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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The third most commonly used non-wedge resection labia-
plasty technique is central de-epithelialization (Fig. 101.3). First
described by Choi and Kim in 2000, the central de-epithelialization
technique involves de-epithelialization of skin from both the
medial and lateral surfaces of the labia minora, typically in either
an elliptical or triangular shape. The de-epithelialized edges are
then sutured back together, which deprojects the labia minora.
The primary advantage of the central de-epithelialization tech-
nique is that this technique preserves the natural appearance and
pigmentation of the free border of the labia. This technique has
also been shown to reduce the number of sebaceous glands on
the medial surface of the labia minora, which may help reduce
excessive vaginal secretions if this is an issue. Criticisms of the
central de-epithelialization technique include the multiple inci-
sions on the medial and lateral labial surfaces, prolonged edema
of the labia, thickening of the labia minora due to the “telescoping”
effect of deprojection, the risk of inclusion cyst formation from
incomplete de-epithelialization, and limitations on how small the
labia minora can be made. Ellsworth et al (2009) suggested that
the central de-epithelialization technique should not be used if
the labia minora length exceeds 4 cm.
Ultimately, selection of the most appropriate labiaplasty
technique largely comes down to individual surgeon preference.
In 2009, Ellsworth et al proposed an algorithmic approach to
labiaplasty techniques based on the degree of labial hypertrophy
and the patient’s aesthetic ideals. However, surveys of plastic sur-
geons have found that most surgeons typically use one labiaplasty
technique, which is adapted for use in all patients.
In our practice, we use an edge excision technique for all
patients undergoing labia minora reduction. We have found
that edge excision is a versatile technique that can provide safe,
effective results with a low risk for complications. Edge excision
labiaplasty is a technique that can be easily adapted to address any
degree of labial hypertrophy or asymmetry while providing the
surgeon with precise control over the resulting projection of the
labia minora. We have also found that edge excision labiaplasty is
the most intuitive technique, making it easier to teach trainees.
In our experience, there are no specific surgical contraindications
to use of the edge excision labiaplasty, though the technique
may not be appropriate for patients who wish to maintain the
natural pigmentation or appearance of the free border of the labia
minora. In those patients, a central de-epithelialization or wedge
resection technique may be preferable. We have not experienced
complications regarding scar contracture along the border of the
labia minora with edge excision and therefore have not found the
non-wedge resection flap-based techniques to be of benefit.
For the majority of plastic surgeons performing aesthetic
labiaplasty, the best technique will be whichever one the surgeon
feels most comfortable with and that in his or her hands delivers
reliably good results with a low risk of complications.
101.3 Indications and
Contraindications
The motivations for women desiring labia minora reduction can
be classified into one or more of the following domains:
• Aesthetic
• Functional
• Sexual
• Psychosocial
Fig. 101.3 The central de-epithelialization labiaplasty technique
achieves deprojection of the labia minora by de-epithelializing skin
from the medial and lateral surfaces of the labia minora. This technique
preserves the pigment and appearance of the free border of the labia
minora.
Fig. 101.1 The edge excision labiaplasty technique involves amputa-
tion of the excess labia minora tissue with direct reapproximation of
the epithelial edges.
Fig. 101.2 The W-plasty labiaplasty technique incorporates a series of
interdigitating flaps from the medial and lateral labial surfaces, which
prevents placement of a straight-line scar along the free border of the
labia minora.

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Aesthetic concerns are frequently cited as the primary reason
for women seeking cosmetic labiaplasty. Aesthetic concerns focus
on the appearance of the labia minora both while naked and in
clothing. Changes in female pubic hair grooming trends, including
the rise in popularity of the hairless Brazilian waxed appearance,
has made the labia minora more visible than ever before. Some
authors have also noted that the increasing popularity and
availability of pornography has propagated an “aesthetic ideal”
of the female genitalia, including a closely groomed or hairless
vulva with labia minora that do not visibly protrude beyond the
labia majora. In comparison with these new “standards,” women
seeking labiaplasty may feel that their labia are in some way
abnormal. As a plastic surgeon, it is important to acknowledge
this concern, but it is equally important to avoid propagating this
concept of abnormality. Instead, patients should be educated to
understand the wide variety of normal anatomical variants of the
labia minora, and it must be made clear that a woman’s desire for
aesthetic improvement of the labia minora does not mean that the
labia are abnormal to begin with.
Functional concerns are the other most commonly cited moti-
vation for women seeking labiaplasty. Prominent, hypertrophic
labia minora can lead to symptoms of chronic irritation, chafing,
pain during activity (e.g., bicycle riding, jogging), discomfort in
clothing (e.g., labia minora pinching, labia minora visibility in
bathing suit or underwear), and difficulty with personal hygiene
or urinary self-catheterization.
Sexual concerns, though typically functional in nature, are often
classified separately. Functional sexual concerns are often related
to dyspareunia as a result of catching, tugging, or tearing of the
labia minora during vaginal penetration, or an inability to achieve
orgasm due to labial redundancy. While aesthetic concerns
have been recognized within the sexual domain, these concerns
are often more closely related to issues within the psychosocial
domain.
Psychosocial concerns of labial minora hypertrophy are typically
related to issues of self-esteem or embarrassment as a result of the
appearance of the external genitalia. Women report feeling abnor-
mal with the general appearance of their vulva, apprehension or
anxiety with sexual partners, or generalized difficulty with rela-
tionships due to prominence of the labia minora. Previous studies
have documented that dissatisfaction with genital appearance can
be associated with lower overall sexual satisfaction, lower sexual
desire, and lower overall body-image ratings.
The primary indication for labiaplasty, independent of tech-
nique, is any woman presenting with aesthetic or functional con-
cerns regarding the labia minora. Patients presenting with sexual
or psychosocial concerns as the primary indication for labiaplasty
may be excellent surgical candidates; however, extra caution
should be taken with these patients to clarify their motivations.
It is important to ensure that patients are not being coerced into
surgery; the decision to undergo labiaplasty must be a personal
choice made of their own volition. It is also important to ensure
that patients are not attempting to use labiaplasty to solve other
underlying relationship issues. Although labiaplasty has been
shown to have a positive impact on a woman’s self-image and
sexual satisfaction, sexuality is only one aspect of a healthy rela-
tionship. In a series of semistructured qualitative interviews of
women who underwent labiaplasty, Bramwell et al (2007) found
that preoperative expectations of the impact that labiaplasty
would have on sexual function and relationships were not all
fulfilled following surgery.
Contraindications to labiaplasty include any active or untreated
pelvic infection or inflammatory process, current pregnancy, pelvic
malignancy, bleeding disorders, and unrealistic expectations.
Chronic pelvic pain and vulvodynia are relative contraindications
to labiaplasty, as these pain conditions may be exacerbated by a
cosmetic genital surgical procedure. As with any aesthetic surgical
procedure, it is important to identify patients with symptoms of
body dysmorphic disorder (BDD) prior to their undergoing labi-
aplasty surgery. A study by Veale et al (2013) found that among a
group of 55 women seeking labiaplasty, 18% met diagnostic crite-
ria for BDD. While this statistic is widely quoted in the labiaplasty
literature, the authors themselves do caution that it is not possible
to extrapolate the prevalence of BDD in labiaplasty candidates due
to the design and small sample size of the study. Interestingly, a
follow-up study by Veale et al (2014) found that among a cohort
of nine labiaplasty patients who met a preoperative definition for
BDD, only one patient retained this diagnosis following surgery.
As literature supporting the positive effect that labiaplasty can
have on body image, genital self-image, and sexual satisfaction
continues to grow, further study may be required to redefine the
definition and criteria for genital appearance dissatisfaction and
BDD in labiaplasty.
A review of the indications and contraindications for labiaplasty,
or female cosmetic genital surgery in general, would not be
complete without discussing the viewpoint of opponents to these
procedures. 4uestions regarding the safety and efficacy of female
cosmetic genital surgery have been raised by several professional
organizations, including the American College of Obstetricians
and Gynecologists (ACOG) and the Society of Obstetricians and
Gynecologists of Canada. These societies have published position
statements discouraging cosmetic genital surgery, recommending
that women seeking a cosmetic genital procedure should be
counseled on the “normal” spectrum of appearances of the female
genitalia and informed of the potential risks of surgery. In partic-
ular, these societies have focused on the lack of data to support
the safety and efficacy of these procedures. :hereas a recent
update by the ACOG on labiaplasty in adolescents does demon-
strate progress from the gynecological societies, these guidelines
remain restrictive.
As plastic surgeons, the idea of operating on patients with
normal anatomy for the purpose of aesthetic improvement is not a
foreign concept. In fact, plastic surgeons in the early days of breast
augmentation faced similar criticisms for operating on patients
desiring to make their normal breasts appear larger or more
attractive. Certainly, it is important for plastic surgeons to educate
patients on the wide variety of normal anatomical variants when
it comes to cosmetic genital surgery, but one must also recognize
that a core principle of aesthetic surgery is operating on patients
with normal anatomy desiring to improve their appearance and
self-esteem.
What is lost in the broad and restrictive society position state-
ments is the impact that these statements can have on a patients’
ability to access to these medical procedures. Bramwell et al
(2007) performed a series of interviews with women who had
undergone labiaplasty, and found that while several of the women
understood the wide variation in normal labial appearance, they
remained dissatisfied with their own genital image and still opted

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for surgery. As physicians, it is important that we not allow our
personal or professional biases, whether based on one’s specialty,
gender, or personal definitions of ´normal,µ to affect our clinical
decision making. The goal should be to assist patients in making
informed decisions about their health and fostering a positive cli-
mate wherein women are able to make choices about their body
without guilt or shame. For practitioners not accustomed to these
concepts, rationalizing the role for cosmetic genital surgery will
likely remain difficult to comprehend.
101.4 Pertinent Anatomy
Prior to performing labiaplasty, it is important for every surgeon
to have a thorough understanding of external female genital
anatomy (Fig. 101.4). The vulva is composed of the mons pubis,
paired labia majora, paired labia minora, clitoris, and vaginal
vestibule. The labia minora are specialized, non-erectile neuro-
vascular folds that function to protect the vaginal vestibule from
dryness, to guide urinary flow, and also play a role during sexual
arousal. The lateral surface of the labia minora is composed of
thinly keratinized skin containing sebaceous glands but lacking
hair follicles and sweat glands. On the medial surface of the labia
minora, the keratinized skin gradually transitions to nonkerati-
nized mucosal tissue in continuity with the vaginal vestibule.
A comprehensive understanding of vulvar anatomy is not com-
plete without a basic understanding of the embryological origins
of the vulvar structures (Fig. 101.5). The labia minora arise from
the urogenital (urethral) folds, while the labia majora originate
from the labioscrotal (urogenital) swelling. The clitoris arises from
the genital tubercle, while the clitoral hood develops from a cel-
lular layer on the dorsum of the clitoris. Though these structures
are closely related anatomically, they are embryologically distinct.
These distinctions must be recognized and respected during any
labiaplasty procedure to avoid potential complications.
On gross examination, the labia minora are fused together ante-
riorly on the ventral surface of the glans clitoris; this fusion point
is referred to as the frenulum of the clitoris. While the clitoral
hood is anatomically distinct from the labia minora, leaflets of the
clitoral hood converge into the labia minora, albeit with signif-
icant anatomical variability. The labia minora diverge to course
on either side of the vaginal vestibule before they converge and
fuse at the posterior fourchette. The labia minora are separated
laterally from the labia majora by the interlabial sulcus.
As a structure of the external genitalia with a role in sexual
function, the labia minora have a dense neurovascular supply.
The arterial blood supply to the labia minora comes predomi-
nantly from the posterior labial branch of the internal pudendal
artery, itself a branch of the internal iliac artery (Fig. 101.6). In
a cadaveric study, Georgiou et al (2015) identified four main
branches of the posterior labial artery, which consistently supply
the labia minora. Each labia minora had a single dominant
artery, termed the central artery, located near the center of the
anterior–posterior axis of the labium. In addition, there were two
smaller arteries posterior to this dominant vessel, and one small
vessel anterior to it (Fig. 101.7). One benefit of the edge excision
labiaplasty is preservation of all four arterial branches, in partic-
ular the dominant central artery, as damage to this branch may
explain the higher rates of wound dehiscence or flap necrosis seen
in wedge-resection labiaplasty techniques. Venous drainage from
the labia minora occurs primarily through the internal pudendal
vein and the vaginal venous plexus.
The sensory innervation to the labia minora arises primarily
from the deep and superficial perineal nerves, branches of the
pudendal nerve (Fig. 101.6). The terminal branches of the deep
perineal nerve become the dorsal nerve of the clitoris, while
the superficial perineal nerve terminates as the posterior labial
nerve. Cadaveric studies of nerve density within the labia minora
have demonstrated a relatively homogeneous distribution of
nerve fibers throughout the labium, from the vestibule to the
free-border, with no significant difference in innervation density
between the lateral and medial surfaces. Historically, a common
criticism of the edge excision technique was loss of sensation with
resection of the labial border; however, recent studies appear to
demonstrate that the concern is no longer clinically relevant.
Fig. 101.4 Anatomy of the female external genitalia.
Fig. 101.5 Embryological origins of the female external genitalia. The
labia minora arise from the urogenital folds, the labia majora from the
labioscrotal swelling, and the clitoris from the genital tubercle.

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101.5 Preoperative Assessment
During the initial labiaplasty consultation, it is important to
remember that this is a highly sensitive and personal issue for
many women. It is important to develop a rapport with the
patient prior to delving into questions of a more delicate nature.
The consultation should take place in a private, comfortable set-
ting and must not be rushed. Younger patients may present with
a parent or guardian, older patients with a partner or friend. One
should remember that personal questions, particularly those
focused on sexual history, may be better asked in a one-on-one
setting. Therefore, it is often advisable to ask the accompanying
individual to step out of the consultation room for this part of the
discussion, though this may vary based on the patient’s wishes.
To ensure that patients are comfortable during the consultation,
we prefer to have all dialogue and discussion take place with the
patient fully clothed. The patient changes into a gown for the
physical examination only and is allowed to re-dress prior to any
further discussion.
It is important for any surgeon to clearly understand the
patient’s concerns and motivations for seeking labiaplasty. The
age of onset of labial hypertrophy, recent changes in labial size,
and prior genital trauma should be reviewed with the patient.
Unilateral or bilateral labia minora hypertrophy can create
aesthetic, functional, sexual, and/or psychosocial distress. Each of
these domains should be specifically addressed with the patient
to develop an understanding of her concerns, as patients may be
nervous to voice concerns regarding these highly personal issues.
Fig. 101.7 Four main arterial branches supply the labia minora: a
dominant central artery, two smaller posterior branches, and a small
anterior branch. The central artery communicates with the external
pudendal arterial system through a branch running along the free
border of the labia minora. Edge excision labiaplasty preserves
the arterial branches to the labia to reduce the risks of wound
dehiscence.
Fig. 101.6 Illustration of the neurovascular anatomy of the female external genitalia.
ves
Superficial transverse
perineal muscle
Deep transverse
perineal muscle
Posterior labial nerves
Dorsal nerve of the clitoris
Perineal nerve
– superficial branch
– deep branch
Posterior labial artery
Perineal artery
Internal pudendal artery
Pudendal nerve
Perineal membrane
Levator ani
Ischiocavernosus muscle
Bulbospongiosus muscle
Ischial tuberosity
Deep artery of the clitoris
Dorsal artery of the clitoris

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If there is any thought that a patient is being coerced or pressured
into surgery, is seeking surgery to resolve other relationship
issues, or has unrealistic expectations or signs of BDD, these must
be identified and addressed during the preoperative assessment.
In addition to a complete review of the patients concerns, a
thorough past medical history should be obtained, including a
complete list of current medications and supplements, allergies,
and smoking status. A specific gynecologic history should also be
obtained preoperatively (Box 101.1).
Box 101.1
Focused questions that should be included as part of a specific
gynecologic history for all patients presenting for labiaplasty
surgery:
• Menstrual history, including any history of bleeding disorder
• Current contraceptive use (e.g., oral contraceptive pill, intra-
uterine device)
• Cervical cytology test results and date of most recent
Papanicolaou (Pap) test
• History of sexually transmitted infections
• History of pelvic pain or malignancy
• Obstetric history (gravidity/parity, method of delivery)
• Past surgical history
A physical examination of the external genitalia should be per-
formed, including a bimanual pelvic examination when indicated.
We advise all surgeons to bring a chaperone into the examination
room for the duration of the physical examination, both for
patient comfort as well as for medicolegal protection. It is import-
ant to document the length and width of each labia minora, the
degree and location of labial asymmetry, and the degree of labia
minora pigmentation. It is important to evaluate all components
of the vulva, including the clitoral hood and labia majora, and not
just focus on the labia minora. It is often helpful to provide the
patient with a mirror during the examination, and to ask her to
point out precisely which aspects of the external genitalia are
of cosmetic concern. This can help to prevent any confusion or
misunderstanding between the patient and surgeon, as patients
may be unaware of the specific anatomical terminology of the
vulva. Patients should also be examined in the standing position
to accurately assess the degree of labia minora protrusion beyond
the labia majora.
101.6 Preoperative Planning,
Including Markings
Prior to undergoing labiaplasty, all patients undergo a standard
preoperative history and physical examination with their
primary care physician. If they have not undergone a cervical
Pap test within 2 years, documentation of an up-to-date test
is required prior to surgery. Basic screening bloodwork is per-
formed within 1 month of surgery, including a serum beta-HCG
pregnancy test. This is particularly important, as we ask all
patients to discontinue oral contraceptive pill use for 1 month
before and 1 month following surgery to reduce the risk of venous
thromboembolism. Patients using long-acting subcutaneous
progesterone-based contraception (i.e., depot medroxyproges-
terone) or with intrauterine devices are not required to modify
their perioperative contraception. Patients are also asked to quit
smoking for 1 month before and 1 month following surgery to
reduce the risk of complications. While we suggest that patients
try to avoid scheduling labiaplasty surgery at the time of men-
struation, this is more for ease of postoperative personal hygiene
and does not impact the procedure itself. On the morning of
surgery, all patients are secondarily screened for pregnancy with
a urine beta-HCG test.
Preoperative photographs are taken in the standing position as
well as in the frog-leg (i.e., knees flexed, hips externally rotated
and abducted) position. Labiaplasty markings are performed on
the day of surgery, with the assistance of the patient. The desired
length of the labia is discussed with the patient. All markings are
reviewed with the patient in both the standing position and the
frog-leg position so that the patient can visualize the planned
resection.
While performing the markings for edge excision and non-wedge
resection technique labiaplasty, it is important to remember that
what is left behind is more important than what is resected. Most
authors suggest leaving at least 1 to 2 cm of labia minora projection,
as measured from the base of the interlabial sulcus to the free edge
of the labia minora, to reduce the risk of complications secondary to
overresection. Care must be taken not to carry the resection into the
posterior fourchette to prevent scar contracture and tightening of
the vaginal introitus, or into the frenulum of the clitoris to prevent
injury to the clitoral complex itself (Fig. 101.8). If labiaplasty is to be
combined with clitoral hood reduction, this is marked at the same
time. We prefer to use a partial-thickness, skin-only wedge excision
to correct horizontal laxity of the clitoral hood. Beginning on the
lateral aspect of the labia minora, a V-shaped extension is drawn
from the edge excision marking. One limb curves anteriorly toward
the interlabial sulcus, and the other limb is drawn at the base of
the clitoral hood to prevent placement of scar tissue on the clitoral
hood itself. The angle and width of the interlabial sulcus limb can be
adjusted based on the degree of horizontal clitoral hood redundancy.
This design results in a Y-shaped skin resection pattern and scar
(Fig. 101.9).
101.7 2SerDWiYe 7eFKniTue
We perform edge excision labiaplasty as a day-surgery proce-
dure, typically under general anesthesia (GA). While labiaplasty
can be safely performed under local anesthesia alone or with
sedation, in our experience patients select GA to minimize any
pain or anxiety associated with the procedure.
The patient is placed in the lithotomy position, with the hips at
the edge of the operating table once the foot of the table has been
dropped. Care must be taken during positioning to raise and lower
the hips symmetrically to prevent injury. All pressure points should
be padded to reduce the risk of iatrogenic peripheral compression
neuropathy. When labiaplasty is performed in conjunction with
another surgical procedure, compression stockings and inter-
mittent pneumatic compression devices are placed on the lower
extremities for the duration of the procedure to provide mechanical

