in the literature, are rarely observed in clinical practice. Minor
wound dehiscence, usually secondary to edema or hematoma,
is not uncommon but, unlike when it occurs with wedge tech-
niques, rarely requires operative treatment. The clitoral frenula, if
detached during minora reduction, should be reapproximated to
avoid subsequent protrusion.
:edge excision techniques, first described by Alter, preserve
the labial edge. The variations are technically more difficult in
most cases, with a greater learning curve, than edge excision. If
overzealously performed, constriction of the vaginal introitus
or wound dehiscence may occur. Wedge excision techniques
frequently require modification to address clitoral hood folds/
redundancy. Incision line dehiscence, frequently a consequence of
excess tension, can be problematic and results in notching of the
minora edges or labial perforation. Surgical correction is required.
I advise waiting 3 to 6 months before revising.
Surgeons desiring to perform labiaplasty should become
competent in several different operative techniques to permit
tailoring the technique choice to each woman’s genital anatomy
and toward achieving the optimal aesthetic result.
98.4 Alteration of the Clitoral Hood
Although occasionally an isolated procedure, clitoral hood alter-
ation is a commonly needed yet often neglected adjunct to labia
minora reduction. Clitoral hood redundancy, when present, may
be in the vertical or horizontal planes, or both. Horizontal excess,
usually redundant hood folds lateral and parallel to the central por-
tion of the clitoral hood, is most common. Folds may be unilateral or
bilateral; asymmetric folds are frequently observed. Vertical clitoral
hood redundancy manifests as elongation or ptosis of the hood.
When present, clitoral hood redundancy should be addressed
during labiaplasty. Horizontal redundancy is usually treated by
vertically oriented excision, parallel to the interlabial sulcus, of
folds or excess skin. Vertical hood excess is usually addressed by
horizontally oriented excision cephalic to the free margin of the
hood. The clitoral glans should not be exposed if covered, and not
further exposed if partially covered.
In my experience, failure to address clitoral hood redundancy
is a common motivator for women to seek labiaplasty revision.
98.5 Alteration of the Labia Majora
Although performed much less often than labia minora reduction,
many women seeking external genital alteration present with
labia majora issues. Majora rejuvenation is most commonly sought
by women unhappy with deflated, ptotic, redundant majora. Labia
majora laxity tends to become more common with increasing
age, so this patient cohort tends to be somewhat older than the
labia minora reduction population. Occasionally women, usually
younger, will present with either fatty fullness of the majora
without skin excess, or with very flat majora without skin excess.
Accurate assessment and a clear understanding of patient
expectations are essential to achieving satisfactory outcomes.
Those presenting with flat majora without skin excess and
desiring fuller majora may be augmented with autologous fat.
Overcorrection should be avoided. Hyaluronic acid and other soft
tissue fillers have also been used. Autologous fat or filler injection
may also be used to ´plumpµ deflated, ptotic majora but in the
author’s experience will often yield an unsatisfactory result.
Redundant, deflated labia majora, in this author’s opinion, are best
treated by reduction rather than augmentation. Surgical excision
of redundant majora results in excellent outcomes.
Although there is a dearth of literature about it, labia majora
reduction and labia minora/clitoral hood procedures can be safely
combined at the same sitting. Experience with both procedures is
advised before attempting a combined surgery.
98.6 Alteration of the Mons Pubis
Women requesting alteration of their mons pubis almost always
are unhappy with its perceived prominence. Bulging, partic-
ularly in tight pants and swimwear, and fatty fullness are the
usual concerns. Some women, particularly older women, will
complain about mons ptosis.
Virtually all mons pubis rejuvenation procedures involve
defatting. It is essential to determine whether skin redundancy
or ptosis is also present. Women, usually younger, presenting
with lipodystrophy of the mons without skin excess or ptosis,
can satisfactorily be treated by suction-assisted lipectomy. Those
with vertical or horizontal redundancy of the mons, or both, will
usually not have a satisfactory outcome with liposuction alone.
Ptosis may even be worsened. This cohort is best treated by
defatting combined with skin excision. Although suction-assisted
lipectomy may be used, I prefer open defatting for these patients.
Skin excision is horizontally oriented if there is vertical mons
redundancy, and both horizontally and vertically oriented (“T”)
when the mons is both long and wide. Overdefatting of the mons
can result in unnatural flatness and should be avoided.