101 Surgical Alteration of the Labia Minora and Clitoral Hood: Part 1
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Fig. 101.8 (a–c) Markings for edge excision labiaplasty. Markings are made along the medial and lateral surface of the labia minora, with care taken
to preserve at least 1 cm of labia minora projection (as measured from the base of the interlabial sulcus). Note how the resection markings do not
extend into the frenulum of the clitoris (to prevent injury to the clitoral complex) or into posterior fourchette (to prevent tightening of the introitus).
Fig. 101.9 (a) Markings for edge excision labiaplasty with clitoral hood reduction. Edge excision labiaplasty is commonly combined with a partial-
thickness, skin-only wedge excision to correct horizontal laxity of the clitoral hood. A V-shaped extension (yellow line) is drawn extending from the
edge excision marking (red line). One limb curves anterior toward the interlabial sulcus, and the other limb is drawn at the base of the clitoral hood.
The angle and width of the interlabial sulcus limb can be adjusted based on the degree of horizontal clitoral hood redundancy. (b) This design results
in a Y-shaped skin resection pattern and scar.
a
b

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venous thromboembolism prophylaxis. The perineal region and
proximal thighs are prepared and draped in a sterile fashion.
Each labia minora is injected with a total of 3 to 5 mL of 0.25%
bupivacaine with 1:100,000 epinephrine at the level of the
planned excision. This injection provides vasoconstriction and
hydrodissection to assist with visualization during the procedure,
as well as long-acting postoperative pain control. It is important
to wait approximately 5 to 7 minutes following local anesthetic
injection to ensure adequate epinephrine effect. Prior to local
anesthetic injection, all markings should be reconfirmed, as the
injection significantly distorts the appearance of the labia minora.
Once the local anesthetic has been injected, the surgical markings
should not be adjusted, as this may result in overresection.
Excision of the excess labial tissue may be performed using either
a scalpel or straight, sharp, serrated scissors. Once the resection has
been completed, careful hemostasis of the area must be obtained.
We prefer to use a needle-tip cautery for precision and to avoid
thermal injury to the wound edges. The arterial blood supply of
the labia minora consists of four main vessels: a dominant central
artery, two smaller posterior arteries, and a small anterior artery.
Each vessel should be visualized and cauterized prior to closure to
minimize the risk of postoperative bleeding or hematoma.
The medial and lateral skin edges are closed with a continuous
4–0 Vicryl Rapide vertical mattress suture (Ethicon Inc.). The
deeper suture pass of the vertical mattress helps to close the
potential space between the skin edges and the deeper tissues and
acts as a hemostatic suture. The superficial pass of the vertical
mattress precisely reapproximates the skin edges while avoiding
the placement of any suture material along the free edge of the
labia minora to reduce the risk of postoperative scalloping. In
cases of significant asymmetry, it may be necessary to use addi-
tional interrupted sutures to precisely realign the wound edges.
If clitoral hood reduction is performed, the Y-point where medial
and lateral skin excisions diverge is inset first, then each limb of
the incision is closed separately (Fig. 101.9).
The incisions are covered with a nonadherent paraffin gauze,
followed by dry gauze and an abdominal pad in case of any post-
operative bleeding from the surgical site.
101.8 Ancillary Procedures
When performing labiaplasty, it is important to consider the
aesthetic implications that labia minora reduction will have on
the overall appearance of the vulva. Reduction of prominent
labia minora will affect the relative appearance of both the cli-
toral hood and the labia majora. Particularly when edge excision
labiaplasty techniques are used (including :-plasty and S-flap
techniques), the transition between the labia minora and the
clitoral hood can become more obvious. This postoperative
clitoral hood prominence can be quite bothersome to patients,
particularly in the standing position, where the clitoral hood
can resemble a small penis. If surgical correction of the clitoral
hood or labia majora are required, they can be performed at the
same time as the labia minora reduction. Surgical alteration of
the clitoral hood and labia majora are discussed elsewhere in
this volume.
In our experience, patients presenting for labia minora
reduction commonly have other areas of cosmetic concern they
would like addressed at the time of the labiaplasty procedure.
In a retrospective case series of 113 consecutive labiaplasty
procedures, we found that 25.6% of patients underwent another
surgical procedure in combination with labia minora reduction,
including breast augmentation, breast reduction, mastopexy,
liposuction, abdominoplasty, inverted nipple correction, and
vaginal tightening. Combined procedures in this case series did
not result in an increased complication rate, and we believe that
ancillary cosmetic surgical procedures can be safely performed in
conjunction with labia minora reduction.
101.9 Postoperative Care
Following labiaplasty, patients are instructed to wash the surgi-
cal site with soap and water four times per day. Patients are also
instructed to wear a sanitary pad in case of any bleeding from the
incision sites during the first week. Patients are typically seen for
follow-up visits at 1 week, 2 weeks, 1 month, and 3 months post-
operatively. At the 2-week follow-up visit, any remaining suture
material that has not yet resorbed is removed to reduce the risk
of edge scalloping. Patients are instructed to avoid strenuous
physical activity, sexual intercourse, and tampon use for 4 to 6
weeks following surgery.
101.10 Outcomes
Outcomes following labiaplasty, including edge excision and
non-wedge resection techniques, have repeatedly demonstrated
good aesthetic results with high patient satisfaction and low
complication rates.
However, one of the criticisms of outcomes research in labi-
aplasty is that most of the literature is based on individual case
series with small sample sizes and lacking standardized outcomes
measure tools. Furthermore, many of the outcome studies on
labiaplasty either fail to specify the labiaplasty technique used or
pool patients treated with different surgical techniques for anal-
ysis, thereby making direct comparison of techniques difficult.
Nevertheless, below we present a review of outcomes in labi-
aplasty, with a focus on edge excision and non-wedge resection
techniques when possible.
101.10.1 Patient Satisfaction
Overall, most patients are very satisfied with their results fol-
lowing labiaplasty surgery.
A systematic review by Oranges et al (2015) found that reported
satisfaction rates for labiaplasty, irrespective of the technique
used, exceeded 90%. Interestingly, Sharp et al (2016) found that
patients undergoing labiaplasty (technique not specified) to
address either functional or sexual concerns had greater overall
satisfaction, while patients experiencing postoperative complica-
tions had lower overall satisfaction.
One study worth highlighting is a prospective study of patient
satisfaction that compared a group of 29 patients undergoing
labiaplasty (technique not specified) to a control cohort of 22
patients not undergoing surgery. This study found that 82.8%
of patients were moderately or extremely satisfied with the

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aesthetic result of the procedure, 86.2% were moderately or
extremely satisfied with the functional result of the procedure,
and 82.8 were moderately or extremely satisfied with the overall
outcome of labiaplasty. The majority of patients (86.2%) reported
that their lives had changed either moderately or greatly following
surgery, with only 20.7% of patients reporting residual concerns
regarding postoperative labial appearance. When compared with
the control group, women undergoing labiaplasty demonstrated
a significant reduction in genital dissatisfaction at 6-month fol-
low-up. Similar improvements in relationship satisfaction, sexual
confidence, psychological distress, self-esteem, and life satisfac-
tion, however, were not observed at 6-month follow-up. Higher
levels of preoperative psychological distress (e.g., depression,
anxiety) and preoperative involvement in a romantic relationship
were associated with lower overall satisfaction. This finding is
similar to other areas of aesthetic surgery, where preoperative
psychological distress has also been shown to be a predictor for
poor psychosocial outcomes.
Two studies have specifically discussed patient satisfaction
and edge excision labiaplasty. A 2014 study by Veale at al pro-
spectively compared 26 women who underwent edge excision
labiaplasty to a matched control group. This study found that
96 of patients who underwent labiaplasty experienced signifi-
cant improvements in their genital appearance satisfaction at 3
months postoperatively, which was maintained in 91% at long-
term follow-up. A cross-sectional study by Goodman et al (2010)
compared edge excision labiaplasty (n = 83) to wedge resection
(n = 70), and found that overall patient satisfaction was similar
between the two techniques (96.4% vs. 95.7%, respectively).
Patient satisfaction outcome data in non-wedge resection labi-
aplasty have similarly demonstrated good results, though these
studies are significantly limited by sample size and the lack of
standardized outcome measures. Two studies have reported spe-
cifically on outcomes using the :-plasty technique. Among the
25 combined patients from these two studies, the authors state
that all patients were satisfied with their results, and no revisional
procedures were required. However, follow-up in these two stud-
ies was limited, and validated outcome measures were not used.
One study has focused on the S-flap technique, and while there
was a low rate of dissatisfaction among 229 patients treated, the
satisfaction rates for S-flap labiaplasty were not distinguished
from all other cosmetic genital procedures, and no standardized
outcome measures were used, thus limiting any interpretation
of these results. Similarly for central de-epithelialization, two
studies have specifically examined this technique. Among the
173 combined patients from these studies, only 2 patients were
dissatisfied with their postoperative appearance and required
additional surgery. Again, no standardized outcome measures for
patient satisfaction were used in these studies.
101.10.2 Sexual Function
As previously mentioned, an intricate relationship exists
between genital self-image, body image, and sexual function.
However, the literature has clearly demonstrated that negative
genital self-image or body image can significantly impact sexual
function, while improvements in those domains can have a
positive effect on sexual function.
Multiple studies have shown that genital self-image, as mea-
sured by the Genital Appearance Satisfaction (GAS) scale, improves
significantly following labiaplasty and that this improvement is
maintained at long-term follow-up. Despite these improvements
in genital self-image, the impact that labiaplasty has on sexual
function is less well defined. In 2016, Goodman et al performed
a prospective cohort case-controlled study of 103 patients
undergoing labiaplasty (technique not specified). Preoperatively,
patients in the labiaplasty cohort had significantly lower body
image and genital self-image scores, as well as lower measures of
sexual satisfaction in comparison to the control group. At 2-year
follow-up, the authors found that body image scores had normal-
ized to the control group level, while genital self-image and sexual
satisfaction measures exceeded control group values. Similarly, a
retrospective study by Sharp et al (2016) of 48 patients that had
undergone previous labiaplasty (technique not specified) found
that patients reported significant increases in genital appearance
satisfaction, sexual satisfaction, and psychological well-being in
comparison to their recalled preoperative levels. Meanwhile, other
prospective studies have found that despite early improvements
in sexual function measures at 3-month follow-up, this result is
lost by the 6- to 12-month follow-up.
One common criticism of edge excision labiaplasty is that
scarring along the free-border of the labia can lead to either a loss
of sensation or hypersensitivity of the labia minora. To determine
the effect of edge excision labiaplasty on labia minora sensation,
Placik et al (2015) performed a prospective evaluation of labia
minora pressure sensitivity in 37 women prior to and following
edge excision labiaplasty. Beyond a slight initial decrease in
sensation at 2 weeks, likely due to swelling, the authors found no
significant alteration in labia minora sensitivity maintained up to
1-year follow-up. Furthermore, the authors performed a survey
of patient sexual function at 6-month follow-up and found that
44.1% of women reported increased sexual relations following
labiaplasty, while 35.3% reported increased orgasm strength and
frequency.
101.10.3 Complications
Complications following labiaplasty, irrespective of the tech-
nique used, are relatively uncommon, and when they do occur
they are typically minor in nature. A systematic review of all
labiaplasty techniques by Oranges et al (2015) reported a com-
plication rate of 6.76%, with the most common complications
being wound dehiscence, hematoma, postoperative bleeding,
and urinary retention.
In regard to edge excision labiaplasty specifically, reported
complication rates are similarly low, ranging from 0.8 to 12.1%. In
2013, we performed a retrospective analysis of 113 consecutive
patients treated with edge excision labiaplasty and found that,
although 13.3% of patients reported transient postoperative
sequelae (e.g., bruising, swelling, pain), only 0.8% experienced a
true postoperative complication (i.e., postoperative bleeding).
The difference between postoperative sequelae rates and true
complications has been similarly noted by other authors and is an
important distinction to make when analyzing the labiaplasty lit-
erature. A similar distinction should be made between patient-re-
ported complications and true postoperative complication rates.

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XIII Female Genital Rejuvenation
Historically, criticisms of the edge excision technique have
included the risk of overresection or complete labial amputation,
altered labial sensitivity, and scar contracture with tightening
of the introitus. However, these complications have rarely, if
ever, been formally reported in the literature. In fact, one of the
potential benefits of edge excision labiaplasty is the reduced risk
of complications, specifically wound dehiscence, when compared
with wedge resection techniques. When performing wedge resec-
tion labiaplasty, tension on the wound closure, combined with
disruption of the labia minora blood supply can impact wound
healing and increase the risk of wound dehiscence. Though few
direct comparisons of complication rates in edge excision and
wedge resection labiaplasty have been performed, Goodman et al
(2010) reported complication rates for edge excision and wedge
resection to be 7.1% and 8.4%, respectively. Ouar et al (2017)
compared the two techniques and found a trend toward increased
rates of wound dehiscence with wedge resection. Issues of wound
dehiscence in edge excision are typically minor and can heal
secondarily, while dehiscence in wedge resections can result in
significant deformities of the labia minora.
Revision rates associated with edge excision labiaplasty are low,
ranging from 0 to 3.5% in the literature. The most common indica-
tions for revisional surgery following edge excision labiaplasty are
inadequate resection and persistent asymmetry.
Complications reported with the W-plasty labiaplasty tech-
nique also appear to be limited. In the initial technique description
by Maas and Hage (2000), among the cohort of 13 patients they
reported 1 hematoma (7.7%) that spontaneously drained, and 1
small wound dehiscence (7.7%) that healed by secondary intent.
None of the patients required additional surgical intervention.
Similarly, among a cohort of 12 patients treated with W-plasty
labiaplasty, Solanki et al (2010) reported 1 hematoma (8.3%)
that required surgical drainage and 1 case of urinary retention
(8.3%) that spontaneously resolved following overnight bladder
catheterization. Complication rates reported with the central
de-epithelialization technique are similarly low. Choi and Kim
(2000) reported on 6 patients that had undergone central de-
epithelialization labiaplasty with no complications. Ellsworth et
al (2009) treated 5 patients with central de-epithelialization and
reported 1 case of wound dehiscence that healed by secondary
intention.
101.11 Results
The following provide examples of typical results of edge excision
labiaplasty in our practice (Fig. 101.10, Fig. 101.11, Fig. 101.12).
101.12 Concluding Thoughts
In our experience with cosmetic labia minora reduction surgery
using an edge excision technique, we have found that this proce-
dure provides satisfactory aesthetic results with a low incidence
of complications. To ensure appropriate patient selection, careful
preoperative evaluation is required to identify the patient’s
motivations for undergoing labiaplasty and to set reasonable
expectations of the results that can be achieved from aesthetic
labia minora reduction. Some of the main advantages of edge
excision labiaplasty over other wedge-resection techniques
are that edge excision may be more intuitive to learn, simpler
to teach, and easier to adapt, with a lower risk of complications
related to wound dehiscence. However, while edge excision labi-
aplasty is not a technically complex procedure, it is important
not to underestimate this procedure and view it as a simple “clip
and snip” surgery, as complications secondary to overresection
of the labia minora are difficult to correct.
Fig. 101.10 (a,b) Preoperative and (c,d) 16-month postoperative photos following edge excision labiaplasty with a partial-thickness wedge excision
to address horizontal laxity of the clitoral hood. (b,d) Note how the labia minora no longer protrude beyond the labia majora in the standing position.

101 Surgical Alteration of the Labia Minora and Clitoral Hood: Part 1
1533
Fig. 101.11 (a,b) Preoperative and (c,d) 3-year postoperative photos following edge excision labiaplasty with vaginoplasty.
Fig. 101.12 (a,b) Preoperative and (c,d) 8-month postoperative photos following edge excision labiaplasty. Note the smooth contour of the edge
of the labia minora with no evidence of scar contracture. With careful suturing technique and the removal of any residual sutures at the 2-week
postoperative visit, scalloping of the free border of the labia minora can be avoided.

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XIII Female Genital Rejuvenation
Clinical Caveats
• Edge excision, W-plasty, S-flap, and central de-epithelialization
have all been shown to be effective labiaplasty techniques
that can achieve satisfactory aesthetic results with a low
complication rate.
• Prior to surgery, it is important to review and understand
the patients’ preoperative concerns in each of the aesthetic,
functional, sexual, and psychosocial domains to ensure that
each patient is an appropriate labiaplasty candidate.
• The dominant blood supply to the labia minora, the “central
artery” of the posterior labial branch of the internal pudendal
artery, is left intact with edge excision and central de-
epithelialization techniques, which may reduce the risk
of wound dehiscence compared with wedge-resection
techniques.
• With a relatively homogeneous distribution of sensory nerves
throughout the labia minora, postoperative sensitivity is not
significantly altered by edge excision labiaplasty.
• When performing edge excision labiaplasty, 1 to 2 cm of
labia minora should be preserved to minimize the risk of
overresection.
• Intraoperative markings should not be adjusted following
injection of local anesthetic into the labia minora.
• Central de-epithelialization may be considered for patients
with shorter labial length (< 4 cm) who want to maintain the
pigmentation and natural appearance of the free border of
the labia minora.
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102 Surgical Alteration of the Labia Minora and Clitoral Hood:
Part 2—Central Wedge Labiaplasty and Clitoral Hood
Reduction
Gary J. Alter
Abstract
The central wedge labia minora reduction was developed to
eliminate the disadvantages of the trimming labiaplasty as it
preserves the normal labial edge and anatomy. A clitoral hood
reduction is performed, if necessary or desired, to achieve the
synchronous appearance of the hood with the labia minora. The
design and technique of the procedures are discussed.
Keywords
labia minora reduction, labiaplasty, female genital surgery,
clitoral hood surgery
102.1 Indications and
Contraindications
Enlargement of the labia minora is usually congenital. It may
appear in childhood but becomes more obvious in adolescence.
Occasionally, enlargement of the labia minora will increase as
a result of pregnancy, birth control pills, aging, or exogenous
hormones. Ideally, the labia minora should be thin, straight,
light-colored, nonredundant, and symmetrical. Most women do
not wish the labia minora to protrude outside of the labia majora
when standing. Ideally, the clitoral hood is relatively short and
narrow, has few vertical or horizontal folds, and also does not
protrude past the labia majora when standing. The entire genital
area should be considered an aesthetic region that necessitates
synchrony when considering the best aesthetic result. Reduction
of the labia minora in a patient with a large clitoral hood or clito-
ris causes the hood and clitoris to look even larger.
Labia minora reduction has traditionally been performed by
trimming the protruding labia along the entire labial length.
The trimming is performed using a scissor, knife, clamp, laser, or
radiofrequency. The labial edge is closed with either interrupted
or running external sutures or a running subcuticular suture. This
procedure has the advantages of a short operative time and of
eliminating some of the dark pigmentation that is disliked by some
women. However, the disadvantages are elimination of the natural
labial edge, which is replaced by an incision line and often a wide,
irregular, scalloped scar; difficulty creating symmetrical labia; an
often unnatural transition between the labium, clitoral frenulum,
and clitoral hood causing the frenular tips to protrude; the possi-
bility of overresection of the labia; and the potential for a higher
incidence of postoperative and chronic discomfort from irritation
of the scar line. Because of the disadvantages of the trimming
labiaplasty, the extended central wedge technique was developed,
which may also include partial reduction of the clitoral hood. The
advantages of the central wedge are preservation of the normal
labial edge and anatomy, scars that are usually difficult to see,
greater ability to achieve symmetry, and a less painful recovery.
The disadvantages of the central wedge labiaplasty are a longer
surgery time, a more technically challenging procedure, often per-
sistent darker pigmentation, an occasional color mismatch at the
suture line, and a wide suture line disruption if poorly performed,
if performed on a smoker, or if a rare infection occurs.
102.2 Pertinent Anatomy
A clear understanding of clitoral anatomy is mandatory to pre-
vent injury. No change in sexual sensation should occur if the
clitoris is uninjured. The glans clitoris is visible underneath an
overlying extension of the clitoral hood, the prepuce. The body
or corpora of the clitoris is attached to the pubic symphysis by
the suspensory ligament of the clitoris. The corpora diverge infe-
riorly and laterally and are attached bilaterally to the ischium.
The clitoral hood anatomy can vary extensively in length,
protrusion, and width. Often, the protrusion results from excess
subcutaneous tissue or a clitoris that is hanging away from the
pubic bone. An excess of clitoral hood skin can result in multi-
ple vertical or horizontal folds or increased length, including
an extensive prepuce. If the clitoris is enlarged from congenital
causes or due to androgen excess from hormonal imbalance or
androgen supplements, the clitoris and hood can dominate the
genital area. Occasionally, a woman can have a clitoris that looks
normal when flaccid but that markedly protrudes with arousal.
A fold of skin (frenulum) extends from the ventral glans
bilaterally to converge with an extension of the clitoral hood to
form a labium minus. The labia minora may meet at the posterior
introitus or gradually taper down. There are many variations in
labia minora size, folds, protrusion, and symmetry.
102.3 Preoperative Assessment
Labiaplasty can be performed on almost any woman with
enlarged labia. Labial protrusion is evaluated with the patient
standing and in the lithotomy position. The labia are examined
for thickness, symmetry, and both anterior and posterior length.
The clitoral hood is examined to determine protrusion; symme-
try; the location of hyperkeratotic, darkened skin; the presence
of extra folds; and the clitoral glans size and exposure. The pos-
terior introitus should be evaluated for a high posterior lip or an
open introitus resulting from a previous episiotomy, childbirth,
or congenital variation.

102 Surgical Alteration of the Labia Minora and Clitoral Hood: Part 2
1537
A V-shaped wedge will be excised from the most protuberant
portion of each labium, which is almost always in the central
labium. Because the labia are often asymmetrical, the amount of
the wedge is varied to achieve symmetry. With the patient hold-
ing a mirror and lying in the lithotomy position, the surgeon holds
the amount to be excised in each hand by bringing the anterior to
the posterior portion of the V together.
There may be a color mismatch between the anterior and pos-
terior labium at the anastomosis, but this is rarely an issue with
the patient if she is told preoperatively, and the color difference
usually lessens with time. The surgical plan and anticipated post-
operative result must be explained to the patient to prevent any
misconceptions or false expectations.
Fig. 102.1 A 47-year-old woman underwent labia reduction and lateral clitoral hood reduction. (a) (Upper left) Preoperation. (b) (Upper middle)
Internal V markings with the labia open. (c) (Upper right) External hockey stick V marking extending along the lateral clitoral hood to the anterior
hood. (d) (Lower left) The completed right side compared with the left side. (e) (Lower middle) Postoperation. (f) (Lower right) Postoperation
with the labia open. (From Alter GJ. Aesthetic labia minora and clitoral hood reduction using extended central wedge resection. Plast Reconstr Surg
2008;122:1780–1789.)

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XIII Female Genital Rejuvenation
102.4 Preoperative Planning
102.4.1 Patient Positioning and
Markings
The patient is placed in the lithotomy position in the operating
room, usually under a general anesthetic. The clitoral glans fren-
ulum converges with the lower clitoral hood to form the labium
minus; the nature of this convergence varies among women. The
anterior incision line is usually at or just posterior to this conver-
gence (Fig. 102.1a,b, Fig. 102.2a). Pickups are used to determine
the appropriate amount of excision in each labium to create a
straight line without causing tension on the incision line or a
tight introitus, which should fit two fingerbreadths. Markings on
the opposite labium are made to achieve symmetry. The medial
portion of the V extends internally to end distal to the hymeneal
ring. The lateral markings end in the labial sulcus if no lateral
clitoral hood is to be excised. If excision of the lateral clitoral
hood or lateral clitoral hood folds is desired, it is designed as an
anterior extended hockey-stick design (Fig. 102.1c, Fig. 102.2b).
Therefore the medial and lateral wedge excisions are asymmet-
rical. Usually the darkest labial skin is excised with the wedge,
since the darkest labial tissue is usually the most protuberant.
If there is extreme posterior labial asymmetry or enlargement,
a second V or a lateral and/or medial vertical ellipse may need
to be excised from one or both sides to achieve symmetry or
adequate reduction.
102.5 2SerDWiYe 7eFKniTue
After marking, the area is infiltrated with lidocaine and bupiva-
caine (Marcaine) with epinephrine. Loupe magnification is usu-
ally required to achieve an excellent closure and anastomosis.
The medial labium is approached first, and only mucosa is
removed (Fig. 102.2c,d). Preserve as much underlying subcu-
taneous tissue as possible. The lateral skin is then excised, also
removing only skin and no subcutaneous tissue.
The subcutaneous tissue is then approximated in two layers
with 5–0 Monocryl on an atraumatic TF needle (Fig. 102.2e,f).
A good subcutaneous closure is mandatory to prevent wound
dehiscence or perforation. Any excess subcutaneous tissue is
removed medially or laterally during the closure to eliminate dog-
ears or an overly thick labium. The skin is then closed from distal
to proximal. Interrupted vertical mattress 5–0 Monocryl sutures
are used at and near the tip but may be used whenever necessary
to achieve good reapproximation (Fig. 102.2g,h). Simple sutures
are usually used medially and laterally. Running sutures can be
used on the deepest portion of the medial incision line or occa-
sionally on the lateral labium. Once one side is completed, the
markings on the opposite side are checked and possibly remarked
for symmetry (Fig. 102.1d). The procedure is then repeated. In
the very unusual situation in which a second wedge is required
on one or both sides, this is performed after the bilateral anterior
wedges are closed (see below). If no excess clitoral hood is present
or if the patient does not want this excised, then the lateral V ends
in the labial sulcus or along the lower clitoral hood to prevent a
dog-ear.
Extending the lateral labial V along the anterior hood in a
hockey-stick configuration can reduce redundant lateral clitoral
hood folds or excess lateral skin, thereby mildly decreasing the
width of the hood. Subcutaneous tissue can also be removed at
the same time to decrease the thickness of the hood. The subcu-
taneous tissue of the clitoral hood is closed with a running 5–0
Monocryl suture, and the skin of the hood is closed with a running
subcuticular 5–0 Monocryl suture. If there is asymmetry of the
clitoral hood folds, these are adjusted accordingly (Fig. 102.1e,f). If
the excess folds or hypertrophic skin are more medial, the lateral
Fig. 102.2 (a) Internal markings for wedge excision of labia minora.
(b) Lateral markings for extended wedge excision. (c) The mucosa is
removed, leaving as much subcutaneous tissue remaining as possible.
(d) The lateral skin has also been removed. The subcutaneous tissue
tends to retract. (e,f) The subcutaneous tissue is closed in two layers
with interrupted 5–0 Monocryl. (g,h) The leading edge is closed with
interrupted vertical mattress 5–0 Monocryl sutures. Interrupted
simple or mattress sutures are usually placed on the medial and lateral
labium and a subcuticular closure along the clitoral hood. (From Aly A
et al., eds. The Art of Body Contouring: A Comprehensive Approach. New
York, NY: Thieme Medical Publishing; 2017:555–579.)

102 Surgical Alteration of the Labia Minora and Clitoral Hood: Part 2
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wedge excision can stop at the lateral labium in the labial sulcus,
and a vertical ellipse can be excised from one or both sides of the
medial–lateral clitoral hood (Fig. 102.3). If there is asymmetry of
the clitoral hood folds, these are adjusted accordingly. Excess per-
ineal skin was also excised in this patient lateral to the posterior
labia.
The introitus should fit two fingers without significant tension
to prevent overtightening. If there is a high posterior lip or overly
tight introitus, a posterior midline incision may need to be made
to prevent difficulty with intercourse. However, this should be
considered prior to the wedge labiaplasty. If the lip is incised, the
vaginal mucosa is sutured to the perineal skin. This creates dog-
ears bilaterally that need to be trimmed and aesthetically closed.
If an intravaginal tightening procedure is performed at the
same time as the labia reduction, the tightening procedure
should usually be performed first and stopped at the hymen. If
the patient has very large labia requiring very large V excisions
extending up to the hymen, the introitus and perineal closure
Fig. 102.3 A 33-year-old woman who underwent labia reduction and medial–lateral clitoral hood reduction. (a) Preoperation. (b) External labia
excision ends at the lateral labium. Separate elliptical excisions of thickened clitoral hood. (c) Same as above. (d) Internal V markings with the labia
open. (e) Post labiaplasty, with markings to excise excess perineal tissue. (f) Postoperation. (From Alter GJ. Aesthetic labia minora and clitoral hood
reduction using extended central wedge resection. Plast Reconstr Surg 2008;122:1780–1789.)

1540
XIII Female Genital Rejuvenation
distal to the hymen should not be completed until the labiaplasty
is finished. The large V excision can elevate the posterior lip and
cause introital tightness. This is best adjusted at the time of distal
vaginal and perineal closure. However, the surgeon must be very
aware of the possibility of introital narrowing prior to the labi-
aplasty, as variations of the wedge excision may need to be done.
If the patient has a protuberant posterior labium on one or both
sides, then the protuberance can usually be corrected with a lim-
ited lateral and/or medial ellipse similar to the technique described
by Choi (Fig. 102.4). The ellipses are closed with interrupted
sutures. In this patient, the prepuce was opened due to a relatively
buried glans clitoris. The lateral ellipse cannot be used if there is
posterior length excess along with the protuberance. In that case,
a second posterior wedge needs to be performed (Fig. 102.5). This
patient also had vaginal tightening and a perineoplasty.
102.6 Ancillary Procedures
102.6.1 Clitoral Hood Reduction
Aside from the lateral extended hockey stick excision and verti-
cal ellipses, other clitoral hood skin excisions can be performed.
If the patient has a long clitoral hood with a buried clitoris or
redundant transverse folds of the clitoral hood, a small amount
can be excised in a transverse ellipse on rare circumstances (Fig.
102.6). Closure is done with interrupted vertical mattress 6–0
Monocryl. Care must be taken not to overly expose the glans,
because patients can be hypersensitive or dislike the aesthetic
appearance. This patient also underwent a routine central wedge
labiaplasty. More aggressive clitoral hood reduction requires
clitoral repositioning (clitoropexy), which is beyond the scope of
this chapter. Clitoral enlargement of the shaft and glans must be
recognized. A labiaplasty in a patient with clitoral enlargement
Fig. 102.5 A 52-year-old woman with very enlarged, asymmetrical
labia minora. (a,b) The asymmetry is obvious with increased protrusion
and length of her posterior right labium. Her vaginal tightening has
been completed. (c,d) The wedge labiaplasty is completed. Two
wedges were removed from the right and one from the left.
Fig. 102.4 A 28-year-old woman with asymmetrical labia minora. (a,b) The posterior left labium is longer. (c) A lateral vertical ellipse of labium is
excised on the left to achieve symmetry. A dorsal slit was made in the distal prepuce to uncover a buried glans clitoris.

102 Surgical Alteration of the Labia Minora and Clitoral Hood: Part 2
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will cause an even greater discrepancy between the smaller labia
and the enlarged clitoris and clitoral hood. The clitoris can be
reduced, but this is also beyond the scope of this chapter.
In unusual situations, the leading edge of the clitoral hood
prepuce can be trimmed and closed with 5–0 or 6–0 Monocryl.
However, this can cause some abnormal distortion and scarring. If
done, be conservative to prevent overresection with overexposure
of the glans clitoris.
102.7 Postoperative Care
Espiral is often injected at the end of the procedure to reduce
postoperative pain. The patient should use ice packs and antibi-
otic ointment for 2 days. Cephalosporin is given prophylactically
for 1 day. The patient should avoid exercise for 3 to 4 weeks, but
yoga and horseback and motorcycle riding should not be done for
at least 8 weeks. Sexual intercourse is allowed at 6 weeks. Usually
80% of the swelling is resolved by 6 weeks, with all swelling
Fig. 102.6 A 35-year-old woman for clitoral hood and labia minora reduction. (a) The clitoral hood is long and extensively covers the glans clitoris.
(b,c) Markings for a conservative transverse clitoral hood reduction and a wedge labiaplasty. (d) The patient postoperation. (e) The patient 3 months
postoperation. (Aly A et al., eds. The Art of Body Contouring: A Comprehensive Approach. New York, NY: Thieme Medical Publishing; 2017:555–579.)

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XIII Female Genital Rejuvenation
and induration commonly gone in 4 months. The sutures start
disappearing in 2 weeks and are usually gone by 6 weeks. The
Monocryl sutures may cause itching and discomfort after several
weeks, which can be partially alleviated with Vagisil or a very
weak cortisone cream.
102.8 Outcomes
Complications are extremely uncommon if meticulous surgery
is performed using the sutures and techniques described here.
Approximately 2% of patients will have a slight separation at
the labial edge. Most of the visible small separations will blend
in 4 to 6 months and will not require revision. A perforation or
major dehiscence occurs in less than 1% of cases and is usually
caused by poor technique, a rare infection, or cigarette smoking.
Surgical revisions may need to be performed for asymmetry of
the labia minora or lateral clitoral hood, unsightly or stretched
scars, separations or dehiscence of the labial edges, or perfora-
tions. Revisions are usually delayed a minimum of 5 months after
the initial surgery to allow healing and resolution of induration.
Rarely, a patient will have some persistent discomfort lasting
over several months. This is usually resolved with a several-week
course of a potent cortisone cream, such as Clobetasol 0.05%.
Fig. 102.7 A 23-year-old woman for labiaplasty. (a,b) Preoperation. (c,d) Immediately postoperation. There is a mild insignificant color contrast at
the labial edge. (e,f) Three months postoperation.

102 Surgical Alteration of the Labia Minora and Clitoral Hood: Part 2
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102.9 Results
A recent study of 407 patients revealed an average patient satis-
faction rate of 9.2 on a scale of 10 (10 indicating most pleased).
Patients reported improvement in self-esteem (93%) and sex life
(71), and reduction of discomfort (95), with a low significant
complication rate (4%).
This 23-year-old woman is shown before and after a labia
minora reduction and lateral clitoral hood reduction (Fig. 102.7).
The appearance is very natural, with a slight color mismatch that
is inconsequential.
This 50-year-old woman is shown before and 3 months after
a labia minora reduction and lateral clitoral hood reduction
(Fig. 102.8). There is significant reduction of her labia and clitoral
hood, with a natural appearance. The scars are almost invisible.
102.10 Concluding Thoughts
Clitoral hood and central wedge labiaplasty surgery can be very
successful if the guidelines are followed meticulously. As more
women become aware that safe, successful operations are available,
the number of procedures performed will continue to increase.
Clinical Caveats
• During preoperative assessment for all procedures, the
patient should hold a mirror while she is shown the tissue to be
excised, and her expected postoperative result is discussed.
Labia Minora Reduction
• The excision should not be closed with tension.
• A good subcutaneous closure, usually in two layers through
most of the length, is essential to prevent dehiscence. The
labium is thus closed in four layers.
• 5-0 Monocryl on an atraumatic TF needle is ideal to prevent a
tissue reaction and trauma that can lead to wound separation.
• Vertical mattress sutures at the leading edge of the labium
minus help to prevent wound separations.
• The surgeon should confirm that two fingerbreadths can be
inserted in the vagina.
• The glans clitoris should not be overexposed if some of the
clitoral hood is being excised vertically or horizontally. The
glans exposure should remain the same as before surgery
unless the patient requests otherwise.
Suggested Reading
[1] Alter GJ. Aesthetic labia minora reduction with inferior wedge resection and
superior pedicle flap reconstruction. Plast Reconstr Surg 2007;120(1):358–359,
author reply 359–360
[2] Alter GJ. Aesthetic labia minora and clitoral hood reduction using extended
central wedge resection. Plast Reconstr Surg 2008;122(6):1780–1789
[3] Alter GJ. A new technique for aesthetic labia minora reduction. Ann Plast Surg
1998;40(3):287–290
[4] Hamori CA. Aesthetic labia minora and clitoral hood reduction using extended
central wedge resection. Plast Reconstr Surg 2009;124(1):337–338
[5] 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
[6] Felicio YdeA. Labial surgery. Aesthet Surg J 2007;27(3):322–328
[7] Gonzalez F, Dass D, Almeida B. Custom flask labiaplasty. Ann Plast Surg
2015;75(3):266–271
[8] Hunter JG. Considerations in female external genital aesthetic surgery tech-
niques. Aesthet Surg J 2008;28(1):106–107, author reply 107
[9] Maas SM, Hage JJ. Re: Aesthetic labia minora reduction. Ann Plast Surg
1998;41(6):685–686
[10] Maas SM, Hage JJ. Functional and aesthetic labia minora reduction. Plast Reconstr
Surg 2000;105(4):1453–1456
[11] Motakef S, Rodriguez-Feliz J, Chung MT, Ingargiola MJ, Wong VW, Patel A. Vaginal
labiaplasty: current practices and a simplified classification system for labial
protrusion. Plast Reconstr Surg 2015;135(3):774–788
[12] Munhoz AM, Filassi JR, Ricci MD, et al. Aesthetic labia minora reduction with
inferior wedge resection and superior pedicle flap reconstruction. Plast Reconstr
Surg 2006;118(5):1237–1247, discussion 1248–1250
Fig. 102.8 A 50-year-old woman with a labiaplasty and lateral clitoral
hood reduction. (a) Preoperation. (b) Postoperation. There is signifi-
cant reduction of her labia and clitoral hood with a natural appearance.
The scars are almost invisible.