1508
XIII Female Genital Rejuvenation
98.7 Treatment of Labiaplasty
&RmSOiFDWiRnV5eYiViRn
Labiaplasty
Labiaplasty procedures have low complication and high patient
satisfaction rates. Complications can and do occur and can be
very difficult to satisfactorily treat. Overresection of the minora
resulting in amputation/near amputation, and wedge excess
closure tension with subsequent minora wound dehiscence
usually require surgical intervention. Both are best avoided by
conservative resection and are technical errors.
Minor revisions, such as further reduction or correction of
minor asymmetries, are usually straightforward and can gener-
ally be performed 3 months or so after the initial surgery. Minor
dehiscence after edge excision can be sutured immediately.
Wedge dehiscence with resulting notching of the labial edges
is best deferred for 3 months or longer. Complex revisions are
usually best deferred for 6 months or longer and are usually best
undertaken by those with expertise in revisional labiaplasty.
98.8 Nonsurgical Rejuvenation of
the External Genitals
and Vagina
Nonsurgical, minimally invasive procedures, including appli-
cation of laser and radiofrequency technologies, platelet-rich
plasma therapy, and injection of soft tissue fillers, have rapidly
increased in use and popularity for numerous aesthetic and
medical conditions over the past decade. The same is true for
external genital issues (labia majora laxity), vaginal issues
(laxity, stress urinary incontinence), and female sexual dysfunc-
tion (decreased vaginal lubrication, decreased erotic vaginal
sensation, decreased sexual arousal/orgasm).
Moderate to severe labia majora redundancy and vaginal laxity
will have better results when treated with surgical procedures.
However, women presenting with mild majora skin excess, mild
vaginal laxity, dryness, or mild urinary stress incontinence may
experience measurable improvement after treatment with either
radiofrequency or laser technologies designed for genital use.
Complication rates appear low, and results are temporary. Long-
term outcomes or consequences are unknown.
Injection of fillers or platelet-rich plasma into or around the
clitoris or into the anterior wall of the vagina (“G-shot,” “O-shot”)
appear to offer some improvement in erotic sensation and ability
to achieve orgasm for some women. Literature is scanty, and long-
term consequences, if any, are unknown.
98.9 Surgical Rejuvenation
of the Vagina
Although nonsurgical laser and radiofrequency treatments
appear to offer at least temporary improvement for many
women with mild vaginal laxity and urinary stress inconti-
nence, surgical tightening remains the gold standard for lasting
treatment of moderate to severe vaginal laxity and urinary stress
incontinence.
A complete gynecological history and examination are required
for candidates for vaginoplasty. Several operative techniques exist,
and hands-on training with an experienced vaginoplasty surgeon
is absolutely recommended before embarking on surgical vaginal
rejuvenation practice.
98.10 Concluding Thoughts
Women unhappy with the appearance, shape, and size of
their vulva or vagina increasingly seek genital rejuvenation or
alteration. Surgical reduction of the labia minora is by far the
most frequently requested external genital procedure today.
Vaginal laxity, or “looseness” during sexual intercourse, as well
as functional complaints such as stress incontinence, frequently
consequences of childbirth, are the common motivators for
women pursuing minimally invasive or surgical rejuvenation of
the vagina. The women seeking external or internal genital reju-
venation are distinct, occasionally overlapping, cohorts, requir-
ing different evaluations and treatments. Accurate assessment
of patient concerns, anatomical issues, and expectations, and
competent performance of the most appropriate procedure(s),
are essential for successful female genital rejuvenation.
Suggested Reading
[1] Hunter JG. Labia minora, labia majora, and clitoral hood alteration: experience-
based recommendations. Aesthet Surg J 2016;36(1):71–79
[2] Hunter JG. Commentary on: labioplasty: anatomy, etiology, and a new surgical
approach. Aesthet Surg J 2011;31(5):519–520
[3] 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
[4] Triana L, Robledo AM. Aesthetic surgery of female external genitalia. Aesthetic
Surg J 2015;35(2):165–177
[5] Oranges CM, Sisti A, Sisti G. Labia minora reduction techniques: a comprehensive
literature review. Aesthet Surg J 2015;35(4):419–431
[6] Hamori CA. Postoperative clitoral hood deformity after labiaplasty. Aesthet Surg J
2013;33(7):1030–1036
[7] Hunter JG. Commentary on: Postoperative clitoral hood deformity after labi-
aplasty. Aesthet Surg J 2013;33(7):1037–1038
[8] Goodman MP, Placik OJ, Benson RH III, et al. A large multicenter outcome study
of female genital plastic surgery. J Sex Med 2010;7(4 Pt 1):1565–1577
[9] Alter GJ. A new technique for aesthetic labia minora reduction. Ann Plast Surg
1998;40(3):287–290
[10] Alter GJ. Aesthetic labia minora and clitoral hood reduction using extended
central wedge resection. Plast Reconstr Surg 2008;122(6):1780–1789
[11] Veale D, Eshkevari E, Ellison N, et al. Psychological characteristics and motivation
of women seeking labiaplasty. Psychol Med 2014;44:555–556
[12] Choi HY, Kim KT. A new method for aesthetic reduction of labia minora (the
deepithelialized reduction of labioplasty). Plast Reconstr Surg 2000;105(1):419–
422, discussion 423–424
[13] Adamo C, Corvi M. Cosmetic mucosal vaginal tightening (lateral colporrhaphy):
improving sexual sensitivity in women with a sensation of wide vagina. Plast
Reconstr Surg 2009;123(6):212e–213e
[14] Alter G-. Labia minora reconstruction using clitoral hood flaps, wedge excisions,
and [15] Millheiser LS, Pauls RN, Herbst SJ, Chen BH. Radiofrequency treatment of
vaginal laxity after vaginal delivery: nonsurgical vaginal tightening. J Sex Med
2010;7(9):3088–3095

99 Surgical and Nonsurgical Female Genital Rejuvenation: Part 1
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99 Surgical and Nonsurgical Female Genital Rejuvenation:
Patient Selection, Preoperative Considerations,
Psychological Considerations, and Patient Satisfaction:
Part 1—Patient Selection and Preoperative Considerations
Christine A. Hamori
Abstract
Successful cosmetic genital surgery requires evaluation of the
patient’s aesthetic goals in light of existing anatomical variations
in order to achieve a pleasing postoperative vulvar appearance.
Most commonly patients request reduction of the protrusion of
the labia minora beyond the labia majora in the standing posi-
tion. Anatomical variations of the vulva are very common, and
frequently the prepubescent appearance sought by the patient
is not achievable. Preoperative education regarding asymmetry,
scar location, and limitations due to native anatomy is important.
Surgical planning of technique requires attention to certain
anatomical variations commonly present in the vulvar area.
Aberrant folds of the lateral labia minora or clitoral hood may not
be a concern to the patient preoperatively but serve as an obstacle
to the surgeon in creating a harmonious postoperative result. It
is important to educate the patient regarding her native anatomy
with the assistance of a handheld mirror. Managing patient
expectations in vulvar aesthetic surgery is important.
Tissue resection in labiaplasty by either an edge trim or a wedge
technique may create a challenge to even the most experienced
aesthetic genital surgeon. Attention must be paid to labia minora
edge pigmentation, thickness, and shape for deciding on the most
appropriate surgical technique. Patient preference for a certain
type of technique is not uncommon. It is wise to base decisions
on experience and anatomical findings. Familiarity with the prev-
alent labial anatomical variations and their surgical solutions is
important for the aesthetic genital surgeon.
Keywords
labiaplasty, genital aesthetic surgery, genital rejuvenation, ana-
tomical variations, labia minora, patient selection, labiaplasty,
surgical planning of labiaplasty, excess labia minora, pertinent
labia minora anatomy, preoperative labiaplasty
99.1 Introduction
A variety of women present for aesthetic genital rejuvenation.
Enlarged labia minora is the most common presenting symptom
of both teenage girls and perimenopausal women who seek labi-
aplasty. The prevailing aesthetic goal is a prepubertal appearance
with small labia minora concealed by plump labia majora as seen
in the standing position. Due to multiple anatomical factors,
achieving this lofty aesthetic goal is frequently not possible.
The selection of the appropriate candidate for cosmetic genital
surgery may seem simple, but both psychological and anatomical
factors must first be taken into consideration. The desire to improve
the aesthetic and function of the labia should be based on the
patient’s own desires and not those of a significant other. Derogatory
comments from a boyfriend or spouse may be a driving factor in a
woman’s seeking surgical improvement of the vulva. A careful social
and sexual history should be obtained from the potential patient.
:hen patients present to the office for consultation, it is helpful
to have them fill out a detailed questionnaire regarding current
sexual history and reasons for requesting a labiaplasty (Fig. 99.1).
Patients are usually reticent to discuss genital issues face to face; the
review of written answers allows a more open conversation to begin
between the patient and the physician. Aesthetic concerns and func-
tional complaints are the mainstay of patients presenting for labi-
aplasty. From an aesthetic standpoint, many patients prefer a very
trim appearance to the vulva with minimal to no show of the labia
minora beyond the majora. Those with functional complaints, such
as pinching with biking or intercourse, seem to be more amenable
to a more natural result as long as the symptoms are alleviated.
It is important to have a third party present during both the
discussion and the physical exam of patients interested in genital
rejuvenation. The questionnaire is reviewed with the patient, and
the aesthetic and functional goals are discussed. It is helpful to
have images of pre- and postoperative labiaplasty results present
in the consultation room to determine the aesthetic preference of
the patient. Some patients prefer a more natural result, with the
preservation of the natural shape of the labia minora (Fig. 99.2),
whereas others prefer a more “slit like” or “coin slot” appearance
to the labia minora (Fig. 99.3, Fig. 99.4). It is prudent to discuss
potential side effects of aggressive labia resection with patients,
including vaginal dryness and scar sensitivity.
The presence of a variety of before and after pictures allows the
surgeon to educate the patient regarding the appearance of scars,
variations in anatomy, postoperative asymmetries, and degree of
reduction performed. The viewing of before and after pictures
with the patient also allows for the surgeon to get a feel for the
expectations of the patient. Good postoperative results should be
acknowledged by the patient. If reasonable postoperative results
are not well received by a patient, a frank discussion regarding the
limitations of surgical correction of aesthetic variations should
ensue. Some patients who request labiaplasty are not good candi-
dates because they have unrealistic expectations.
Physical examination of the vulva should include an assessment
of the labia majora, labia minora, clitoral hood, and clitoral size.
It is important to document any anatomical variations that may
impact surgical planning, such as double folds (Fig. 99.5, Fig.
99.6), thickened clitoral frenulum (Fig. 99.7), connected posterior
fourchette (Fig. 99.8), and irregular pigmentation (Fig. 99.9).