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103 Surgical Alteration of the Labia Minora and Clitoral Hood:
Part 3—Surgical Alteration of the Clitoral Hood
Carlo M. Oranges
Abstract
The surgical alterations of the clitoral hood are reported by
experts as a frequent cause of reoperation after labia minora
reduction. However, their frequency has not been extensively
investigated in the peer-reviewed literature, and it has not been
outlined in research describing labiaplasty procedures. The most
common surgical alteration is the redundancy of the clitoral
hood, which may be absolute, in the case of an iperthophic cli-
toral hood not corrected at the time of labia minora reduction,
or relative, in the case of a clitoral hood appearing iperthophic
in relation to the reduced labia minora. Although the topic is still
under debate, among the eight labiaplasty techniques described,
some authors have indicated edge resection as the most likely
to cause this complication, whereas the Alter’s wedge resection
technique and the composite resection technique have been
considered to be less associated. Inexperience of surgeons per-
forming the edge resection technique, erroneously considered
to be simple, and failure to address the female genital area as a
whole may be among the causes.
Treatment of horizontal iatrogenic redundancy includes verti-
cally oriented excision of the lateral clitoral hood folds, whereas
the vertical redundancy often requires a transversely oriented
inverted V-wedge excision.
Keywords
clitoral hood, clitoral hood ipertrophy, surgical alterations,
complications, labia minora edge resection, labia minora wedge
resection, labia minora composite resection
103.1 Introduction
A recently published comprehensive review of the literature,
which analyzed 1981 cases described in articles selected with-
out restriction of time in English and non-English publications,
identified eight techniques for reducing the labia minora, namely
composite reduction labiaplasty (n = 812), wedge resection (n =
702), de-epithelialization (n = 173), edge resection (n = 161), laser
labiaplasty (n 55), custom flask labiaplasty (n = 50), W-shaped
resection (n 25), and fenestration labiaplasty with inferior flap
transposition (n = 3). All techniques were associated with high sat-
isfaction of patients and surgeons, always exceeding 90%, and low
complication rates, overall equal to 6.76%. Importantly, revision
surgery was needed in a small number of patients (82/1981, 4.1%)
and caused by wound healing complications or postoperative
bleeding. Secondary resection was performed in 1.7% of patients
because of failure to achieve the desired labial length. No articles
among those meeting inclusion criteria reported iatrogenic
alteration of the clitoral hood as a consequence of labia minora
reduction. However, several reports have indicated the surgical
redundancy of the clitoral hood appearing after labiaplasty as one
of the most relevant causes of reoperation, while edge resection
have been primarily associated with this complication.
It is therefore essential for surgeons to be able to examine and
treat the overall genital region while performing labiaplasty, in
order to address the hypertrophy of the labia minora, ensuring a
harmonious postoperative relation with the clitoral hood, which
must also be reduced when appropriate. Other possible surgical
alterations include exposure of the glans clitoris as a consequence
of excessively deep resection of the clitoral hood. Conversely,
isolated congenital malformation of the clitoral hood, such as
pseudohermaphroditism, in combination with clitoral hypertro-
phy and labial fusion, are rarely observed.
The contributions of Hunter, Hamori, and Alter are essential to
an adequate understanding of this topic and will be largely refer-
enced in this text. This chapter highlights relevant anatomy of the
clitoral hood, causes and presentation of its surgical alterations,
and related treatment options.
103.2 Clitoral Hood Relevant
Anatomy
Perfect knowledge of the normal anatomy of the clitoral hood
is essential to conduct a proper preoperative exam. The clitoral
hood is a fold of skin, which covers and protects the glans clitoris
and the external part of the clitoral shaft. It may present as a
smooth structure or with multiple longitudinal folds and pleated
redundancies. A lateral fold, parallel to the main clitoral hood,
may also be observed (Fig. 103.1).
From inside to outside, the clitoris is composed of two corpora
cavernosa, each surrounded by a fibrous layer of connective tissue,
the tunica albuginea. Moving superficially we find the Buck’s
fascia and the subcutaneous tissue or dartos fascia of the clitoral
hood. Clitoral hood thickness is correlated to the thickness of the
skin and underlying dartos fascia.
It is essential to record preoperatively the clitoral hood length,
which is measured from the midline of the anterior labial com-
missure to the distal clitoral prepuce. There is great variability
among women in terms of clitoral hood length, which normally
ranges between 2 and 6 cm, and it is often characterized by asym-
metry between the two sides. Depending on its length, the clitoral
hood may appear to protrude slightly or generate a “penis-like”
appearance if associated with clitoromegaly. There is a commonly
mild but variable protrusion of the glans clitoris from beneath the
prepuce of the clitoral hood.
The neural supply to the glans clitoris is provided by dorsal neu-
rovascular bundles within the Buck’s fascia. The region is highly vas-
cularized. The blood supply is guaranteed by the external superficial

103 Surgical Alteration of the Labia Minora and Clitoral Hood: Part 3
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pudendal artery and the internal pudendal artery and often also
by the internal circumflex artery. The anastomosis between the
external superficial pudendal artery and the posterior labial artery,
a branch of the internal pudendal artery, takes place in the labia
majora. The extensive blood supply to the labia minora is then deliv-
ered by multiple arterial arches originating from this initial arch.
103.3 Presentation and Clinical
Examination of the
Surgical Alterations
Patients undergoing labiaplasty seek a youthful appearance of
the genital area with minimal show of the labia minora and the
clitoral hood. With reference to the clitoral hood, this means no
protrusion of the clitoral hood between the anterior labial com-
missure. This is normally achieved with all available procedures.
However, a select group of patients present after the operation
complaining about a clitoral hood looking larger and an imbal-
anced relation between the clitoral hood and the labia. Among
these cases we can recognize two separate conditions that must
be identified: absolute or relative clitoral hood redundancy. The
absolute clitoral hood redundancy is observed when the native
clitoral hood is enlarged in addition to labia minora redundancy
but it is not addressed with a reduction treatment (Fig. 103.2).
This emphasizes the imbalance between the remaining more
apparent clitoral hood and the postoperative flattened labia
minora. The relative clitoral hood redundancy is observed in
the case of patients with a native, not enlarged, clitoral hood
that appears excessively full in the anterior aspect in relation to
postoperative labia minora, which are no longer visible. In both
cases, the prominence of the clitoral hood was not observed prior
to labiaplasty, and motivates surgical correction. Moreover, both
conditions may be characterized by a masculine “penis-like”
appearance of the clitoral hood. Patients may also express con-
cerns regarding the new shape of the labia minora, sometimes
judged as being relatively too short. These surgical alterations, if
present, may therefore have a huge impact on the self-perceived
genital body image, be responsible for tremendous embarrass-
ment, and interfere with the patient’s sex life.
The patient is examined in the standing position to reveal a
bulky clitoral hood separating the labia minora at the anterior
vulvar commissure. In this view, the clitoral hood may show
several drapelike folds. It is in the standing position that patients
may manifest the typical appearance referred to as a “small
penis,” which bothers them most. The patient is also observed in
lithotomy, to estimate the clitoral hood width, length, and relation
with the labia minora. Palpation of the clitoral area is performed
to exclude clitoromegaly and assess the excess width and length
of the clitoral hood in comparison with the labia minora. It is rele-
vant to note that in general isolated clitoral hood deformities, such
as congenital malformations, such as pseudohermaphroditism
associated with clitoral hypertrophy and labial fusion, are rare.
Hunter underlined that clitoral hood redundancy may present a
horizontal or vertical orientation, or both. Horizontal redundancy
is the most typical condition, and it is characterized by multiple
unilateral or bilateral additional folds (Fig. 103.3).
The skin excess may extend lateral and parallel to the central
portion of the clitoral hood symmetrically or asymmetrically.
Conversely, ptosis and lengthening of the clitoral hood are
described as vertical hood redundancy (Fig. 103.4).
It has been reported that patients tend to find horizontal redun-
dancy more bothersome.
Fig. 103.2 Labia minora hypertrophy associated with clitoral hood
redundancy.
Fig. 103.1 Schematic representation of the normal anatomy of the
clitoral region.

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XIII Female Genital Rejuvenation
103.4 Causes, Prevention, and
Preoperative Information
for the Patient
Several experts have indicated inappropriate performance of
edge resection labiaplasty as one of the main causes of surgical
alteration of the clitoral hood. Many gynecologists and some
plastic surgeons tend to prefer this technique, sometimes
erroneously considered to be easier. However, in a recent com-
prehensive review on the subject, this technique was found to
be only the fourth among those that were published in terms of
number of patients treated (161/1981), after composite resection,
wedge resection, and de-epithelialization. Moreover, the level
of evidence of the articles describing edge resection was found
to be very low, including overall 11 retrospective reviews and 8
case reports.
Edge resection consists of direct excision and trimming of
the labial excess. Authors reported high patient satisfaction and
low morbidity rates, with the only exception being Hodgkinson
and Hait, who observed postoperative aesthetic and functional
unsatisfactory protrusion of the labia minora. Importantly, a
possible complication correlated with this technique is exces-
sive tissue resection, which can result in complete amputation
of the labia minora or centrally foreshortened labia minora with
dog-ears superiorly and inferiorly. The resulting deformities are
difficult to treat because of the deficit of central labial tissue.
This situation is considered one of the most likely to be respon-
sible for postoperative relative clitoral hood redundancy, as the
clitoral hood appears enlarged in relation to the amputated
labia.
On the other hand, if the absolute preoperative prominent
clitoral hood is not addressed, the simple free-edge trimming
or sculpting of the labia minora excess creates a disharmo-
nious result with surgical alteration of the clitoral hood as a
consequence. In this case, after removing the excessive circum-
ferential rim of the labia minora, a redundant clitoral hood,
which appeared proportional to the large labia, will appear
bulky, and its protrusion from the introitus more noticeable.
Overresection of the labia will emphasize the imbalance. The
resulting unusual and eventually masculine genital aspect
may lead to extremely dissatisfied patients seeking revision
surgery.
However, independently from the technique used, labiaplasty
must be tailored on overall patient needs. An appropriate approach
to labia minora reduction must address comprehensively all
anatomical issues of the vulva, including labia majora skin
excess, ptosis of the mons pubis, and clitoral hood redundancy. In
particular, this is relevant for the clitoral hood, which presents a
multitude of anatomical variations and whose reduction must be
always carefully considered in association to labiaplasty in order
to ensure a natural result.
It is therefore imperative for the surgeon to include the clitoral
area in the preoperative examination prior to labia minora
reduction. In the case of native clitoral hood redundancy, the
patient should be informed and made aware. Expectations and
goals should be discussed in the light of functional anatomy,
native asymmetries, and risks and limitations of each surgical
procedure, also with regard to the surgical alterations of the
clitoral hood.
It is essential to select a labiaplasty technique not just suited
to achieving a youthful appearance of the vulva but also able to
harmonize and balance the different anatomical elements. It has
been suggested that the wedge resection technique, especially in
its modification as extended central wedge resection described
by Alter, is able to prevent the development of clitoral hood
redundancy. This is achieved because with this procedure the
anterior projection of the clitoral hood is tensioned posteriorly
through the closure of the labia minora wedge defect. In the case
of native redundancy of the clitoral hood, its width may be treated
by closing the wedge defect with superior dog-ear excision along
either the clitoral hood or more laterally, by placing the scar in the
vulvar–labial sulcus.
Another technique that deserves special consideration for its
ability to minimize the onset of this complication is certainly
the composite reduction labiaplasty described by Gress in a
2013 article that considered 812 patients in the largest body
of research ever published. Indeed, the composite procedure
implies removal of tissue located cranial or caudal to the clitoris
in combination to the reduction of the labia minora, unlike the
other procedures that are designed to reduce the labial tissue
only in the part below the clitoris. Separate segments are
Fig. 103.3 Horizontal clitoral hood redundancy.
Fig. 103.4 Vertical clitoral hood redundancy.

103 Surgical Alteration of the Labia Minora and Clitoral Hood: Part 3
1547
removed to achieve uniform reduction of the labia across their
entire length and particularly in the clitoral hood area. The
technique also entails additional correction of the protruding
glans of a protruding clitoris when indicated. Gress reported
a very high overall patient aesthetic satisfaction at 6 months
follow-up, which equaled 9.4/10. Importantly, he also observed
sexual excitability improvement in around 35% of the cases,
especially among patients who underwent correction of clitoral
protrusion. This was correlated with the clitoris being positioned
closer to the vaginal introitus and therefore exposed to more
direct stimulation.
Finally, in order to prevent complications when performing
labiaplasty, it is important to avoid unintentional detachment of
the clitoris frenulum, as the release of this structure may deter-
mine and emphasize postoperative clitoral hood prominence.
All these technical considerations must be part of the preoper-
ative evaluation to ensure the selection of the appropriate treat-
ment option. It is also essential to recognize the importance of
adequate surgical training, as inexperienced surgeons may avoid
operating on the clitoral hood for fear of damaging the glans cli-
toris and consequently choose to perform only the edge resection
technique without clitoral hood reduction.
103.5 )reTuenFy
None of the original articles reporting on labiaplasty has indi-
cated the surgical alteration of the clitoral hood as a complica-
tion observed in the cases examined. However, the overall low
level of evidence of these publications may represent a bias, as
authors tend to promote their own techniques. Indeed, authors
such as Dr. Hunter have indicated that in their practice, clito-
ral hood redundancy is the most common reason motivating
women to seek corrective surgery after labia minora reduction.
Others have stated that in the majority of the cases patients
seeking labiaplasty in addition to labia minora ipertrophy also
present with clitoral hood ipertrophy, which must be treated
to avoid postoperative alterations and imbalanced results.
Although many surgeons would agree, further research is
required to validate this statement. Finally, regarding the char-
acteristics of the postoperative deformity of the clitoral hood,
horizontal excess has been reported to be more frequent than
vertical excess.
103.6 Treatment
Recommendations for the treatment of iatrogenic clitoral hood
redundancy appearing after labiaplasty were primarily formu-
lated by Dr. Hunter and Dr. Hamori. The first goal to be achieved
is the restoration of the balance between the clitoral hood and
the labia minora. Revision surgery is performed depending on
the orientation of the clitoral prominence, and it addresses
horizontal and vertical redundancy differently. The intervention
may be conducted under local anesthesia and be associated
with other procedures, such as fat grafting of the mons pubis
and labia minora to enhance volume and further balance the
clitoral hood. In all cases, reattachment of the frenulum of the
clitoris must be performed when required to retract the clitoral
hood posteriorly.
In the case of horizontal prominence, the lateral clitoral folds
are reduced with an excision oriented vertically, parallel to the
groove between the clitoral hood and the labia majora, where
the scar may be placed. Width reduction may be performed by
resection of triangles of the lateral clitoral hood as an anterior
extension of the central wedge resection, or by direct edge
resection, avoiding following previous incision lines. It can be
monolateral or more often bilateral, depending on the alteration
(Fig. 103.5).
In the case of vertical redundancy, the clitoral hood is reduced
by a transversely oriented excision performed via an inverted V
wedge, cephalic to the free margin of the clitoral hood, across its
full width and proximal to the free caudal hood margin. A con-
servative approach entailing direct excision of clitoral hood free
margins is recommended if the hood is significantly elongated
and covers abundantly the clitoral glans. The shortening is per-
formed in the anterior–posterior direction. With a conservative
approach, it is important to preserve the investing fascia of the
clitoris, which is reached by the incision but not penetrated by it
(Fig. 103.6).
Care must be taken in dorsal clitoral hood reduction, as this
may cause exposure of the glans clitoris. The resection must
always be superficial to avoid exposure of the clitoral glans if
they are covered or further exposure of a partially covered glans,
as this may damage the neurovascular structure with possibly
Fig. 103.5 Clitoral hood reduction for horizontal prominence using a
vertically oriented excision, parallel to the groove between the clitoral
hood and the labia majora, according to Hunter. (Right) Central wedge
resection associated with resection of triangles of the lateral clitoral
hood. (Left) Direct edge resection.

1548
XIII Female Genital Rejuvenation
permanent consequences for clitoral sensation. In particular,
special care must be taken in the case of dorsal hood excision
with inverted V resection as required by vertical redundancy.
To minimize the risk of lesions to the glans clitoris, it is appro-
priate to palpate the clitoris while performing dissection and to
dissect the dartos fascia superficial to the shaft and Buck’s fascia
of the clitoris. If, regardless of all the preventive maneuvers,
the patient presents with glans clitoris exposure, correction is
performed through clitoral hood advancement as a V-to-Y flap,
which may be safely transposed with an adequate base.
Hunter noted that in the case of simultaneous presence of verti-
cal and horizontal clitoral hood redundancies, it is recommended
to treat them with a single operation combining lateral vertical
excision with central horizontal excision. Although not fully
described in the peer-reviewed literature, such an approach was
defined by =eplin as an H-shaped excision.
Finally, for those patients presenting with overreduced labia
minora associated with prominent clitoral hood redundancy,
Alter proposed using the redundant hood to design a rotational
flap in order to reconstruct the amputated areas (Fig. 103.7).
This flap is described as an island clitoral hood flap randomly
based on the dartos fascia of the lower clitoral hood and the medial
labium majus, rotated ipsilaterally to reconstruct the labium. It
can be associated with wedge excisions and YV advancement
flaps. Patients with an absent upper and mid–labium minus and
clitoral hood redundancy, particularly those with multiple clitoral
hood folds or a separate fold lateral to the main clitoral hood, are
indeed ideal candidates for the procedure. The best result may
be guaranteed by the rotation of a single fold, ideal to mimic a
labium.
Fig. 103.7 Alter’s clitoral hood flaps: in patients with an absent upper and mid–labium minus associated with clitoral hood redundancy, an island
clitoral hood flap randomly based on the dartos fascia is rotated ipsilaterally to reconstruct the labium
Fig. 103.6 Clitoral hood reduction for vertical redundancy with a
transversely oriented excision performed via an inverted V wedge, as
described by Hunter.