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XIII Female Genital Rejuvenation
A handheld mirror serves as a useful tool to allow the patient to
demonstrate specific anatomical concerns as well as preferences
regarding labial shape and majora coverage postoperatively.
The relationship of the labia majora to the labia minora is very
important to assess. Many patients have enlarged labia minora
but smaller, atrophic labia majora. These patients need to be
informed that they will always have visible labia minora in the
standing position, unlike some women who have better majora
coverage. Both anatomical variations are normal, but the effaced
labia majora seems to be the aesthetic goal of most women.
Once the patient has been examined, the details of the surgi-
cal plan need to be discussed. Diagrams or animations are very
helpful in educating patients regarding the details of the labia
reduction, including scar location and technical limitations. Two
dominant techniques in labiaplasty are wedge resection and
edge trim. Patients may have a preference regarding the type of
Fig. 99.1 Vaginal questionnaire.
Fig. 99.2 A 30-year-old woman (a,b) before and (c,d) 1 year after
extended wedge labiaplasty with preserved natural contour of the
labia minora.
a
c
b
d
Fig. 99.3 A 45-year-old woman (a) before and (b) 2 years and 8
months after wedge labiaplasty.
a
b

99 Surgical and Nonsurgical Female Genital Rejuvenation: Part 1
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resection performed, based on their “research” on the Internet. It
is important for surgeons to evaluate the anatomy and choose the
best technique based on their own operative experience.
Some patients prefer a more aggressive labia minora resection
where the labia are nearly flush with the perineum, resulting in
complete coverage of the minora by the majora.
Patients should be educated on normal anatomy and
understand the variability of appearance of the vulvar region.
Preoperative photographs of patients in both the standing and the
lithotomy position are helpful to the surgeon intraoperatively. It is
important to arrange the labia in several positions so as to reveal
all anatomical structures (Fig. 99.10). Discerning postoperative
patients may inquire about incision location and the presence
of new folds or creases. Good preoperative photographs should
demonstrate any asymmetry, folds, or webs that remain after
surgery due to their unique anatomy.
Fig. 99.5 (a,b) Double fold.
Fig. 99.6 (a–d) Unilateral double fold.
Fig. 99.7 Thickened clitoral frenulum.
Fig. 99.8 Connected post fourchette.
Fig. 99.4 A 31-year-old woman (a,b) before and (c,d) 3 months after
wedge labiaplasty with a slitlike appearance.
a
c
b
d

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XIII Female Genital Rejuvenation
Managing patient expectations is a large part of genital aesthetic
surgery. When assessing patients for aesthetic genital surgery, as
with any other plastic surgery procedure, it is important to choose
patients wisely. Red flag patients would be those who are unable
to describe or show the surgeon what bothers them about their
genitalia. They might say something like “I just don’t like how
things look down there” or refuse to view the area with a mirror.
It has been my experience that such patients have an underlying
emotional issue that may require attention prior to proceeding
with surgery.
99.2 Management of
Anatomical Variations
99.2.1 Thickened Labia Minora
Patients who present with complaints of labia minora excess may
either have very long labia minora or thickened labia minora or a
combination of both. The operative plan for a patient with thick
labia minora must include some form of debulking to achieve
a satisfactory postoperative result. The labia minora volume
excess may be present either distally along the edge of the labia
or more centrally. The thickness may be attributable to excess
submucosa, varicosities, or dermis. Patients with bulk along the
edge of the minora do well with edge trim techniques, whereas
those with more proximal volume may benefit from a wedge
resection (Fig. 99.11, Fig. 99.12).
99.2.2 Thin Atrophic Labia Minora
Some women present with elongated labia minora with very little
subcutaneous tissue. This variant may be seen in postmenopausal
patients as well as the very young. It has been my experience
that this population is the most prone to dehiscence with wedge
techniques (Fig. 99.13); perhaps there is not enough space for the
placement of dermal sutures after the resection (virtually no sub-
mucosa). Since the base of this subtype of labia is thin, edge trim
is an excellent option, as it will address the excess radial length
without the need for a layered closure. Usually a single running
absorbable suture will suffice (Fig. 99.14, Fig. 99.15).
Fig. 99.9 Irregular pigmentation.
Fig. 99.10 (a–e) Preoperative photographs, five views.

99 Surgical and Nonsurgical Female Genital Rejuvenation: Part 1
1513
Fig. 99.11 (a–e) Extended wedge. A 49-year-old woman 4 months postoperative photos.
Fig. 99.12 A 35-year-old woman 2 months after an edge trim.
Fig. 99.13 (a–d) A 20-year-old woman 2 months s/p R unilateral
wedge resection with central dehiscence. Note the lack of subcutane-
ous tissue or submucosa in this patient.