103 Surgical Alteration of the Labia Minora and Clitoral Hood: Part 3
1549
103.7 Concluding Thoughts
Surgical alterations of the clitoral hood after labia minora
reduction include primarily clitoral hood redundancy. This may
result from an inappropriate preoperative evaluation not con-
sidering possible native clitoral hood redundancy or the need
for balancing labial reduction with the remaining clitoral hood
tissue. The complication is mainly associated with the edge
resection technique not combined with clitoral hood reduction.
Revision surgery is performed by addressing the resulting
horizontal clitoral hood redundancy with vertically oriented
excision of lateral clitoral hood folds, and vertical redundancy
with transverse excision of a portion of the hood, usually as
an inverted V wedge. The surgeon performing labiaplasty is
required to have a complete understanding of the anatomy
of the clitoral hood and its relations with the labia minora, to
master all techniques able to treat the area globally, and to
discuss expected outcomes and possible complications with
the patient.
Clinical Caveats
• Labiaplasty must be tailored to overall patient needs.
• An appropriate approach addresses comprehensively all ana-
tomical issues of the vulva, including labia majora skin excess,
ptosis of the mons pubis, and clitoral hood redundancy.
• It is imperative to include the clitoral area in the preoperative
examination prior to labiaplasty.
• Reduction of the clitoral hood must always be carefully
considered in association with labiaplasty to ensure a more
natural result and prevent surgical alterations of the clitoral
hood.
• It is essential to select a labiaplasty technique suited to har-
monizing and balancing the different anatomical elements.
• Special attention has to be paid while performing the edge
resection technique to avoid excessive labial resection, which
can result in postoperative relative clitoral hood redundancy.
• If the absolute preoperative prominent clitoral hood is not
addressed, the simple free-edge trimming or sculpting of
the labia minora excess will create an unharmonious result
emphasizing the redundancy of the clitoral hood.
• In case of native redundancy of the clitoral hood, it is appro-
priate to consider using Alter’s extended central wedge
resection or Gress’s composite resection.
• While performing any type of labiaplasty, it is important to
avoid unintentional detachment of the clitoral frenulum,
which may determine and emphasize postoperative clitoral
hood prominence.
• Care must be taken in dorsal clitoral hood reduction, espe-
cially when inverted V resection is used to treat vertical
redundancy, as this may cause exposure of the glans clitoris
and damage of the neurovascular structure with possibly
permanent consequences for clitoral sensation.
• To minimize the risk of lesions to the glans clitoris, it is appro-
priate to palpate the clitoris while performing dissection and
to dissect the dartos fascia superficial to the shaft and Buck’s
fascia of the clitoris.
Suggested Reading
[1] Alter G-. Labia minora reconstruction using clitoral hood flaps, wedge excisions,
and [2] Alter GJ. Aesthetic labia minora and clitoral hood reduction using extended
central wedge resection. Plast Reconstr Surg 2008;122(6):1780–1789
[3] Gress S. Composite reduction labiaplasty. Aesthetic Plast Surg 2013;37(4):674–
683
[4] Hamori CA. Postoperative clitoral hood deformity after labiaplasty. Aesthet Surg J
2013;33(7):1030–1036
[5] Hamori CA. Aesthetic surgery of the female genitalia: labiaplasty and beyond.
Plast Reconstr Surg 2014;134(4):661–673
[6] Hodgkinson DJ, Hait G. Aesthetic vaginal labioplasty. Plast Reconstr Surg
1984;74(3):414–416
[7] Hunter JG. Labia minora, labia majora, and clitoral hood alteration: experi-
ence-based recommendations. Aesthet Surg J 2016;36(1):71–79
[8] Hunter JG. Commentary on: Postoperative clitoral hood deformity after labi-
aplasty. Aesthet Surg J 2013;33(7):1037–1038
[9] Hunter JG. Response to “Clitoral Hood Reduction.” Aesthet Surg J
2016;36(7):NP232
[10] Hwang WY, Chang TS, Sun P, Chung TH. Vaginal reconstruction using labia mino-
ra flaps in congenital total absence. Ann Plast Surg 1985;15(6):534–537
[11] Liu L, Fan J, Gan C, Tian J. Staged reconstruction of the labia minora and re-
duction clitoroplasty for female pseudohermaphroditism. Aesthetic Plast Surg
2010;34(5):652–656
[12] Oranges CM, Sisti A, Sisti G. Labia minora reduction techniques: a comprehensive
literature review. Aesthet Surg J 2015;35(4):419–431
[13] Tepper OM, Wulkan M, Matarasso A. Labioplasty: anatomy, etiology, and a new
surgical approach. Aesthet Surg J 2011;31(5):511–518
[14] Zeplin PH. Clitoral hood reduction. Aesthet Surg J 2016;36(7):NP231

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XIII Female Genital Rejuvenation
104 Surgical Alteration of the Labia Majora and Mons Pubis
John G. Hunter and Yhelda Felicio
Abstract
Alteration of the external genitalia is increasingly sought by
women dissatisfied with the size, shape, or appearance of their
vulva. The labia majora and mons pubis are occasional sources
of concern: flatness at one end of the spectrum, and redundancy
and sagging at the other for the labia majora, and excessive
prominence for the mons pubis. Satisfactory outcomes require
accurate assessment of patient concerns and anatomic findings,
along with selection of the appropriate procedure.
Keywords
labia majoraplasty, labia majora reduction, mons pubis reduc-
tion, mons pubis lipoplasty, labiaplasty
104.1 Indications and
Contraindications
Aside from the medical issues complicating most surgical
procedures, contraindications to labia majora and mons pubis
rejuvenation are uncommon.
104.1.1 Labia Majora
Surgical alteration of the labia majora is sought for one of three
reasons: atrophic, redundant, ptotic majora (majora skin excess,
with wrinkles/folds being a common feature); very flat majora
with no skin excess for women desiring fuller majora—the
´Barbie Dollµ vulvar appearance (puffy majora fully covering the
minora) is a subset; and, least often, for debulking/defatting of a
puffy majora lacking skin redundancy.
Accurate assessment of patient concerns and evaluation of
their labia majora anatomy, along with selection of the proper
alteration procedure, however, is essential.
104.1.2 Mons Pubis
:omen with prominent, puffy, and occasionally sagging mons
areas often seek surgical alteration. Many are embarrassed by
the appearance of the mons in swimsuits or tight-fitting pants. If
mons fat pad prominence is present, contraindications to mons
pubis reduction are rare. Bony prominence without fat bulging,
however, would contraindicate intervention. As with labia
majora alteration, accurate anatomic assessment and procedure
selection are critical for optimal outcome achievement.
104.2 Pertinent Anatomy
104.2.1 Labia Majora
The labia majora (singular: labium majus) are bilateral, longitu-
dinal, hair-bearing, usually pigmented, skin and subcutaneous
fibrofatty and fascial tissue structures (equivalent to the scrotal
dartos in males) that form the lateral boundaries of the vulva (Fig.
104.1). They extend from the mons pubis anteriorly, where they
meet and form the anterior labial commissure, to the perineum
posteriorly, forming the posterior labial commissure. Medially
they are separated from the labia minora by the interlabial sulci,
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. 104.2).
The labia majora are mainly vascularized by branches of the
internal pudendal artery and vein. Innervation is by perineal
branches of the pudendal nerve, genitofemoral nerve, and poste-
rior femoral cutaneous nerve (Fig. 104.3).
Progressive atrophy and laxity of the majora commonly occur
after menopause.
104.2.2 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. 104.4). 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
Fig. 104.1 Labia majora anatomy.

104 Surgical Alteration of the Labia Majora and Mons Pubis
1551
production accompanying menopause. Pubic ramus angle vari-
ation can also contribute to degree of mons pubis prominence.
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.
104.3 Preoperative Assessment and
Operation Planning
Accurate assessment of patients’ concerns and expectations,
as well as detailed evaluation of vulvar anatomy, is essential.
Examination of the labia majora with the patient in the lithot-
omy position and while standing with feet shoulder width apart
is recommended. The mons patient can usually be examined just
standing, but if sagging is an issue, examination in lithotomy
should also be done. Internal examination is unnecessary for
both majora and mons patients. Photographs in all positions
examined should be taken and evaluated with the patient during
operative planning.
104.3.1 Labia Majora
As previously indicated, alteration of the labia majora is sought
by women concerned with prominent, puffy majora at one end of
the spectrum, and redundant, ptotic, lax majora at the other. In
between are women bothered by very flat outer lips.
Treatment is different for each of these conditions. Fatty
fullness without skin redundancy, occasionally seen in young
women seeking labia majoraplasty, may be treated by liposuction,
although improvement is usually modest. Flat or deflated majora
Fig. 104.3 Superficial and deep nerves of the female perineum.
(Reproduced from Hamori C. Female Cosmetic Genital Surgery. New
York, NY: Thieme; 2017.)
Fig. 104.2 (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. (Reproduced from Hamori C. Female Cosmetic Genital Surgery. New York, NY: Thieme; 2017.)

1552
XIII Female Genital Rejuvenation
with little or no skin excess may be successfully treated using
standard autologous fat grafting techniques. Deflated majora with
significant skin redundancy/ptosis (Fig. 104.5) are best treated
by reduction rather than augmentation. This cohort, in Hunter’s
experience, is the most common seeker of labia majora alteration.
Augmentation in these women should be considered with cau-
tion, as overly puffy outer lips, and unhappy patients, may result.
104.3.2 Mons Pubis
Women requesting alteration of their mons pubis often express
unhappiness with its perceived prominence—usually stating “it’s
too big.” Accurate assessment of the exact concern and precise
evaluation of mons pubis anatomy are needed to achieve optimal
outcomes. Usually, younger, nonobese women presenting with
mons prominence may be treated by suction-assisted lipectomy
(SAL), as the bulging is almost always due to fatty tissue, and
they have neither vertical nor horizontal mons skin excess. Many
women, however, have vertical skin excess—a long, sagging mons
(Fig. 104.6) requiring a horizontally oriented excision (as well
as defatting) to reduce the skin envelope and elevate the mons.
These women often complain that their labia majora appear to
have “dropped.” The anterior labial commissure is either very
low or not visible in these women. Some women, especially those
who are older and overweight, have both vertical and horizontal
skin excess—an excessively wide, U- rather than V-shaped mons
pubis (Fig. 104.7). The latter women require both vertical and
horizontal (T) excision, in addition to defatting. Proper proce-
dure selection is critical to achieve a satisfactory outcome.
104.4 2SerDWiYe 7eFKniTueV Dnd
Surgical Markings
104.4.1 Labia Majora
Depending on the patient’s complaint, vulvar anatomy and
expectations, one of three surgical techniques is employed: SAL,
autologous fat graft augmentation (or less commonly dermal
filler augmentation), or labia majora reduction by direct excision
of redundant majora skin and subcutaneous tissue.
Although infrequently requested, SAL of the labia majora may
be a reasonable surgical option for the rare woman presenting
with prominent labia majora and little or no skin redundancy/
laxity. Modest reduction may occur and is all that should be
offered or expected, as the prominence commonly is not due to
excess subcutaneous fat but rather muscle fibers and fascia of the
labia, dartos muliebris (“woman’s dartos”).
Autologous fat graft augmentation, by popularly described (i.e.,
Coleman) techniques, yield good outcomes in women with flat
majora and little or no skin laxity. Usually more than one grafting
session will be necessary to achieve the desired degree of “plump-
ness,” and this should be discussed preoperatively. Generally, no
more than 20 mL of fat per labium should be injected at a session
to avoid overcorrection. The entire labium should be injected, in
the superficial subcutaneous plane, using multiple passes with
an injection cannula. Waiting a minimum of 3 months before
performing subsequent fat injection is recommended. More than
two augmentation sessions are rarely requested, and the degree
of augmentation persisting at 6 months anecdotally appears
to be permanent. Autologous fat graft augmentation should be
employed with caution in women with more than mild skin laxity,
as an unacceptable degree of puffiness and majora prominence
may result. As stated, augmentation of the labia majora with
dermal fillers, such as hyaluronic acid, has been described in the
literature. Although evidently effective when a small amount of
augmentation or laxity correction is desired, the potential mate-
rial cost for large-volume augmentation and the temporary nature
of most dermal fillers appear to make their use less attractive than
autologous fat graft augmentation. Long-term studies are needed.
Deflated, ptotic labia majora are best treated by reduction.
Multiple excision techniques have been described. Excision from
the central portion of the labium (resulting scar longitudinally in
the midportion of the labium), the labium–thigh crease (scar at
the thigh–labium crease), and the medial portion of the labium
(scar in the interlabial sulcus) appear most commonly used.
Felicio has recommended central excision (Fig. 104.8) and
Hunter medial excision. Medial excision, which is crescentic
along the entire labia majora from the anterior to posterior
commissures, places the medial incision and the resulting scar
in the interlabial sulci and the lateral incision in the majora (Fig.
104.9). The markings should be made with the patient supine,
with maximum thigh abduction (frog-leg position), while pinch-
ing each redundant majus with forceps to determine the lateral
extent of excision. This must not pull the vaginal introitus open.
Fig. 104.4 Mons pubis anatomy.

104 Surgical Alteration of the Labia Majora and Mons Pubis
1553
Conservatively done in this manner, overresection—a severe
complication—should not occur. Resection should always be in
the subcutaneous plane; the fascial and muscular tissue should
not be excised but can be contracted by electrocauterization.
Properly performed with this technique, the resulting scar should
be minimally visible and the outcome consistently satisfactory
(Fig. 104.10, Fig. 104.11). For surgeons adequately experienced
in performing the procedures, combined labia majora and labia
minora reduction (Fig. 104.12, Fig. 104.13) or combined labia
majora and mons pubis reduction (Fig. 104.14) can be safely
performed. When combined majora and minora reductions are
performed, Hunter recommends majora reduction first. Greater
vulvar edema than seen with single-procedure surgery in the
early postoperative period (3–4 weeks) is common and should
be expected. The most common complication after labiaplasty,
although rare, is hematoma, so absolute hemostasis is essential.
104.4.2 Mons Pubis
As indicated, there are three mons pubis reduction procedures:
SAL, vertical excision (horizontal incision), and vertical plus hor-
izontal excision (T incision). The skin excision procedures always
include defatting; this can be done by SAL or open excision.
Hunter prefers open excision as it results in less edema and offers
more control in excision quantity and contour. For all patients.
regardless of reduction technique, the perimeter of the mons
to be defatted should be marked. For SAL (Fig. 104.15), bilateral
stab incisions should be planned and marked at the cephalic
lateral borders of the mons. For vertical excision, crescentic exci-
sion should be performed, with a Pfannenstiel-like incision scar
resulting (Fig. 104.16). Women presenting with both vertical and
horizontal skin excess—a long, U-shaped mons pubis—T excision
with defatting is needed. The horizontal crescentic marking is
made first. Then the vertical marking is made, in the midline,
extending to the anterior labial commissure (Fig. 104.17). All
markings should be made with the patient standing, and then
confirmed supine.
Fig. 104.5 A 36 -year-old woman with deflated, ptotic labia majora.
Fig. 104.6 A 32 -year-old woman with prominent mons pubis vertical
redundancy.
Fig. 104.7 A 35 -year-old woman with a prominent mons pubis with
vertical and horizontal (U-shaped) excess.
Fig. 104.8 (a) Labia majora central excision markings and (b,c) immediately after excision (Felicio).
a
c
b

1554
XIII Female Genital Rejuvenation
Fig. 104.14 A 29-year-old woman immediate post combined labia
majora and vertical mons pubis reduction
Figs. 104.11 (a) A 35-year-old woman before and (b) 4 months after
labia majora reduction (standing view).
a
b
Figs. 104.10 (a) A 27-year-old woman before and (b) 4 months after
labia majora reduction (medial excision).
a
b
Fig. 104.9 A 30-year-old woman with medial labia majora excision
markings.
Figs. 104.12 (a) A 26-year-old woman before and (b) 5 months after
combined labia majora and minora reduction.
a
b
Figs. 104.13 (a) A 33-year-old woman before and (b) 5 months after
combined labia majora and minora reduction.
a
b

104 Surgical Alteration of the Labia Majora and Mons Pubis
1555
Hunter performs SAL, vertical excisions, and most T excisions
under local anesthesia with oral diazepam sedation. Occasional
T excisions—in large excisions in obese patients—are done under
local anesthesia with intravenous (IV) sedation. SAL is performed
using standard wet techniques using small (< 3 mm) cannulas.
Care should be taken not to overresect, as a flat or concave mons
pubis will look abnormal. Incisions are closed with fast-absorbing
dissolving sutures.
Open excisions are performed with a scalpel blade and Colorado
tip electrocautery. Small closed suction drains are occasionally
used for T procedures and removed with the surgical dressing on
the second postoperative day. Otherwise, patients may remove
their own dressings. A two-layer closure is always performed,
with long-lasting monofilament dissolving sutures for the deep
dermal layer.
104.5 Ancillary Procedures:
Labia Majora and Mons Pubis
Minimally invasive, nonsurgical alteration of the labia majora is
also a reasonable treatment option for women with minimal or
mild laxity/redundancy. Technologies adapted for vulvovaginal
use, utilizing either radiofrequency or laser energy, have been
demonstrated to effectively tighten majora skin for many in this
patient cohort. Results appear to be temporary. Recovery is rapid
and reported complications minimal. Long-term side effects, if
any, are unknown.
Although apparently rare in the United States, Felicio has
reported patients requesting augmentation for mons pubis hyp-
otrophy. This can be achieved through standard autologous fat
grafting techniques. Felicio recommends that no more than 200
mL of fat be injected.
104.6 Perioperative Considerations,
Postoperative Care, and
Complications
104.6.1 Labia Majora
Labia majoraplasty may be performed under general anesthesia,
local anesthesia with IV sedation, or straight local anesthesia.
Hunter performs virtually all procedures under local anesthe-
sia—2% lidocaine with epinephrine and 0.5% bupivacaine—with
mild oral sedation (10–20 mg diazepam). Although procedures
can be performed in the lithotomy position, Hunter performs
all in the supine, frog-leg position, with the table in a slight
Trendelenburg position. Antibiotics, beyond topical antibiotic
ointment, are unnecessary, as there is no evidence-based liter-
ature supporting their efficacy for either labia majora or mons
pubis alteration. If prescribed, Hunter suggests a single oral
dose of a cephalosporin (or clindamycin for beta-lactam-allergic
patients) should be delivered intravenously 30 to 60 minutes
before incision if the procedure is being performed under general
anesthesia or taken 1 to 2 hours orally if it is being performed
under local anesthesia. Felicio prescribes oral antibiotics up
to 1 week post operatively. For SAL, small-diameter (< 3 mm)
cannulas are recommended. For reduction procedures, absolute
hemostasis is essential. Hunter also recommends a two-layer
closure, with a long-lasting monofilament interrupted dissolv-
ing suture used for the deep dermal layer. Aftercare is usually
straightforward: sanitary napkins are used as dressings for 5 to
7 days; minimal ambulation and ice compacts for 2 days; topical
antibiotic ointment application to incision lines twice daily for
5 days. Opioid analgesics are usually not needed beyond 1 or 2
days. Exercise is permitted after 1 week, and vaginal penetration
after 4 weeks. The result is usually evident in in 9 months.
Figs. 104.15 A 31-year-old woman (a,b) before and (c,d) 8 months after mons pubis suction-assisted lipectomy.
a
c
b
d

1556
XIII Female Genital Rejuvenation
Figs. 104.18 A 28-year-old woman (a) before and (b) 6 months after vertical and horizontal (T) mons pubis reduction.
a
b
Fig. 104.16 Vertical (horizontal incision) mons reduction markings.
Fig. 104.17 Vertical and horizontal (T incision) mons reduction
markings.
Figs. 104.19 A 24-year-old woman (a) before and (b) 8 months after vertical and horizontal (T) mons pubis reduction.
a
b