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XIII Female Genital Rejuvenation
99.2.3 Double Fold
The anteriormost portion of the labia minora either fuses with the
lateral clitoral hood or remains an independent separate entity,
terminating at the intervulvar commissure (Fig. 99.16). If the fold
is relatively symmetric, then it is best to leave both intact unless
they are bothersome to the patient, in which case linear edge
trim could be performed. In patients with wide double fold(s), the
fold may be resected directly as part of an edge trim or as the
anterior extension of wedge labiaplasty, where the fold is excised
as a dog-ear, as described by Gary Alter in 1998 (Fig. 99.17).
The junction of the labia minora with the clitoral hood and
clitoral frenulum is another area that warrants attention in the
preoperative planning process. This area tends to be difficult
to contour with either an edge trim or a wedge technique. If a
wedge is planned, it is best to position the wedge posterior to this
Fig. 99.14 (a–d) A 17-year-old woman with asymmetry 2 months after
L (unilateral) edge trim. Note base of L minora thin as compared with
edge. Wedge resection would have been difficult to close.
Fig. 99.15 (a,b) A 39-year-old woman 2 months and 2 weeks s/p R
(unilateral) edge trim. Note persistent thickness of base of R minora
after edge resection. A wedge resection may have been a better choice
in this patient to reduce the base thickness.
Fig. 99.16 A 25-year-old woman (a,b) before and (c,d) 3 months s/p
wedge labiaplasty. Note double fold preserved.
Fig. 99.17 Alter’s extended wedge procedure narrows the clitoral
hood by lateral extension. (From Hamori C. Female Cosmetic Genital
Surgery. New York, NY: Thieme Publishers; 2017.)

99 Surgical and Nonsurgical Female Genital Rejuvenation: Part 1
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confluence to avoid the need to suture the now separated folds
of the anterior segment(s) (clitoral hood and the minora) to the
single posterior minora segment (Fig. 99.18). If the junction of the
clitoral hood and the labia minora is so posterior that the wedge
must be placed proximal to the confluence (Fig. 99.19), options
include suturing the clitoral hood to the posterior segment and
excising the lateral labia minora segment as a dog-ear or sutur-
ing the anterior labia minora to the posterior minora segment
and removing the medial fold as a dog-ear intravaginally. As an
alternative, an attempt may be made to unfurl the medial clitoral
hood segment and approximate the edge to the inferior minora
segment (Fig. 99.20).
99.2.4 Prominent Clitoral Hood
Clitoral hood assessment as part of a preoperative exam of the
genitalia is important. Women often attribute their aesthetic
and functional symptoms to enlarged labia minora but fail to
realize that the clitoral hood impacts the appearance, especially
in the standing mirror view. If a patient has a large clitoral hood,
it behooves the surgeon to consider a wedge resection to reduce
the anterior protrusion (Fig. 99.21, Fig. 99.22, Fig. 99.23). An
edge trim is an option, but careful attention must be paid to avoid
overresection of the minora. Once the minora are trimmed, the
clitoral hood may appear larger (Fig. 99.24).
Fig. 99.18 The anatomy of wedge incision placement just posterior
to the confluence to prevent closure of a W edge to a V edge. (From
Hamori C. Female Cosmetic Genital Surgery. New York, NY: Thieme
Publishers; 2017)
Fig. 99.20 (a,b) A 25-year-old woman 3 months s/p wedge labiaplasty.
Note the reduction in the thickened medial labia minora at the
junction with the clitoral hood.
Fig. 99.19 A 25-year-old woman with clitoral hood distally conjoined
to the medial labia minora.
Fig. 99.21 (a–d) A 31-year-old woman 10 months s/p extended wedge
labiaplasty and clitoral hood reduction. Note the reduction in width
and length of the clitoral hood.

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XIII Female Genital Rejuvenation
99.2.5 Pigmentation
Many women present with varying amounts of labial pigmen-
tation. Technique selection depends on several factors. First,
patients may have a strong desire to eliminate as much pigmen-
tation as possible. Edge trim techniques tend to do this well. If a
wedge is planned, say, for minora bulkiness or a prominent pro-
jected clitoral hood, it is important to match the pigmentation
as closely as possible. A “stripe” or abrupt color change along the
length to the labia minora can detract from the final aesthetic
result (Fig. 99.25).
Fig. 99.22 (a–d) Preoperative standing and 3 weeks s/p wedge
labiaplasty and clitoral hood reduction. Note the improved overall
aesthetic of the clitoral hood and labia minora.
Fig. 99.24 A 48-year-old woman 1 year after edge trim labiaplasty
with iatrogenic excess of clitoral hood.
Fig. 99.23 (a-d) A 26-year-old woman s/p extended wedge labiaplasty.
Note the significant tapering of the clitoral hood as a result of the
wedge labiaplasty.
Fig. 99.25 (a–d) A 22-year-old woman 8 weeks s/p wedge labiaplasty.
Note the reduction in pigmentation with some color variation

99 Surgical and Nonsurgical Female Genital Rejuvenation: Part 1
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99.3 Concluding Thoughts
Patient selection for labiaplasty entails a thorough understand-
ing of the patient’s concerns and desired outcome. The genitalia
have a tremendous amount of anatomical variation, with no clear
aesthetic gold standard other than airbrushed images available
on the Internet. It is the labiaplasty surgeon’s responsibility to
determine whether the patient has legitimate aesthetic concerns
and can understand the risks and limitations of performing a
labiaplasty. Anatomical variations are the norm in this area, with
most variations requiring modifications of standard labiaplasty
procedures.
Suggested Reading
[1] Clerico C, Lari A, Mojallal A, Boucher F. Anatomy and aesthetics of the labia mino-
ra: the ideal vulva? Aesthetic Plast Surg 2017;41(3):714–719
[2] Gonzilez PI. Classification of hypertrophy of labia minora: consideration of a
multiple component approach. Surg Technol Int 2015;27:191–194
[3] Gress S. Aesthetic and Functional Labiaplasty. New York, NY: Springer; 2017
[4] Hamori C, et al. Cosmetic Female Genital Surgery. Thieme; 2017
[5] Hamori CA, Stuzin JM. Female cosmetic genital surgery. Plast Reconstr Surg
2018;141(4):916–918
[6] Hamori CA. Aesthetic surgery of the female genitalia: labiaplasty and beyond.
Plast Reconstr Surg 2014;134(4):661–673
[7] Hamori CA. Postoperative clitoral hood deformity after labiaplasty. Aesthet Surg J
2013;33(7):1030–1036
[8] Placik OJ, Arkins JP. A prospective evaluation of female external genitalia sensi-
tivity to pressure following labia minora reduction and clitoral hood reduction.
Plast Reconstr Surg 2015;136(4):442e–452e
[9] Sisti A, Tassinari J, Nisi G, Grimaldi L. Labia minora reduction: a growing female
need. Plast Reconstr Surg 2016;137(6):1055e–1056e
[10] Sorice SC, Li AY, Canales FL, Furnas HJ. Why women request labiaplasty. Plast
Reconstr Surg 2017;139(4):856–863

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XIII Female Genital Rejuvenation
100 Surgical and Nonsurgical Female Genital Rejuvenation:
Patient Selection, Preoperative Considerations,
Psychological Considerations, and Patient Satisfaction:
Part 2—Psychological Considerations and Patient
Satisfaction
Gemma Sharp
Abstract
Women are often psychologically motivated to undergo genital
rejuvenation procedures and are generally satisfied with the
outcomes. Procedures on the external genitalia are primarily
motivated by dissatisfaction with genital appearance, whereas
internal procedures are usually requested to improve sexual
function and satisfaction. Women with poorer preoperative psy-
chological functioning and unrealistic expectations for proce-
dure outcomes are less likely to be satisfied with outcomes. These
factors should be discussed with patients prior to surgery. Body
dysmorphic disorder has been diagnosed in some women seek-
ing genital rejuvenation procedures, but whether this diagnosis
is a contraindication to surgery is yet to be firmly established.
Patients are usually very satisfied with the appearance and
function of their genitalia after surgery; however, the field is still
lacking in high-quality outcome studies to confirm these find-
ings. The results are mixed in regard to whether improvements
in women’s attitudes toward their genitals lead to improvements
in their overall psychological and sexual well-being.
Keywords
female genital rejuvenation, labiaplasty, vaginoplasty, moti-
vations, predictors, body dysmorphic disorder, satisfaction,
psychological functioning, sexual functioning
100.1 Psychological Motivations
Women’s decisions to undergo genital rejuvenation procedures
often have a strong psychological basis. Most of the research
investigating the motivations for these procedures has focused
on labia minora reduction, the most commonly performed type
of surgery. Patients in multiple countries consistently report that
dissatisfaction with their genital appearance is their primary
motivation for labiaplasty. For example, in Crouch et al’s (2011)
study of 33 adolescent and adult women seeking labiaplasty in
the United Kingdom, appearance concern was the most com-
monly reported presenting complaint, with 78% mentioning
this reason, and in a study by Sorice et al (2017), almost all
teenagers and adult women (47/50, 94%) reported that they were
“self-conscious” about their genital appearance. These appear-
ance concerns usually involve dissatisfaction with labia minora
tissue that protrudes beyond the labia majora, or asymmetry of
the labia minora.
The underlying reason for this dissatisfaction has been the
subject of much debate in recent years, both within the medical
community as well as the general public. There is naturally great
diversity in female genital anatomy in terms of size, shape, color,
and rugosity. However, there are concerns that girls and women
may not be aware of this natural variation in their own genitalia.
Instead, it has been proposed that media images of female genitals
may be shifting perceptions of what constitutes an “acceptable”
genital appearance. The “ideal” genital appearance for females
in Western society is considered to be one completely lacking in
pubic hair, with small, symmetrical external genitalia. Images in
the media of female genitalia tend to conform to this ideal either
through the selection of women who have smaller external
genitalia or through the airbrushing of the external genitalia in
the images. :omen who do not fulfill this appearance ideal may
become dissatisfied with their own genital appearance and seek
aesthetic surgery to alleviate their concerns. It is also possible that
women who have genital concerns may actively seek out these
media sources rather than be influenced by them in the first
instance. Nevertheless, a discussion about the range of normal
genital anatomy should be routinely offered to educate patients.
Of course, women may already be well aware that their genitalia
are within the normal range for appearance before consulting a
surgeon, as my own research has shown (Suggested Reading, #13),
and still wish to change the look of their genitals. This issue is the
essence of aesthetic surgery—patients have normal anatomical
features, but they wish to modify them in a way that they feel will
improve their overall appearance.
Although addressing aesthetic concerns is the primary moti-
vator for women to undergo labiaplasty, they usually report
multiple reasons for seeking surgery. This includes sexual and
physical/functional reasons. Sexual reasons can be physical
in nature, such as pain and physical discomfort. Patients may
report that their labia minora is “tugged” or pushed into the
vaginal canal during penetrative sexual intercourse, leading to
pain during and after intercourse. However, women also report
emotional concerns around sex and intimacy. More specifically,
women may avoid entering into intimate relationships owing
to concerns that a potential new partner may have a negative
opinion of their labial appearance. Alternatively, women may be
anxious about their current partner seeing or touching their labia,
particularly during certain sexual acts like oral sex, and so avoid
engaging in these activities. This, in turn, may lower their overall
satisfaction with their sex lives. These fears of potential negative
reactions from sexual partners have been reported in several