104 Surgical Alteration of the Labia Majora and Mons Pubis
1557
104.6.2 Mons Pubis Alteration
Mons pubs alteration may also be performed under local anes-
thesia, local anesthesia with IV sedation, or general anesthesia,
depending on the procedure and surgeon preference. Procedures
are performed supine with the thighs spread. Hunter routinely
performs SAL and vertical excisions of the mons, if isolated pro-
cedures, under straight local anesthesia. Combined procedures
and most vertical plus horizontal (T) mons pubis reductions/lifts
are usually done under local with IV sedation. General anesthesia
is rarely employed.
As with majora SAL, small-diameter cannulas (< 3 mm) are
used for mons pubis liposuction. Laser or ultrasound adjunctive
technologies can be employed to assist in defatting but are not
essential. Generally, two cephalic bilateral stab incisions are
adequate for access. Care should be taken not to overresect, and to
maintain a convex mons contour. Postoperative care is minimal.
Fast-dissolving stitches can be used, and antibiotic ointment
applied for a few days. Compressive panties can be worn for 7 to
14 days. Exercise and sexual activity should be limited for 7 to 10
days. The result is usually seen in 6 to 9 months.
Vertical (horizontally oriented excision) and T excision (both
horizontally and vertically oriented) both involve excision of skin
and subcutaneous fat. The defatting can either be performed by
SAL or open defatting. Hunter prefers open defatting. A closed
suction drain is occasionally used for T excisions. Two-layer clo-
sure is always used, with long-lasting, dissolving monofilament
sutures for deep dermal approximation. Topical antibiotic and
a compressive gauze dressing are applied and maintained for 2
days. If inserted, the drain is removed with the dressing. Exercise
can be resumed in 10 to 14 days. Scar management principles,
especially if a vertical incision has been made (T), should be used
to optimize the cosmetic scar appearance at 1 year. Results of T
excisions are shown in Fig. 104.18 and Fig. 104.19.
104.7 Outcomes and Results
The published literature specific for the labia majora and mons
pubis reduction outcomes, patient satisfaction, and compli-
cations/complication rates is very sparse. The extant overall
labiaplasty literature to date offers high satisfaction and low
complication rates. In his large labia minora and mons pubis
alteration surgery experience, Hunter anecdotally finds good sur-
gical outcomes and minimal, largely self-limited complications.
Persisting scar hypertrophy or keloid formation, particularly the
vertical limb of T mons excision, has been observed, as has been
an inclusion cyst after labia majora reduction. Overly aggressive
resection of the labia majora may result in either scar widening
or pulling open the vaginal introitus with thigh abduction. This
would be a serious complication that is difficult to correct. It is
best avoided by conservative reduction. The most common sig-
nificant complication observed is hematoma, which may require
evacuation. It is best avoided by meticulous hemostasis. Minor
persisting edema of the majora or minora after either majora
or mons rejuvenation, particularly SAL, is not uncommon, but
always self-limited. Mild asymmetries are not uncommon, but
rarely require revision. Significant asymmetry should be revised.
104.8 Concluding Thoughts
External genital cosmetic surgical procedures, including labia
majora augmentation/reduction and mons pubis reduction, are
increasingly being requested by women today. Competently per-
formed, labia majora and mons pubis rejuvenation procedures
can and should yield consistently good cosmetic results with
low complication rates. Plastic surgeons should be aware of the
genital anatomic variations and procedure options available to
achieve an optimal result for women seeking surgical rejuvena-
tion of their labia majora or mons pubis.
Clinical Caveats
• Listen to what the patient wants first, then accurately assess
anatomy, then choose the proper procedure.
• If the patient’s desired procedure and the anatomy-driven
procedure choice do not match (e.g., the patient has a
deflated sagging labia majora and wants fat augmentation,
or has a redundant mons and will only accept suction-assisted
lipectomy), explain why the particular procedure is wrong for
them. If the patient persists, do not do the procedure.
• Use surgical tapes, massage, silicone gel, etc., for incisions of
the mons pubis, especially if a T excision performed, and if the
patient does not have pubic hair. Scar lasers can be helpful
also.
• Edema of the labia minora is common after both majora and
mons surgery. It always resolves.
Suggested Readings
[1] Felicio YdeA. Labial surgery. Aesthet Surg J 2007;27(3):322–328d
[2] Hunter JG. Labia minora, labia majora, and clitoral hood alteration: experi-
ence-based recommendations. Aesthet Surg J 2016;36(1):71–79
[3] Hunter JG, Cross KJ. Cosmetic surgery of the female external genitalia. In:
Grant RT, Chen CM, eds. Current Cosmetic Surgery. New York, NY: McGraw-Hill;
2010:263–277
[4] Hunter JG. Considerations in female external genital aesthetic surgery tech-
niques. Aesthet Surg J 2008;28(1):106–107, author reply 107
[5] Triana L, Robledo AM. Aesthetic surgery of female external genitalia. Aesthet Surg
J 2015;35(2):165–177
[6] Fournier FP. Liposculpture Ma technique/Pierre François Fournier/”Mon Expe-
rience de la chirurgie intime”- 2 Edition - Paris - Arnette Blackwell SA- 75007
Paris - France;1996
[7] Felicio Y. Plastic of the pubis and external genitalia: two decades of experience.
Revista Brasileira de Cirurgia Plastica. 2011;26(2) April/June:321-327

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XIII Female Genital Rejuvenation
105 Vaginal Rejuvenation and Perineoplasty,
Surgical Alteration and Minimally Invasive Procedures:
Part 1—Vaginal Rejuvenation and Perineoplasty,
Surgical Procedures
John R. Miklos and Robert D. Moore
Abstract
This chapter provides a comprehensive review of tightening
the internal vaginal canal and the external vaginal opening
using both traditional surgical techniques and contemporary
nonsurgical minimally or noninvasive techniques, such as laser
and radiofrequency. These techniques are most commonly used
to tighten the inside and opening of the vagina in patients who
suffer from sexual dysfunction in the form of diminished vaginal
friction during intercourse. This chapter focuses on rejuvenation
for the most common indications of sexual function as well as an
enlarged vaginal opening, and reviews the indications, contrain-
dications, pertinent anatomy, operative technique, postoperative
care, and results.
Keywords
vaginal rejuvenation, vaginal tightening, perineoplasty, sexual
dysfunction, cosmetic vaginal surgery
105.1 Introduction
Female genital cosmetic surgical procedures, such as G-spot
amplification, labiaplasty, vulvar liposculpturing, and vaginal
rejuvenation, are becoming increasingly popular within the
fields of plastic surgery, gynecology, and urogynecology. Of these
procedures, vaginal rejuvenation has become the most debated
and controversial, due to the fact that the outcome of this pro-
cedure is considered by many to be primarily cosmetic with no
clear medical indication. Moreover, most discussions of vaginal
rejuvenation narrowly focus on the common controversy and fail
to fully explore the various surgical techniques used for these
procedures, which are aimed at both correcting the appearance
of female genitalia and improving female sexual functioning.
For this reason, this chapter provides an in-depth review of the
history and background of these female genital rejuvenation
and cosmetic procedures, including a review of the specific
techniques used for each. Common complications that arise due
to these types of procedures are reviewed, along with several of
the most common controversies on the topic. Finally, we discuss
common myths regarding these techniques and what has been
backed by science, in order to shed light on this burgeoning issue
regarding elective female genital surgery.
It is important to note that the phrase vaginal rejuvenation
has commonly been used within the literature to characterize all
elective surgeries performed on the vagina or vulva. We propose
that a clear distinction be made between these two categories.
Henceforth, the term vaginal rejuvenation will refer to procedures
that target the function of the female genitalia, including those
focused on the vaginal introitus and vaginal canal. While the term
vaginal rejuvenation has historically been applied rather broadly,
the term elective vaginal surgery on the other hand can be used
too narrowly and thought to include only the reduction of the
labial minora or labiaplasty. While these procedures are consid-
ered elective, individuals choose to undergo these surgeries with
the goal of improving sexual function through ensuring that there
is adequate support for the floor of the pelvis and repairing areas
of the vaginal introitus and vaginal canal. Female genital cosmetic
surgery, and specifically vaginal rejuvenation surgery, is truly an
´artµ and requires the surgeon not only to fix the appearance of
the internal and external vaginal canal but also to estimate the
caliber of both areas to improve sexual function for the patient.
105.2 Vaginal Rejuvenation
As already described, vaginal rejuvenation is a category of
surgical procedures whose target is to improve the function of
the internal female genitalia, including the vaginal introitus and
vaginal canal. There are several methods by which this goal can
be achieved. In particular, vaginoplasty and perineoplasty are
considered to fall into this category, as they are both surgical
techniques by which to “tighten” or decrease the overall diam-
eter of the vaginal introitus and vaginal canal to restore typical
structure and function. These methods do not target and repair
defects of the pelvic floor, rather they emerged as modifications
to the traditional posterior repair technique (i.e., colporrhaphy).
The colporrhaphy is a commonly employed technique used to
repair defects in the wall of the vagina due to the prolapse of a
pelvic organ, such as rectocele (prolapse of the rectum) or cysto-
cele (prolapse of the bladder). On the other hand, a perineoplasty
is performed by removing a small portion of skin tissue in the
shape of a triangle right above the anus, with sutures then placed
to tighten the vaginal introitus and perform perineal body recon-
struction. However, this procedure alone is useless in restoring
sexual function to a patient. A woman does not rely solely on
pressure and light touch receptors of her vaginal introitus (e.g.,
opening) to stimulate sexual arousal, enhance friction, create the
feeling of intimacy, or achieve orgasm but instead relies on the
stimulation of the receptors on the internal aspect of the vagina.
Perineoplasty and vaginoplasty can be used to repair the
tissue of the vaginal introitus and vaginal canal that has been
damaged during childbirth (Fig. 105.1). Even during normal

105 Vaginal Rejuvenation and Perineoplasty: Part 1
1559
vaginal deliveries, the stretching of the pudendal nerve often
leads to pudendal nerve latency and relaxation of the levator ani,
pubococcygeal, puborectalis, and transverse perineal muscles,
resulting in vaginal fascia trauma and subsequent separation from
the adjacent levator ani muscles. This sequence of events leads to
vaginal prolapse as well as to an overall widening of the vaginal
introitus and vaginal canal. It is well documented that the trauma
encountered during vaginal childbirth can lead to an increased
risk for many pelvic floor disorders, including overactive bladder
syndrome, stress urinary incontinence, pelvic organ prolapse, and
fecal incontinence. Looseness in the vaginal tissue at postpartum
can lead to gaping at the perineum and vaginal canal and diminish
the sensation of friction, which together significantly diminish the
capacity to reach a climax during sexual intercourse. The degree
of damage caused to the tissue of the vagina during childbirth also
significantly correlates with later reports of sexual functioning.
More specifically, at 6 months postpartum, women with either a
first-degree perineal tear or a perineum that is intact were much
less likely to experience sexual dysfunction compared to those
who sustained perineal tears of higher degrees (second, third,
fourth). Indeed, gynecologists have been grappling with issues of
sexual dysfunction owing to vaginal pathology following vaginal
childbirth for hundreds of years.
A number of pathophysiologic studies have found that delivery
through the vagina can significantly increase a woman’s risk
for marked changes in levator muscles, nerves, and support of
the pelvis. In fact, findings from the :omen’s Health Initiative
revealed that, compared to nulliparous women, the risk of
cystocele and uterine or vaginal prolapse is two times higher for
women who gave birth to one or more children, after adjusting
for body mass index (BMI), ethnicity, age, and other character-
istics. Furthermore, when polled, about 80% of urogynecologists
reported a willingness to conduct a primary cesarean section if a
woman elected to do so.
While these techniques of decreasing the diameter of the vag-
inal introitus and vaginal canal are not necessarily avant-garde,
they have traditionally been performed in the event of injury
following obstetric delivery that results in vaginal prolapse and
Fig. 105.1 (a) Torn transverse perineal muscles resulting in gaping introitus (photo). (© John R. Miklos.) (b) Torn transverse perineal muscle resulting
in gaping introitus (illustration). (© John R. Miklos.) (c) Enlarged vaginal caliber due to relaxation of the levator ani muscles (photo). (© John R. Miklos.)
(d) Enlarged vaginal caliber due to relaxation of the levator ani muscles (illustration). (© John R. Miklos.)

1560
XIII Female Genital Rejuvenation
perineal injury, rather than owing to complaints of sexual dys-
function, much less aesthetic concerns.
105.2.1 Indications and
Contraindications
Though many think the surgical indication for vaginal rejuvena-
tion is laxity, this is not entirely true. We have seen thousands
of patients in our practice who have vaginal laxity but do not
require vaginal rejuvenation. There is only one indication for
vaginal rejuvenation surgery: diminished or lack of friction/sen-
sation with intercourse. This diagnosis can be made only by the
patient who feels less vaginal friction and sensation with inter-
course resulting in less sexual satisfaction. This is not a diagnosis
a health care professional makes; it is a self-made diagnosis that
is presented to the surgeon for evaluation and recommenda-
tions. The health care provider should never recommend vaginal
tightening based on an exam alone.
Contraindications to vaginal rejuvenation surgery include
radiation therapy, vesicovaginal fistula, rectovaginal fistula,
enterovaginal fistula, lichen sclerosis, lichen planus, chronic pelvic
pain, levator myalgia, and diagnosed urogenital cancer. Relative
contraindications include uterine or vaginal vault prolapse,
dyspareunia, vulvodynia, levator myalgia, vaginal infections,
interstitial cystitis, a short vagina, and previously placed posterior
vaginal wall mesh.
105.2.2 Sexual Dysfunction
and Prolapse
Sexual dysfunction in women includes disorders related to
sexual arousal, desire, difficulty or inability to reach a climax,
and/or pain during sexual intercourse, that lead to distressing
feelings. This multifaceted disorder emerges as the result of
complex, interactional relationships among a number of factors,
including biologic, emotional, and psychological factors. A
number of the physical factors impacting sexual functioning
are attributed to the floor of the pelvis. The correlation between
pelvic floor disorders and sexual dysfunction among women is
very high. Moreover, findings suggest that receiving treatment
for a pelvic floor disorder may also have a beneficial impact on
symptoms of sexual dysfunction. While reviewing the compre-
hensive anatomy and neuroanatomy of the structures making
up the pelvic floor is beyond the scope of this review, it suffices
to highlight the findings suggesting that interventions designed
to improve the functioning of the pelvic floor typically also lead
to improvements in reported sexual function, as well as body
self-image.
105.3 Pertinent Anatomy
There is little doubt that patients requesting vaginal rejuvenation
have some type of anatomic distortion. It is extremely rare if not
nonexistent for a patient to present with diminished sensation
with intercourse and not have pelvic organ (vaginal) prolapse.
To understand vaginal prolapse, one must first understand the
pertinent normal anatomy. Contrary to popular belief, the vagina
is not a circular muscle. Instead, the vagina is shaped more like
a square with the anterior (i.e., ceiling) and posterior vagina
(i.e., floor) composed of a supportive layer known as fascia (Fig.
105.2a), and only the lateral walls are composed of muscles, spe-
cifically the levator ani muscles (Fig. 105.1d). A weakening of the
anterior pubocervical fascia can result in the bladder falling (i.e.,
cystocele; Fig. 105.2b), and loss of integrity of the rectovaginal
fascia will lead to a weakening of the posterior floor, resulting in
displacement of the rectum upward into the vagina (i.e., recto-
cele; Fig. 105.2c). The deepest point of the vagina, known as the
vaginal vault, and its uterus can also prolapse if their supportive
ligaments (i.e., uterosacral ligaments) are compromised. This
results in conditions known as uterine vaginal vault prolapse
(Fig. 105.2d) when the uterus is present and vaginal vault pro-
lapse when the uterus is absent.
It is extremely rare for a woman who complains of diminished
sensation with intercourse not to have a at least one type of vagi-
nal prolapse. The most common prolapse in patients complaining
of diminished friction with intercourse is a rectocele. Fixing
vaginal prolapse will often help or fix the symptoms (pressure,
bulge, difficulty emptying the bladder or rectum) associated with
the prolapse. Studies have also shown that fixing prolapse has
a positive effect on sexual function, but it does not tighten the
vagina. In other words, relaxation of vaginal tissue and vaginal
prolapse both appear to have an adverse impact on a woman’s
sexual functioning.
Surgery to repair pelvic floor disorders is not new. Moreover,
it is reasonable to assume that the goal of any of these surgical
repairs is to “restore sexual function.” A number of studies
highlight the connection among ratings of sexual functioning (as
reported by empirically validated questionnaires assessing for
sexual functioning) and pelvic floor prolapse, as well as the pos-
itive correlation between recovery following prolapse treatment
and sexual functioning. Table 105.1 and Table 105.2 provide
an overview of the existing studies examining the relationships
between pelvic organ prolapse and sexual functioning, pre– and
post–pelvic floor repair.
It is proposed that in the posterior region of the vaginal wall
there is some anatomic control over the vaginal caliber and that
this control is similar to its connection with the genital hiatus
and levator ani. The majority of surgical procedures aimed at
rejuvenation target and repair this wall. Given this, it is logical
that literature exploring repairs of the rectocele may more appro-
priately correlate with sexual function and vaginal caliber. For
example, one study examined female sexual function index (FSFI)
scores pre- and postsurgical repair of rectocele among a group of
symptomatic patients who were sexually active. Results from this
study indicated that domain scores of pain, desire, and satisfaction
all achieved significant improvements postoperatively. Similarly,
another study found that repairing the posterior region through
levatorplasty increased the risk for pain and decreased sexual
function among woman patients; however, when the colporrha-
phy was performed alone in the absence of levator ani plication,
sexual function tended to improve. The efficacy of posterior
surgery for sexual function has also been explored through scores
from the Pelvic Organ Prolapse Urinary Incontinence Sexual
4uestionnaire (PIS4-12). More specifically, one study examined
a group of patients following the surgical reconstruction of the

105 Vaginal Rejuvenation and Perineoplasty: Part 1
1561
pelvic floor with and without correction of the posterior. Results
from this study demonstrated significant total score improve-
ments for sexual functioning on the PISQ-12 for both groups.
Lastly, another study examined sexual functioning ratings on the
PISQ-12 across three distinct approaches of repairing a posterior
vaginal prolapse, which includes the use of a tissue graft. Similar
to the previous studies, findings from this study suggested that
posterior rectocele repair was associated with improvements in
ratings of sexual functioning on the PISQ-12.
105.4 Preoperative Assessment
A comprehensive evaluation is an essential process for a woman
who presents with a chief complaint of diminished vaginal sensa-
tion with intercourse or a relaxed or loosened vagina and would
like to experience tightening that enhances sexual function or the
correction of having a widened opening of the vagina, for exam-
ple, through vaginal rejuvenation. Accordingly, the evaluation
should include a medical history, the psychosocial assessment
of sexual problems, and/or satisfaction before anatomic changes
related to childbirth were observed. In addition, relationship or
marital issues, the evaluation of a women’s surgical expectations,
and the underlying reasons why she is choosing to undergo
the procedure should also be assessed. Sexual dysfunction is a
multifaceted issue, and it is vital to emphasize that the surgical
reconstruction, which is intended to restore vaginal support or
decrease vaginal caliber, cannot change psychosocial or psycho-
logical sexual problems, which may be the result of relationship
difficulties, abuse, depression, primary anorgasmia, or additional
psychological factors that may be even more complex.
Furthermore, a psychosocial and medical history must accom-
pany a physical examination and urogynecology assessment.
Fig. 105.2 (a) Normal supportive anatomy of the vagina (sagittal section) (illustration). (© John R. Miklos.) (b) Cystocele, a defect in the pubocervical
fascia (sagittal section). (© John R. Miklos.) (c) Rectocele, a defect in the rectovaginal fascia (sagittal section). (© John R. Miklos.) (d) Uterine vaginal
vault prolapse, a defect in the uterosacral ligaments (sagittal section). (© John R. Miklos.)