100 Surgical and Nonsurgical Female Genital Rejuvenation: Part 2
1519
studies. For example, Veale et al (2014; Suggested Reading #19)
reported that almost 40% of adult women seeking labiaplasty had
experienced teasing about their labial appearance, predominantly
from ex-boyfriends, compared with only 5% of a control group of
women who were not seeking labiaplasty. Importantly, this study
also reported that women seeking labiaplasty were no more
likely to have been sexually abused as a child or raped as an adult,
suggesting that labiaplasty was not being sought in response to
sexual trauma. Nevertheless, the topic of sexual trauma has not
been extensively researched in the field, and this topic should be
raised with patients in a sensitive manner.
Women will also commonly express physical discomfort as
a motivator for labiaplasty. This may involve the sensation of
rubbing or chafing while wearing tight clothing like underwear,
gym/exercise pants, or swim suits. Women may also mention that
their labia minora becomes sore during sporting activities like
cycling or horseback riding. It is also common for women to report
embarrassment or anxiety around the outline of their external
genitalia being seen by others when they wear tight clothing. It
is important to remember that these anxieties around the labia
being visible through clothing are likely to exacerbate physical
discomfort symptoms. Another important consideration in the
discussion of physical symptoms with patients is that these rea-
sons may be emphasized more than aesthetic concerns in order to
add legitimacy to their surgery request. This may be particularly
relevant in cultures or countries where seeking an aesthetic proce-
dure is stigmatized. Thus having a genital rejuvenation procedure
to address a physical concern would be considered more socially
acceptable. As a result, patients should be encouraged to discuss
all of their reasons for seeking a procedure, be they aesthetic,
sexual, and/or physical.
As expected, genital rejuvenation procedures performed on the
internal genitalia are not usually driven by aesthetic concerns.
Instead, these procedures usually address the uncomfortable
sensation of a “wide vagina,” which has implications for women’s
sexual functioning and satisfaction. For example, in Goodman et
al’s (2010) study of 47 women undergoing vaginoplasty and/or
perineoplasty in the United States, 58% were seeking surgery to
“increase friction and enhance sexual pleasure,” 54% to “increase
partner’s sexual pleasure,” and 52% to address feeling “loose, large,
etc., with or without incontinence.”
Requests for hymenoplasty raise different issues yet again, and
we are lacking reports from patients for this surgery type. These
women often come from African or Middle Eastern countries,
where bleeding on first sexual intercourse after the wedding
ceremony is considered proof of virginity. For some women who
undergo this procedure, it is viewed as a means of allowing them
to meet societal expectations of virginity and marriageability.
Furthermore, hymenoplasty may offer them a way of avoiding
potential social and physical harm if their hymen was found not
to be intact upon marriage.
100.2 Psychological Predictors
of Outcomes
Identifying patients who are less likely to benefit from cosmetic
interventions is of prime importance, but, surprisingly, the
research in this area still lags behind, particularly in the field of
genital rejuvenation procedures. A few patient characteristics
that predict lower satisfaction with procedure outcomes have
been identified to date, and these focus on psychological and
sexual functioning.
Some women may be so deeply distressed about their genital
appearance that they meet diagnostic criteria for body dysmorphic
disorder (BDD). BDD is the most well studied psychiatric disorder
in cosmetic patient populations and is generally considered to
be a contraindication to cosmetic procedures. Research thus far
involving other forms of aesthetic surgery suggests that patients
with BDD either do not improve or their symptoms worsen after
undergoing surgery. Patients with BDD are also at higher risk of
taking legal action against their treating practitioner and, in some
rare cases, become violent. The examination of BDD has been
included in a limited number of genital rejuvenation studies at
the time of writing. Veale et al (2014; Suggested Reading, #18)
reported that of 55 women seeking labiaplasty in the United
Kingdom, 10 individuals (18%) met diagnostic criteria for BDD.
Seven of these 10 women reported that their labia was the sole
focus of their preoccupation, whereas the other three were preoc-
cupied with areas in addition to their labia. Surprisingly, 3 months
after labiaplasty, 8 of the 9 patients (89%) who were able to be
followed up no longer met diagnostic criteria for BDD. It appeared
that the distress surrounding their labial appearance had been
alleviated through surgery. However, as the authors suggest, these
results must be interpreted with considerable caution owing to
the small sample size as well as the short duration of follow-up
after surgery.
Nevertheless, Goodman et al (2016) also showed that women
in the United States seeking a range of female genital plastic
surgeries (e.g., labiaplasty [labia minora and labia majora], clitoral
hood reduction, and perineoplasty including vaginoplasty) were
“mildly to moderately dysphoric” before surgery, but were com-
parable to a control group of women not seeking genital surgery
at 1 to 2 years postprocedure. Notably, there were no clinical
diagnostic interviews in this study to confirm the BDD diagnosis,
and the use of a patient self-report measure for BDD was also a
limitation. The findings suggest that there is a possibility that BDD
may not necessarily be a contraindication for genital rejuvenation
procedures if symptoms are mild with low accompanying levels of
distress. Importantly, there is always the possibility that the BDD
diagnosis may remain after the procedure, but the preoccupation
may shift from the genital region to another body part. Thus
screening for BDD in patients seeking genital rejuvenation proce-
dures is still recommended. It is also important to note that while
BDD has been documented in patients seeking genital rejuvena-
tion procedures, several studies have shown that women seeking
genital rejuvenation procedures are no more likely to experience
other psychological disorder symptoms.
My own research (Suggested Reading, #15) has examined the
relationship between a range of preoperative patient character-
istics and satisfaction with labiaplasty outcomes. In my sample
of 29 adult Australian women who underwent labiaplasty, higher
psychological distress (particularly anxiety and depression symp-
toms) prior to surgery was significantly related to dissatisfaction
with surgical outcomes at 6 months. In contrast, preoperative
self-esteem and life satisfaction were not significantly associ-
ated. Of the patient demographic features examined (age, body
mass index, ethnicity, sexual orientation, sexual activity, parity,

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XIII Female Genital Rejuvenation
education) only involvement in an intimate relationship was a
significant predictor of dissatisfaction. My coauthors and I sug-
gested that the reason for these two key findings was that women
may have had unrealistic expectations of how their psychological
well-being and quality of their intimate relationship would
improve after surgery, and when this did not occur, they were
less satisfied. Although this is a smaller study, unrealistic patient
expectations have been associated with lower satisfaction for
other types of cosmetic surgery, so this illustrates the importance
of discussing patient expectations/goals for surgery at the initial
consultation.
Other research has shown that the patient’s particular moti-
vation for undergoing genital rejuvenation procedures is linked
to satisfaction with outcomes and postoperative experiences.
In my own research (Suggested Reading, #16), women who
reported undergoing labiaplasty for physical/function reasons
(e.g., discomfort wearing tight clothing and during sporting
activity) or sexual reasons (e.g., anxiety around a partner seeing
their labia or physical discomfort during sexual intercourse) were
significantly more satisfied with their outcomes than women who
reported aesthetic motivations or a desire to improve their psy-
chological well-being. This may be because the removal of labia
minora tissue that causes discomfort while engaging in routine
physical activities would likely make an obvious improvement to
women’s overall quality of life. However, patient interpretations
of improvements to their genital appearance and psychological
well-being may carry greater subjectivity.
Interestingly, a recent study by Bucknor et al (2018) investi-
gating postoperative sequelae in 451 labiaplasty patients in the
United States found that patients who were motivated to undergo
labiaplasty to address sexual dysfunction were actually more likely
to experience complications. The authors reasoned that women
may have expected greater improvements in their sex lives than
the surgery may have delivered, and so these women were more
likely to request revision procedures. Alternatively, these women
may have been so eager to return to sexual intercourse after their
procedures owing to the alleviation of their sexual concerns that
they were at greater risk of wound dehiscence.
Research involving other forms of cosmetic procedures has also
reported that poorer psychological functioning and unrealistic
expectations are linked to lower satisfaction with outcomes. This
research also suggests that another factor that may impact on sat-
isfaction with outcomes is the influence of others on the patient’s
decision to have the procedure. If other people are heavily involved
in the surgery decision-making process, patients are usually less
likely to be satisfied with the results. Although it does not seem to
be highly prevalent in genital rejuvenation procedures, there have
been reports of women undergoing procedures at the “urging” of
their partner. The partner may have thought that the procedure
would lead to improvement in the couple’s sexual relationship
and level of intimacy. However, this may lead the patient to have
a lower sense of “ownership” over the surgical decision. Having
a detailed discussion surrounding how the patient arrived at
her decision to have surgery and the potential influence of other
people in her life is a worthwhile pursuit.
100.3 Patient Satisfaction
with Outcomes
A growing number of studies suggest that women are generally
satisfied with their genital rejuvenation procedures. Most of
these studies have focused on labiaplasty, often accompanied by
clitoral hood reduction. In Goodman et al’s (2010) study in the
United States, of the 83 patients who underwent labiaplasty by
linear excision, 96 were satisfied when provided with ´yes/noµ
response options, and 96 of 70 modified wedge patients were
satisfied after 6 to 42 months. In Alter’s (2008) study, also in the
United States, there was a very high average “happiness with
surgery” rating (9.2 out of a possible 10) for the 166 patients who
underwent labiaplasty and clitoral hood reduction by extended
central wedge resection at 4 months or more postoperatively.
Furthermore, when presented with “yes/no” categories, Rouzier
et al (2000) found that 89% of 98 women who underwent labi-
aplasty by inferior wedge resection were satisfied with their aes-
thetic results, 93% with the functional results and 96% with the
overall results. Oranges et al’s (2015) comprehensive literature
review of eight labia minora reduction techniques (composite
reduction labiaplasty, wedge resection, de-epithelialization, edge
resection, laser labiaplasty, custom flask labiaplasty, :-shaped
resection, and fenestration labiaplasty with inferior flap trans-
position) reported that high patient satisfaction was observed
for all techniques, with no one technique superior to the others.
There is also evidence, albeit more limited, to suggest that
women are satisfied with internal vaginal procedures too. For
example, in Pardo et al’s (2006) study of 53 women in Chile who
underwent colporrhaphy, 96 were satisfied with undergoing the
surgery at 6 months (4% “felt regret,” and none thought the issue
was “immaterial”). Furthermore, in Goodman et al’s (2010) study
of 47 women in the United States who underwent vaginoplasty
and/or perineoplasty, 83 of patients were ´satisfiedµ (17 ´not
satisfiedµ) at 6 to 42 months. In addition to traditional surgical
methods, techniques using radiofrequency and laser technology
have also been used with positive patient-reported outcomes.
Salvatore et al (2015) used a functional microablative CO2 laser
on 77 postmenopausal Italian patients with vulvovaginal atrophy.
This prospective study showed significant improvements in
overall sexual functioning as well as quality of life at 12 weeks.
Similarly, Sekiguchi et al (2013) reported significant increases in
overall sexual functioning and decreases in sexual distress in the
12 months following radiofrequency treatment of 30 premeno-
pausal women in Japan. At the time of writing, there have been
no systematic reviews comparing vaginal rejuvenation techniques
(both surgical and nonsurgical) to suggest that any technique
leads to superior patient outcomes over any other.
The published literature on other genital rejuvenation pro-
cedures, such as labia majora augmentation or reduction, and
hymenoplasty, is even more limited; thus it is difficult to make
an overall comment on patient satisfaction in these areas. In fact,
most of the research in this area suffers from some important
methodological limitations. These include small sample sizes and
often a lack of long-term follow-up. In addition, most studies have
employed retrospective rather than prospective study designs

100 Surgical and Nonsurgical Female Genital Rejuvenation: Part 2
1521
without the inclusion of an appropriate comparison or control
group. Moreover, the questionnaires used by the investigators
were often overly simple, nonvalidated measures of satisfaction
(e.g., “yes/no” for satisfaction), which can only provide limited
insights into the postprocedure experience of the patient.
At the time of writing, there have only been four high-level-
evidence prospective, controlled studies of female genital reju-
venation procedures to date using validated outcome measures.
Two of these have focused exclusively on labiaplasty. In Veale
et al’s (2014; Suggested Reading, #20) study, 23 women (49 at
baseline) undergoing labiaplasty in the United Kingdom were
compared with a group of women who were “characterised by
not wanting labiaplasty.” A range of labiaplasty techniques were
employed in this patient sample; labial trimming, central wedge
reduction, de-epithelization technique, and superior pedicle flap
reconstruction. However, the results were not differentiated by
technique type. The labiaplasty and control groups both com-
pleted validated measures of genital appearance satisfaction, BDD,
anxiety and depression symptoms, body image quality of life, and
sexual functioning at three time points: before surgery, 3 months
after, and 11 to 42 months after surgery. At 3 months, there was a
small but significant reduction in the labiaplasty group’s anxiety
levels and a medium significant increase in their overall sexual
function. However, these returned to presurgery levels in the long
term. 1evertheless, the women were significantly more satisfied
with their genital appearance after labiaplasty with large effect
size, and this was maintained in the long term. For BDD, there
was a reduction in the percentage of women who met diagnostic
criteria before surgery (18%) to 3 months postsurgery (2%).
My own prospective, controlled study published in 2016
(Suggested Reading, 15) echoes many of the findings of Veale et
al’s study (Suggested Reading, #20). We included 29 Australian
women who underwent labiaplasty (35 at baseline) using a range
of different surgical techniques, and 22 control group women
(30 at baseline) who were attending gynecology clinics and
expressed no interest in undergoing labiaplasty. The vast majority
of labiaplasty patients reported that they were “moderately” or
´extremelyµ satisfied with the aesthetic (83), functional (86),
and overall (83%) outcomes at 6 months postsurgery. In addition
to these measures, both groups completed validated measures of
genital appearance satisfaction, relationship satisfaction, sexual
confidence, psychological distress (anxiety and depression),
self-esteem, and life satisfaction both before and 6 months post-
surgery. As in Veale et al’s study, the only significant change for
women who underwent labiaplasty was a large improvement in
their genital appearance satisfaction but not their psychological
or sexual well-being. Notably, both my own study and that by
Veale et al included smaller sample sizes; therefore it is possible
that our studies lacked statistical power to detect more modest
improvements in well-being.
Positive impacts on broader quality of life factors were evident
in Goodman et al’s (2016) study of a range of genital plastic sur-
gery procedures. In this study, 120 genital plastic surgery patients
(86% labia minora labiaplasty, 58% clitoral hood reduction, 18%
perineoplasty, and 15% labia majora labiaplasty) in the United
States were compared with 50 control group women who were
attending the same clinics as the surgery patients. According to
the authors, by the final study time point of 2 years, there was a
47% follow-up rate equating to approximately 56 genital surgery
patients completing the entire study. The specific surgery tech-
niques used in the study were not specified by the authors. Both
groups of women completed measures of genital self-image, BDD,
sexual satisfaction, and body esteem. The surgery group were, on
average, classified in the ´mild to moderately dysmorphicµ BDD
range prior to surgery, which significantly improved after surgery,
and the surgery group were not significantly different from con-
trol women by 1 to 2 years postsurgery. In addition, both genital
self-image and sexual satisfaction significantly increased for the
genital surgery patients and even surpassed the control group at
2 years postsurgery. However, it must be noted that the results
presented were the combination of the results from all patients,
irrespective of the surgical procedure(s) performed. One could
potentially expect a different postsurgical experience for a woman
who has had an internal vaginal/perineal procedure compared
with labiaplasty, particularly with regard to sexual satisfaction.
Finally, Krychman et al’s (2017) prospective, randomized,
single-blinded, sham-controlled trial involving a cryogen-cooled
monopolar radiofrequency vaginoplasty method reported posi-
tive effects on women’s sexual functioning. In the study, 108 (117
at baseline) women in Canada, Italy, Spain, and Japan received the
active treatment, whereas 56 (57 at baseline) received a subther-
apeutic radiofrequency energy dose and were followed at 1, 3,
and 6 months postprocedure. A significantly higher percentage of
women in the active treatment group (44%) reported no vaginal
laxity at 6 months compared with the control group (20%). In
addition, the active group reported a significantly greater increase
in overall sexual function (including desire, arousal, lubrication,
orgasm, satisfaction, and pain) over the 6-month period than
the control group. However, the improvement in sexually related
personal distress (as measured by the Female Sexual Distress
Scale–Revised) did not reach statistical significance for the active
group.
Collectively, these studies suggest that genital rejuvenation
has a positive effect on women’s satisfaction with their genital
appearance and psychological distress in this domain, as has
been found for cosmetic surgery on other body parts. However,
the findings for whether the improvements in genital appearance
satisfaction translated to improvements in more general sexual
and psychological functioning were mixed.
Along with a limited number of prospective studies, there is also
a lack of in-depth qualitative analysis of patient satisfaction with
genital rejuvenation procedures. Qualitative methodologies are
ideal for exploring complex topics like satisfaction or dissatisfac-
tion with surgery as patients can freely expression their opinions
as well as providing detailed justifications for their thoughts. At
the time of writing, only two qualitative studies have addressed
the outcomes of genital rejuvenation procedures, labiaplasty in
particular. In the first study, Bramwell et al (2007) interviewed six
women in the United Kingdom who had undergone a labiaplasty
procedure and provided some insights into why some women
may not be as satisfied with their surgical results. For example,
one woman stated that she still thought her labia minora were
“ugly” even after surgery, so she still felt self-conscious during sex.
Another woman expected that labiaplasty would make her appear