1562
XIII Female Genital Rejuvenation
Sexual dysfunction that is the result of a loose, relaxed, or widened
vagina may also be one of the first symptoms of the early stages of
pelvic floor problems, such as prolapse. Therefore, it is essential to
conduct a thorough evaluation.
When performing a vaginal examination to assess for vaginal
prolapse, it is wise not to use a full speculum but instead to
use one blade of a speculum (i.e., a half-speculum). Using a full
speculum obscures the vaginal prolapse, as the speculum covers
the anterior and posterior vaginal wall upon insertion. We rec-
ommend examining the patient in the dorsal lithotomy position,
placing the half-speculum in the vagina along the floor of the
vagina, and then having the patient Valsalva maneuver. Doing so
should allow the examiner to determine whether the anterior
vaginal or uterus prolapses, resulting in a cystocele (Fig. 105.2b)
or uterine vaginal vault prolapse (Fig. 105.2d). The examiner
should remove the half-speculum and then reinsert the speculum
so the blade slides across the anterior vaginal wall. With gentle
traction upward, one can then assess the posterior vaginal wall for
a rectocele (Fig. 105.2c) during Valsalva maneuver.
If a patient complains of less friction with intercourse and has
a rectocele, she is then considered a candidate for vaginal tighten-
ing. Please note that, if the patient has other forms of vaginal or
uterine prolapse, these areas should be fixed concurrently when
performing vaginal rejuvenation surgery.
105.5 Preoperative Planning
Preoperative planning is dependent upon the patient complain-
ing of a lack of friction with intercourse. At that time, she should
be assessed for vaginal prolapse. In our career of tightening
vaginas for more than 20 years, we can anecdotally say that 99%
of all patients seeking vaginal tightening have a vaginal prolapse
in the form of a rectocele. If a patient has vaginal prolapse, spe-
cifically a rectocele, she should be given an informed consent.
The patient needs to be told that her condition is not life threat-
ening but is instead a quality of life issue, and the choice of having
surgery is purely elective. She should also be informed of other
potential noninvasive therapies, such as Kegel exercises and phys-
ical therapy to strengthen her pelvic floor muscles. Though there
is little scientific literature supporting these minimally invasive
techniques to enhance sexual function, they are rarely associated
with complications. Finally, if available, she can be informed of
novel radiofrequency, laser, and magnetic devices, which have yet
to be scientifically proven for the treatment of vaginal laxity.
If the patient expresses interest in vaginal rejuvenation surgery,
the surgeon should discuss the success rate of achieving vaginal
tightness as well as the risks and complications of the surgery,
including injury to the rectum, rectovaginal fistula, infection,
abscess formation, failure to achieve vaginal tightness, recurrent
Table 105.1 The effect of pelvic organ prolapse on sexual function
Author, year
Study design
N
Objective
Population
Sexual function
measurement
Results
Ellerkmann
et al, 2001
Prospective
observational
study
237
To compare the
symptoms associated
with dysfunction of
the pelvic floor and the
severity/location of the
prolapse that coexists
Patients at Johns Hopkins
Medicine presenting with
symptomatic prolapse
of the pelvic organ
symptoms
The Pelvic Floor
Dysfunction
Questionnaire
Sexual dysfunction is
linked to increased POP
severity.
Barber et al,
2002
Multiarmed
clinical trial
343
To compare sexual
problems in women who
experienced prolapse
of the pelvic organ and
urinary incontinence
Women who were
community dwelling (n
= 343), 45 years of age
or older, presenting with
advanced prolapse or
urinary incontinence
The condition-specific
sexual function
questionnaire
Over 30% of the group
presenting with POP
reported that urine
leakage or prolapse
affected their sexual
function, in comparison
to 10% of patients with
urinary incontinence (p
= 0.02).
Novi et al,
2005
Unmatched
case-control
60
To compare sexual
problems for women who
experienced POP and
those without prolapse
Women presenting with
POP (n = 30), compared
to unmatched controls
(n = 30) without prolapse
symptoms
PISQ-12
POP may significantly
decrease sexual function
in comparison with
controls (81.4 ± 7.3 vs.
106.4 ± 15.5, p < 0.001).
Botros et al,
2006
Identical twin
study
542
To evaluate the influence
that childbirth has on
sexual abilities
Identical twins who were
sexually active (n = 276)
PISQ-12
Scores for sexual
satisfaction were higher
for nulliparous women
in comparison to parous
women, irrespective of
delivery mode and age
(102.5 vs. 93.5, p < 0.001).
Srikrishna et
al, 2008
Prospective
observational
study
43
To assess women’s
goals and expectations
when undergoing POP
restorative surgery
Recruitment group was:
women presenting with
POP symptoms who were
placed on a waiting list
for surgical pelvic floor
reconstruction
The prolapse quality-of-
life (pQoL) questionnaire
Approximately 20%
of women reported
dissatisfaction with
their sex life due to their
prolapse.
Abbreviations: PISQ-12, Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire-12; POP, pelvic organ prolapse; pQoL, prolapse quality-of-life.

105 Vaginal Rejuvenation and Perineoplasty: Part 1
1563
Table 105.2 Pelvic organ prolapse repair improved sexual function studies
Author, year
Study design
N
Objective
Population
Sexual function
measurement
Results
Barber et al,
2002
Multiarmed
clinical trial
343
To compare sexual
problems in women
presenting with POP and
urinary incontinence
Community-dwelling
women (n = 343), 45
years of age or older, who
presented with advanced
prolapse or urinary
incontinence
The condition-
specific sexual
function
questionnaire
Fewer women with
symptoms of POP indicated
that the capacity to engage
in sexual activity 6 months
after vaginal surgery was
affected by the prolapse
when compared to baseline
(0% vs. 33%, p < 0.01).
Rogers et al,
2006
Prospective
observational
269
To evaluate postsurgery
sexual problems in
women (e.g., POP and/or
urinary incontinence) at 3
and 6 months
Women who underwent
different forms of
reconstructive and anti-
incontinence surgeries
PISQ-12
Improvement of sexual
function scores was
observed after surgery (89
vs. 95, p < 0.001).
Stoutjesdijk
et al, 2006
Prospective
observational
67
To compare sexual ability
in women presenting with
symptoms of POP pre–
and post–vaginal surgery
Women who chose
to undergo surgical
reconstruction of the
vagina
The urogenital
distress
inventory and
incontinence
impact
questionnaire
revisited
A significant degree of
postsurgical improvement
was observed for women
with dyspareunia. The ease
of sexual activity, frequency,
and satisfaction from
intercourse also improved,
but not significantly.
Paraiso et al,
2006
Randomized
controlled
trial
106
To compare surgical
outcomes for three
distinct approaches to
prolapse (rectocele)
repair: site-specific
prolapse repair, posterior
colporrhaphy, or prolapse
repair with augmentation
from a submucosa graft
of the porcine small
intestine
Patients who underwent
surgery for posterior
prolapse that was stage II
or higher
PISQ-12
Postoperative PISQ-12 scores
significantly improved for all
groups (p < 0.001), and no
differences were observed
between groups.
Handa et al,
2007
The CARE trial
224
To provide a description
of sexual function pre-
and postsacrocolpopexy
Women with stress
incontinence and
prolapse (stages II to
IV) who planned to
undergo abdominal
sacrocolpopexy
PISQ-12
Mean PISQ-12 score means
significantly improved for
sexually active women pre-
and postsurgery (34.1 ± 5.2,
p < 0.001).
Komesu et
al, 2007
Multicenter
prospective
cohort
73
To evaluate the efficacy
of posterior repair on
sexual ability in women
who elected to undergo
reconstructive surgery
of the pelvis and/or
incontinence
Sexually active patients
who had undergone
pelvic reconstructive
and/or incontinence
procedures
PISQ-12
Surgery significantly
improved PISQ scores
in both PR and non-PR
groups, without a difference
between groups.
Azar et al,
2008
Prospective
observational
60
To assess the efficacy
of surgical POP
reconstruction for women
with sexual problems
Women who presented
with POP
FSFI
Postoperative improvement
was observed after 12 to 16
weeks (15.9 ± 10.7 vs. 21.9 ±
11.1, p < 0.05).
Kuhn et al,
2009
Prospective
observational
70 women,
64 men
To assess sexual function
in men and women
pre- and 4 months
postsurgery for POP
Heterosexual couples who
were sexually active and
presented with symptoms
of vault descent,
rectocele, or cystocele
FSFI
A significant improvement
was demonstrated for
the women’s FSFI scores
for factors such as desire,
lubrication, arousal, pain,
and satisfaction. For men,
significant improvements in
satisfaction and sexual drive
were observed.
Brandner
et al, 2011
Prospective
observational
68
To assess sexual abilities
pre- and postsurgery for
the repair of rectocele
fascial in patients who
were sexually active
and suffering from the
symptoms of rectoceles
Women who were
sexually active and chose
to undergo the surgical
repair of rectocele fascia
FSFI
Improvements for pain (p <
0.0001), desire (p < 0.001),
and satisfaction (p < 0.0001)
demonstrated significance.
Continued on page 1564

1564
XIII Female Genital Rejuvenation
vaginal prolapse, wound dehiscence, perineal dehiscence, levator
myalgia, and painful intercourse. The success and risks of these
complications are directly related to the skills of the surgeon and
should be described to the patient during the informed consent.
Like most plastic surgery and even more so with vaginal reju-
venation the postoperative results are dependent upon setting a
patient’s postoperative expectations. When pursuing cosmetic
surgery, patients will describe to a surgeon, most often using
photos, their desired postoperative results. The surgeon will then
discuss with the patient whether those results are achievable
based on the preoperative condition and the surgeon’s experi-
ence. The difference between setting postoperative expectations
with a visually aesthetic cosmetic surgery (e.g., labiaplasty,
breast augmentations, and rhinoplasty) and functional cosmetic
surgery (e.g., vaginal rejuvenation) is that there is no concrete
way for a patient or surgeon to describe postoperative subjective
tightness. Therefore, the preoperative explanation of success is
truly dependent upon the skills, technique, experience, and past
success of the surgeon. Because the majority of the vaginal rejuve-
nation is performed inside the vagina, it is impossible to mark the
vagina for tightness preoperatively. Vaginal tightness is assessed
throughout the surgery and is based on the surgeon’s experience
and basic knowledge of penile size and vaginal caliber. Obviously,
if a patient states her partner is well endowed, less surgical tight-
ening will be needed.
Finally, if the patient chooses to proceed with vaginal rejuvena-
tion a full discussion about treating all of her prolapse (i.e., uterine
prolapse, cystocele, enteroceles, urethroceles, vaginal vault
prolapse) and associated conditions (urine leakage, frequency,
urgency, constipation, dyspareunia, voiding dysfunction) should
be pursued if within the scope of the surgeon. It is not advisable to
tighten a vagina if a patient has uterine or vaginal vault prolapse
unless these conditions are treated prior to rejuvenation. Failure
to do so may result in a shortened vagina.
It has been observed that approximately 50 to 75% of women
who elect to undergo vaginal rejuvenation have additional symp-
toms, such as difficulty emptying the bladder, an overactive blad-
der, defecatory problems, increased pressure in the urinary region,
or dyspareunia associated with prolapse that causes the uterus
to be hit during sexual intimacy. It is also critically important to
gain an understanding of additional symptoms a prolapse may
cause by using validated instruments such as the PISQ-IR (Pelvic
Organ Prolapse Incontinence Sexual Questionnaire, International
Urogynecological Association [IUGA]-revised), the IIQ-7 (Impact
Incontinence Questionnaire), and the UDI-6 (Urogenital Distress
Inventory) in addition to a urogynecologic history form in order
to assess for these types of symptoms. If significant urogyneco-
logic pathology symptoms are present, evaluating them prior to
surgery is important, as this allows the symptoms to be properly
addressed preoperatively. Any type of prolapse that is discovered,
including rectocele, cystocele, enterocele, or vault/uterine pro-
lapse, must be properly repaired during the surgical procedure, as
vaginal rejuvenation does not effectively target these health prob-
lems. The pelvic floor’s foundation must also be fully supported
and intact before any type of procedure that is intended to tighten
the introitus or vaginal caliber is performed.
105.6 2SerDWiYe 7eFKniTueV
The surgical approach that is required for treatment is deter-
mined based on the results of the physical examination. It is
often discovered that most women who present with a widened
or loose vagina have prolapse (e.g., vault/uterine prolapse, recto-
cele, cystocele). In many instances, the prolapse is moderate (i.e.,
stage II at the vaginal opening) or lower, but it must be repaired if
it is present. The prolapse, which must first be corrected, dictates
the type of surgery that will be required for rejuvenation. Most
importantly, correction of the prolapse is the first step in the
Table 105.2 (Continued) Pelvic organ prolapse repair improved sexual function studies
Lakeman
et al, 2014
Prospective
observational
29
To determine the
effectiveness of prolapse
surgery for sexual ability,
sensitivity of the vaginal
wall, and vasocongestion
Patients who were
scheduled to undergo
a surgical procedure for
vaginal prolapse
FSFI
There was a significant
change in postoperative
sexual function (20.5 vs.
23.3, p = 0.30).
Thibault
et al, 2013
Multicenter
prospective
148
To assess the impact
that laparoscopic
sacrocolpopexy has on
health-related quality
of life, sexuality, and
sexual health in women
with urogenital prolapse
symptoms
Patients presenting
with POP symptoms
who chose to
undergo laparoscopic
sacrocolpopexy
PISQ-12
Postsurgical sexual function
was significantly heightened
(35.42 vs. 32.07, p < 0.05)
Kim et al,
2014
Prospective
observational
143
To determine the
effectiveness of surgery
that repairs POP toward
improved female sexual
ability
Patients who scheduled
a surgical procedure for
stages II to IV of POP
FSFI, PISQ-12
Postoperative increases in
PISQ scores were observed
25.0 ± 4.95 to 28.33 ± 5.1
(p < 0.001). Differences
were not observed pre- and
postsurgery for FSFI scores
(p = 0.08). Scores increased
significantly only for
satisfaction (p = 0.029).
Abbreviations: FSFI, female sexual function index; PISQ-12, Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire-12; POP, pelvic organ prolapse.

105 Vaginal Rejuvenation and Perineoplasty: Part 1
1565
repair of the pelvic floor and the vagina. If significant cystocele
(anterior compartment) and/or vault/uterine prolapse is encoun-
tered, the common approach to repair is robotic/abdominal/lap-
aroscopic before targeting the vaginal caliber and the posterior
region.
105.6.1 Traditional Posterior Repair
A short discussion on the surgical treatment of a rectocele is
essential in understanding the difference between posterior
vaginal wall prolapse surgery and vaginal rejuvenation. A tra-
ditional posterior repair is performed for patients who suffer
from a symptomatic rectocele. A rectocele is due to a break or
attenuation in the supporting structure of the posterior vaginal
wall (i.e., the rectovaginal fascia). When the fascia breaks or
weakens, the pressure inside the rectum will push into this
weakness, manifesting as a bulge. This bulge is a known as a
rectocele (Fig. 105.2c).
Though there are different techniques in repairing a rectocele,
the most common technique is called the posterior colporrhaphy
and simply requires dissecting the overlying vaginal epithelium
from the underlying fascia and plicating the rectovaginal fascia
(Fig. 105.3a–c). The surgery is usually performed using 0 or
00 absorbable or delayed absorbable suture. Then the skin is
closed using the same suture. This surgical procedure can fix
the rectocele, and this might improve sexual function as laxity is
removed, but this does not tighten the vagina.
105.6.2 Posterior Vaginal Wall
Rejuvenation
The repair of the introitus and the posterior region of the vaginal
wall is an essential component of the vaginal rejuvenation pro-
cess. In particular, surgical procedures for vaginal rejuvenation
are modifications and alterations of the vaginal correction for
prolapse, which focuses on the vaginal caliber and final diameter
as well as restoring the vagina to a prechildbirth state. These
procedures also extend well beyond the conventional perineo-
plasty and posterior repairs. That is, older approaches were
simply meant to reduce bulging skin/tissue, whereas the aim
of vaginal rejuvenation is to narrow approximately two-thirds
of the length of the vagina by reducing the genital hiatus and
vaginal caliber, thereby achieving the physical state that similar
to what it was prior to childbirth.
Vaginal rejuvenation begins just like a posterior repair and
entails making a skin incision at the perineum and inside the
vaginal introitus, usually in the pattern of a diamond, to remove
the excess skin. Next, a small incision is made in a vertical manner
in the vaginal epithelium of the posterior vaginal wall, followed by
the dissection of the vaginal epithelium away from the underlying
Fig. 105.3 (a) Skin incision at the perineum and posterior vaginal wall. (© John R. Miklos.) (b) Dissection of the skin from underlying rectovaginal
fascia and laterally to the levator ani muscles. (© John R. Miklos.) (c) Plication and repair of the rectovaginal fascia to fix a bulging rectocele (tradi-
tional posterior repair). (© John R. Miklos.) (d) Levatorplasty, initial suture placement. (© John R. Miklos.) (e) Levatorplasty, vaginal tightening of the
distal two-thirds of the vagina (inner tightening). (© John R. Miklos.) (f) Vaginal rejuvenation, a combination of a levatorplasty (inner two-thirds of the
vagina) and perineoplasty (vaginal opening). A direct 0-degree angle view. (© John R. Miklos.)

1566
XIII Female Genital Rejuvenation
rectovaginal fascia and then laterally out toward the levator ani
muscles. The dissection should extend approximately two-thirds
of the length of the vagina so the surgeon can tighten the distal
two-thirds of the vagina for the best results. Vaginal rejuvenation
is an extension of the posterior repair (Fig. 105.3a,b). After the
plication of the rectovaginal fascia (Fig. 105.3c) the next step
requires placing sutures at the base of the wall of the vagina,
which is the edge of the levator ani muscles (Fig. 105.3d). Tying
these sutures down will distort the normal anatomic position of
these muscles by pulling the levator muscles over the rectovag-
inal fascia in a process known as a levatorplasty (Fig. 105.3e).
Sometimes multiple layers of this suturing technique are required
to adequately tighten the vagina (i.e., the process of vaginal rejuve-
nation). A comparison of Fig. 105.1d and Fig. 105.4 shows how a
levatorplasty narrows the vaginal caliber. During the rejuvenation
surgery the vaginal diameter needs to be assessed repeatedly, as
several layers of plication are often required to reduce the vaginal
caliber and genital hiatus to an appropriate state (Fig. 105.4).
An overly aggressive plication can lead to an abnormally narrow
vagina and dyspareunia. Finally, the posterior vaginal skin incision
is closed using a delayed absorbable suture (Fig. 105.3f).
105.6.3 Perineoplasty and
Vaginal Rejuvenation
The next phase of vaginal rejuvenation involves completing a
perineoplasty, which involves the very detailed and meticulous
lateral dissection to achieve the lacerated edges of the superficial
transverse perineal muscles and to conjoin them in the midline
to promote uniformity at the level of the repaired posterior wall
(Fig. 105.5). To perform the tightening of the vaginal opening, a
sufficient amount of skin has to be excised from the introitus and
perineum (Fig. 105.5a). The lacerated or torn edges of the superfi-
cial transverse perineal muscles are identified and brought to the
midline with 0 delayed absorbable sutures (Fig. 105.5b,c). The
adjacent adventitia is also sutured, pulling the lateral adventitia
toward the midline. Finally, the skin incision is closed with 00
delayed absorbable sutures (Fig. 105.5d). A perineoplasty with-
out a levatorplasty will only tighten an enlarged vaginal opening.
Tightening of the vaginal opening alone will not enhance friction
during intercourse for a woman. In fact many woman who
receive a perineoplasty without a levatorplasty will suffer form
introital dyspareunia due to a narrowing of the vaginal opening.
For a patient to have a successful surgical repair her enlarged
vaginal caliber (lower two-thirds of the vagina) as well as the
vaginal introitus (opening of the vagina) must be narrowed (Fig.
105.6).
105.7 Ancillary Surgical Procedures
As already discussed vaginal rejuvenation surgery is routinely
coupled with other vaginal reconstructive surgeries, such as
cystocele repairs (paravaginal and anterior repairs), rectocele
repairs (posterior repair), intestinal hernia repair (enterocele
repair), vaginal vault prolapse (sacrocolpopexy, sacrospinous
ligament suspension, uterosacral vault suspension), uterine pro-
lapse surgery (hysteropexy), stress urinary incontinence surgery
(sling, Burch, Kelly plication) as well as hysterectomy.
Other commonly performed surgical procedures to enhance
the external vulvar aesthetics include labiaplasty—minora (Fig.
105.6b), labiaplasty—majora, clitoropexy, clitoral hood lift,
Fig. 105.4 Vaginal rejuvenation, a combination of a levatorplasty
(inner two-thirds of the vagina) and perineoplasty (vaginal opening). A
45-degree angle view. (© John R. Miklos.)
Fig. 105.5 (a) Gaping introitus. Enlarged vaginal opening is a result of
damaged transverse perineal muscles. (© John R. Miklos.) (b) Suture
placement in transverse perineal muscles. (© John R. Miklos.) (c)
Approximation of the transverse perineal muscle. (© John R. Miklos.)
(d) Perineoplasty completed. (© John R. Miklos.)