1522
XIII Female Genital Rejuvenation
more attractive to her husband and thus improve her marriage.
However, she stated that her husband was still “not interested”
and the marriage was now “over.” One woman also potentially
indicated the need for further surgery, as she did not feel her labia
were sufficiently symmetrical.
My own qualitative research published in 2016 (Suggested
Reading, #13) involving 14 Australian women who had undergone
labiaplasty provided further insights into women’s perceptions of
their surgery outcomes. All women expressed satisfaction, but like
Bramwell et al’s study, some noted that their labial appearance was
still not “perfect,” owing to some minor asymmetry. In addition,
while women felt generally more confident in intimate situations
after surgery, some still had concerns about certain sexual acts,
such as receiving oral sex, even though they were happier with
their genital appearance. This result suggested that not all of their
psychosexual issues had been addressed through surgery.
100.4 Concluding Thoughts
There is often a strong psychological basis underlying women’s
request for genital rejuvenation procedures on both the internal
and the external genitalia. These psychological concerns are
usually alleviated through surgery, and patients are satisfied
with their outcomes. Further high-quality research will add to
the evidence base for this growing area of aesthetic surgery.
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central wedge resection. Plast Reconstr Surg 2008;122(6):1780–1789
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tion: a qualitative study. BJOG 2007;114(12):1493–1499
[3] Crouch NS, Deans R, Michala L, Liao L-M, Creighton SM. Clinical characteristics
of well women seeking labial reduction surgery: a prospective study. BJOG
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[4] Goodman M, Faschler S, Miklos JR, Moore RD, Brotto LA. The sexual, psycholog-
ical, and body image health of women undergoing elective vulvovaginal plastic/
cosmetic procedures: a pilot study. AJCS 2011;28(4):219–226
[5] Goodman MP, Placik OJ, Benson RH III, et al. A large multicenter outcome study
of female genital plastic surgery. J Sex Med 2010;7(4 Pt 1):1565–1577
[6] Goodman MP, Placik OJ, Matlock DL, et al. Evaluation of body image and sexual
satisfaction in women undergoing female genital plastic/cosmetic surgery.
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[8] .rychman M, Rowan CG, Allan BB, et al. Effect of single-treatment, surface-
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[9] Oranges CM, Sisti A, Sisti G. Labia minora reduction techniques: a comprehensive
literature review. Aesthet Surg J 2015;35(4):419–431
[10] Pardo -S, Solj VD, Ricci PA, Guiloff EF, Freundlich O.. Colpoperineoplas-
ty in women with a sensation of a wide vagina. Acta Obstet Gynecol Scand
2006;85(9):1125–1127
[11] Rouzier R, Louis-Sylvestre C, Paniel BJ, Haddad B. Hypertrophy of labia minora:
experience with 163 reductions. Am J Obstet Gynecol 2000;182(1 Pt 1):35–40
[12] Salvatore S, Nappi RE, Parma M, et al. Sexual function after fractional microabla-
tive COʊ laser in women with vulvovaginal atrophy. Climacteric 2015;18(2):219–
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[13] Sharp G, Mattiske J, Vale KI. Motivations, expectations, and experiences of
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[14] Sharp G, Tiggemann M, Mattiske J. Predictors of consideration of labiaplasty: an
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2015;39(2):182–193
[15] Sharp G, Tiggemann M, Mattiske J. Psychological outcomes of labiaplasty: a
prospective study. Plast Reconstr Surg 2016;138(6):1202–1209
[16] Sharp G, Tiggemann M, Mattiske J. A retrospective study of the psychological
outcomes of labiaplasty. Aesthet Surg J 2017;37(3):324–331
[17] Sorice SC, Li AY, Canales FL, Furnas HJ. Why women request labiaplasty. Plast
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[18] Veale D, Eshkevari E, Ellison N, et al. Psychological characteristics and motivation
of women seeking labiaplasty. Psychol Med 2014;44(3):555–566
[19] Veale D, Eshkevari E, Ellison N, et al. A comparison of risk factors for women
seeking labiaplasty compared to those not seeking labiaplasty. Body Image
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[20] Veale D, Naismith I, Eshkevari E, et al. Psychosexual outcome after labiaplasty:
a prospective case-comparison study. Int Urogynecol J Pelvic Floor Dysfunct
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[21] Wild V, Poulin H, McDougall CW, Stöckl A, Biller-Andorno N. Hymen reconstruc-
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