105 Vaginal Rejuvenation and Perineoplasty: Part 1
1567
clitoral hood reduction, autologous fat transfer (majora), liposuc-
tion (thighs, majora, mons pubis), hymen restoration, and mons
pubis lift.
105.8 Postoperative Care
Regular postoperative care is provided to women who have
undergone reconstructive surgery of the vagina. Most of the
procedures can be performed in an outpatient setting, and
surgery is conducted under general, spinal, or local anesthesia.
Additionally, a pudendal nerve block may be performed before or
during the surgery to help reduce postoperative pain. After the
surgery, the vaginal packing is briefly left in place and removed
before the patient is discharged. Postsurgical care instructions
are provided to the patient as well, and a 4-week follow-up
appointment is scheduled at the time of discharge. Pain is
managed with ketorolac 10 mg every 6 hours for 3 days, followed
by ibuprofen 800 mg three times per day for 10 to 14 days, and
narcotics are used as needed. A vaginal examination is not
necessary prior to discharge unless abnormal vaginal bleeding
or hematoma is suspect. We also recommend using polyethylene
glycol, 17 g in 8 ounces of water, every day for 28 days to enhance
bowel movements. The patient is instructed not to strain the
pelvic floor more than a bowel movement; not to straddle objects
(e.g., motorcycles, bicycles, horses); no intercourse for 6 weeks;
no vaginal insertion for 6 weeks; no tub baths, swimming pools,
lakes, or oceans for 4 weeks; and no driving while on narcotics.
The patient is instructed to call in case of fever, excessive pain,
vaginal bleeding, or difficulty emptying her bladder or rectum.
105.9 Outcomes, Risks,
Complications
Potential complications that are associated with vaginal reju-
venation include bleeding, infection, dyspareunia, wound rup-
turing, insufficient tightening, rectovaginal fistula, and introital
narrowing. Furthermore, a study involving 248 women who
underwent this procedure reported that 24% experienced tem-
porary constriction of the vaginal apex, and there was also 2%
extreme postsurgical pain, 1 wound rupturing, 2 insufficient
tightening, 2% overtightening, 2% bleeding that occurred after
the first sexual encounter, and 1 perineum microtears during
intercourse.
105.10 Results: Sexual Function
after Vaginal Rejuvenation
There is little doubt that pelvic prolapse leads to an increased
risk of sexual problems. The specific mechanisms underlying
this association, however, are not fully understood. Sexual
dysfunction is a complex disorder that arises as the result of a
confluence of a number of factors. Due to this complexity, it is
difficult to design adequate empirical studies to examine the
relationship between the two conditions. Treatment to repair
weakened and damaged vaginal tissue typically also leads to
reductions in sexual dysfunction and improvement in overall
sex life. It is possible that this is due to the relief experienced
from the distressing symptoms of pelvic prolapse, which led to
an avoidance of intercourse. Alternatively, it is also possible that
symptoms of prolapse led to decreased sensation, which led to
a difficulty in reaching a climax. The relationship could also be
explained by an enhanced self-consciousness surrounding the
distressing symptoms of pelvic prolapse (e.g., feeling as if the
vagina has become too relaxed, loose, or stretched).
Ozel and White conducted a ground-breaking study that exam-
ined sexual arousal, libido, vaginal sensations, and capability to
achieve orgasm among several women who had been diagnosed
with pelvic prolapse and compared their reports with a matched
group of women without pelvic prolapse (participants were
matched on age, marital status, and childbirth history). Results
of this study indicated that the group of women with relaxation
of the vaginal region and pelvic prolapse were at a significantly
greater risk for experiencing a lack of libido and diminished
Fig. 105.6 (a) Before vaginal rejuvenation: note the rectocele, enlarged vaginal caliber, and introitus (photo). (© John R. Miklos.) (b) After vaginal
rejuvenation, levatorplasty, perineoplasty, and labiaplasty (photo). (© John R. Miklos.)

1568
XIII Female Genital Rejuvenation
arousal during sexual intercourse, in addition to a lower number
of achieved orgasms during sexual intercourse, when compared to
the matched group of women without evidence of pelvic prolapse.
Given the findings that pelvic prolapse increases the risk
for sexual dysfunction, and repair of pelvic prolapse improves
symptoms of sexual dysfunction, it is logical that should a woman
present with symptoms of a widened vaginal introitus or vaginal
canal as well as genital hiatus enlargement, even in the absence of
symptoms of prolapse, she may be experiencing clinically signifi-
cant symptoms of reduced sexual sensation and function. So why
then are these women being assured that nothing is wrong with
them physically and, thus, given no recommendations for improv-
ing vaginal sensation and restoring their sexual functioning?
Pardo and colleagues were the first to provide empirical
evidence confirming the link between the size of the vaginal
introitus and vaginal canal and reported symptoms of sensation
during sexual intercourse. This study compared several women
presenting with signs of relaxed or wide vaginal introitus and
vaginal canal with a group of women who were simply interested
in undergoing vaginal repair to restore sexual functioning alone.
Women who were included did not exhibit signs of incontinence
or prolapse. A total of 53 women were included. Ninety-six
percent of participants reported experiencing a reduced sen-
sation in the vagina, 73 reported having difficulties reaching a
climax, followed by 27% who reported that they were completely
unable to achieve an orgasm. Only two of the participants had no
prior vaginal deliveries. After a surgical procedure that entailed
vaginal caliber repair and vaginal canal tightening, participants
were assessed for sexual functioning. Ninety percent of women
indicated that they experienced significant improvements in their
overall sexual satisfaction, while 94% of the participants indicated
that they could achieve an orgasm (Table 105.3). It is reasonable
to conclude from these data that vaginal diameter can have a sig-
nificant impact on the sensitivity and capacity to reach a climax
during sexual intercourse. Further, when these issues are repaired
using surgical procedures, ratings of sexual functioning are also
expected to improve. Indeed, Pardo and colleagues conducted
follow-up studies with a separate group of women that corrob-
orated these original data, such that the overall diameter of the
vaginal introitus and vaginal canal appeared to be directly related
to reported sensation and capacity to reach a climax during sexual
intercourse. Moreover, as with previous studies, reports of sexual
dysfunction improved following repair of relaxed or wide vaginal
introitus and vaginal canal.
Matlock and Simopoulos conducted a study that explored the
impact of subjective relaxation of the vaginal region in the presence
or absence of stress urinary incontinence on measures of sexual
functioning using the PISQ-12 following vaginal rejuvenation
through laser technology. Ninety-six participants were enrolled
in the study. Participants completed the PISQ-12 regarding their
current sexual functioning prior to undergoing the surgery, as
well as at 6 months postoperatively. The chief complaints across
all participants in the study included relaxed or wide vagina and
decreased sensation during sexual intercourse. Stage II POP-Q was
present in 65% of participants, suggesting that symptoms of pelvic
organ prolapse in the early stage may include a manifestation of
vaginal relaxation or widening. In terms of overall reports follow-
ing surgery using laser vagina rejuvenation, sexual functioning
appeared to improve significantly after the repair was complete
for most participants, with 53% reporting a notable increase in the
intensity of orgasms during intercourse following treatment. Only
13% of participants reported decreased PISQ-12 scores following
the procedure (Table 105.3).
A multicenter study conducted in the United States exploring
the sexual functioning of women who elected to have vaginal
rejuvenation genital surgery (e.g., vaginoplasty and/or perineo-
plasty) collected data from several diverse practices. The data also
encompassed outcomes from surgical specialists who perform
several procedures to improve patient satisfaction. Prior to the
operation, about 70% of the women who participated in the study
reported that their level of sexual behavior was poor/fair. After
the procedure, 86% of women who underwent perineoplasty/
vaginoplasty for their sexual problems reported experiencing
heightened sexual ability, and only 1% experienced a negative
effect. These results indicated that surgically repairing the vaginal
caliber, both the internal canal and vaginal introitus, can improve
sexual ability in women who are experiencing a relaxed vaginal
region. Furthermore, 83% of the women who underwent surgery
reported feeling satisfied with the vaginal rejuvenation outcomes.
The primary reason that this type of surgery was performed,
according to both physicians and patients, was due to limited
coital friction, sexual satisfaction, and looseness. More specif-
ically, Goodman explained that plastic surgery on the female
genitals (e.g., vaginal rejuvenation) fulfilled most patients’ goals of
achieving functional and cosmetic improvement that heightened
their sexual experience. Furthermore, many patients experienced
overall improvement and satisfaction of their body image as well
as enhanced sexual abilities (Table 105.3).
More recently there was an evaluation of sexual ability in 78
women who presented with decreased sensation in the vagina
during intercourse and vaginal laxity for which they elected to
undergo vaginoplasty/vaginal rejuvenation. The assessment of the
procedural outcomes entailed using the PISQ-12 prior to the repair
and once again after 6 months. Overall sexual ability pre- and
postsurgically, demonstrated a statistically significant improve-
ment in PISQ-12 scores (30.3 ± 6.6 vs. 38.2 ± 5.2, p < 0.001), and
all individual scores improved statistically except for premature
ejaculation of the partner, pain, and desire. Nonetheless, satis-
faction, intensity while climaxing, and excitement during sexual
intercourse all heightened following the procedure. However,
pre- and postsurgical subscores for painful intercourse did not
change (Table 105.3).
105.11 Concluding Thoughts
Vaginal rejuvenation surgery is becoming an increasing popular
form of elective surgery for women. It involves the repair and
restoration of the vaginal caliber for women who are experienc-
ing reduced vaginal friction or sensation during intercourse, or a
widened, loose vagina that negatively impacts their sexual lives.
It is often discovered that most women who are struggling with
these types of symptoms also have additional pelvic pathology
issues, such as prolapse, which must be addressed before any
form of vaginal rejuvenation can be performed. Typically, less
friction during intercourse, a decrease in the ability to have a
vaginal orgasm, and sexual dysfunction are among the first signs

105 Vaginal Rejuvenation and Perineoplasty: Part 1
1569
Table 105.3 Vaginal rejuvenation surgery and sexual function
Author, year
Study design
N
Population
Intervention
Outcomes
Results
Follow-up
(months)
Complications
Pardo et al,
2006
Prospective
observational
53
Women who experienced
a narrowed vagina as well
as the decreased ability/
inability to achieve a
climax
Colpoperineoplasty
(dissected with a YAG
laser)
Vaginal width,
sexual satisfaction/
activity, and
achievement of
expectations
90% reported a sufficient
improvement in satisfaction
94% reported reaching a climax
and a tightened vagina,
74% reported that their
expectations were completely
fulfilled.
15
4% of the women regretted the
outcomes.
Pardo et al,
2007
Prospective
observational
100
Women who experienced
a widened vagina as well
as the decreased ability/
inability to achieve a
climax
Colpoperineoplasty
Vaginal width,
sexual satisfaction/
activity, and
achievement of
expectations
95% reported experiencing a
tightened vagina during sexual
activity, 85% reported reaching
a vaginal climax, 79% reported
that their expectations were
completely fulfilled.
4
4% of the women regretted the
outcomes. For two patients
(0.02%) surgical complications
occurred that were minor.
Adamo and
Corvi, 2009
Prospective
observational
40
Women who experienced
a widened vagina
Lateral colporrhaphy
Sexual/vaginal
sensitivity
95% reported a widened vagina
by 6 months and a marked
improvement of vaginal
sensitivity, and 80% of the
patients’ partners reported a
marked improvement.
1.5
5% of the patients developed an
infection locally, and 2.5% of the
patients experienced vaginal
bleeding postoperatively.
Matlock and
Simopolous,
2011
Retrospective
96
Women who elected
to undergo vaginal
rejuvenation with laser
technology
Laser-assisted anterior
and posterior repair w/
perineorrhaphy
The comparison
of pre- and
postsurgical scores
for the PISQ-12
53% of the women experienced
heightened intensity during
sexual climax, and 13%
demonstrated a decrease in
PISQ-12 scores.
6
Goodman et
al, 2010
Multicenter
cross-sectional
258
Women who elected to
undergo plastic surgery for
the female genitals
vaginoplasty/
perineoplasty
procedures (n = 81)
Sexual function
prior to surgical
procedure,
procedural
satisfaction,
influence on
sexual partner’s
enjoyment,
complications
85% reported mild to significantly
heightened sexual ability, 86%
reported heightened satisfaction,
and subjective enhancement in
sexual ability for women as well
as their partners (p = 0.008).
6 to 42
4% reported temporary
stiffening of the vaginal apex,
2% reported wound rupture, 2%
reported extreme postsurgical
pain, 2% reported insufficient
tightening, 2% reported
microtear at 1-year follow-up,
2% reported excessive
tightening of the vaginal
introitus, 2% reported that
bleeding occurred after the first
sexual activity, 2% reported felt
the stitches inside the vagina,
2% reported narrowing of the
vaginal introitus.
Moore et al,
2014
Prospective
observational
78
Women who presented
with decreased sensation
in the vagina during
intercourse and vaginal
laxity for which they
elected to undergo
vaginoplasty/ vaginal
rejuvenation
Vaginal rejuvenation
The comparison
of pre- and
postsurgical sexual
ability through
PISQ-12 scores
Mean PISQ-12 score improved
from 30.3 ± 6.6 to 38.2 ± 5.2 (p
< 0.001).
> 6
Abbreviations: PISQ-12, Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire-12; YAG, yttrium-aluminum-garnet.

1570
XIII Female Genital Rejuvenation
women tend to experience when an underlying prolapse may be
progressing, and this necessitates a thorough initial examina-
tion. There is also ample evidence that shows that the relaxation
of the vagina and prolapse may induce sexual dysfunction and
that a successful repair may restore full sexual function in many
women. It is important to mention, however, that when address-
ing sexual problems that are exclusively the result of vaginal
laxity, the surgical procedure becomes quite meticulous, as it
is essential to enhance function and sensitivity while avoiding
complications that can cause further impairments. This reflects
what is known as The Art of Surgery!
Overall, this form of cosmetic, elective vaginal surgery is rap-
idly advancing both in terms of favorability for patients and suc-
cessful outcomes. It is also changing the face of our body-image-
conscious society. Although this discipline is still in the early
phases, it continues to progress and become well known as a
distinct field. Partially promoted by the ever-evolving global-
ization process, the Internet, and the desire to achieve antiaging
to maintain a vibrant, youthful appearance and sexual capacity,
elective vaginal surgery is here to stay. A woman’s desire to enjoy
life to its fullest requires a good body image, and sometimes a
little surgical help might be necessary to help maintain that body
image.
Clinical Caveats
• Though vaginal laxity can be seen on examination, the lack of
friction during intercourse is not a physical finding and can be
diagnosed only by the patient.
• It has been the authors’ experience that patients pursuing
vaginal rejuvenation almost inevitably have posterior vaginal
wall prolapse in the form of a rectocele on examination.
However, not everyone with a rectocele desires vaginal
tightening. Fortunately, the best area to perform surgery to
tighten a vagina is the posterior vaginal wall by combining a
levatorplasty and a perineoplasty.
• Surgical success is best defined by the patient postoperatively
and is most often seen in patients who have had approxi-
mately two-thirds of their vagina tightened. In experienced
hands, success rates of 90% can be achieved after vaginal
rejuvenation surgery.
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XIII Female Genital Rejuvenation
106 Vaginal Rejuvenation and Perineoplasty, Surgical
Alteration and Minimally Invasive Procedures: Part 2—
Vaginal Tightening, Surgical and Nonsurgical Options
Lina Triana
Abstract
After pregnancies the vagina loses tone, which contributes to a
decrease in friction on the anterior vaginal wall during sexual
intercourse that affects female sexual gratification. This is why
more and more woman seek vaginal tightening options.
The vagina is a tubelike structure that is located between the
urethra and vesical anteriorly and the rectum posteriorly and has
four distinctive layers in sum up are only 3- to 4-mm thick.
When examining a patient for a vaginal tightening procedure,
it is important to do a correct assessment to determine the best
treatment option for the patient. If a prolapse is discovered, or if
urine stress incontinence is present and is her main concern, she
should be sent to another specialist. Perform an internal vaginal
exam and look for looseness at the entrance and in the anterior
and posterior aspects of the vagina.
Several treatment options exist for vaginal tightening, such as
G-spot enhancers with hyaluronic acid and/or plasma; nonsurgi-
cal options, such as lipofilling, lasers, and radiofrequency devices;
and surgical approaches for tightening the vaginal entrance with a
perineoplasty and anterior and posterior vaginoplasties.
With the increase in patient demand for vulvovaginal proce-
dures, plastic surgeons are receiving more labiaplasty inquiries as
well as vaginal tightening options. As plastic surgeons we work on
the external body tissues, and a vaginoplasty is very similar to a
tummy tuck, in which we elevate the excess skin and plicate the
fascia in a manner similar to what is done during a vaginoplasty
procedure. If we want to lead in vaginal rejuvenation, we need to
obtain the knowledge of, training in, and experience with surgi-
cal and nonsurgical external and internal vaginal rejuvenation
options.
Keywords
surgical vaginal tightening, nonsurgical vaginal tightening,
sexual gratification, vaginal laxity, loose vagina, vaginal
rejuvenation
106.1 Indications and
Contraindications
During pregnancy the fetus’s weight is supported by the pelvic
floor muscles and will tend to elongate, just as during pregnancy
the breasts enlarge and tend to fall. These same muscles help
maintain the vagina in place, so, once the baby is born, these
muscles decrease in tone and thus provide less support to the
vagina and decreasing vaginal contraction, important for sexual
gratification. This is why any woman whose sexual gratification
decreases after giving birth can be a good candidate.
Women who present with vaginal prolapses are not candidates
for this procedure and must be sent to other specialists. Also, those
who want a correction of their stress urinary incontinence are not
good candidates for the procedure, although many times these
symptoms can be decreased with vaginal tightening options.
106.2 Pertinent Anatomy
The vagina is like a tube that on its apex has the uterine opening,
the cervix. It has an intimate relationship with other pelvic
organs, such as the bladder and urethra anteriorly and the rectal
canal posteriorly.
Vaginal walls, although only millimeters in thickness, have four
identifiable layers: mucosa, lamina propria (connective tissue),
vaginalis muscularis (smooth muscle), and adventitia (an exten-
sion of the endopelvic facia). Also, the pubocervical (anteriorly)
and rectovaginal (posteriorly) fasciae are present; they develop
from the separation of the mucosa and muscularis layers.
The vagina is held in position on its apex by the paracolpium; on
its middle level by the pubocervical and rectovaginal fasciae, which
hold the vagina in position by attaching to the arcus tendineus
anteriorly and to the levator ani muscles posteriorly; and on its
lower portion to the urogenital diaphragm and perineal body.
106.3 Pretreatment Assessment
Vaginal rejuvenation procedures require a thorough understand-
ing of what bothers the patient and what she really wants. As
with other procedures in our aesthetic plastic surgery practice,
this begins with listening to the patient and thereby establishing
the correct treatment plan. It is also important to address the
entire vulvovaginal area by examining the genital and vaginal
areas when developing the treatment plan.
When considering a vaginal tightening procedure for a patient
with stress urine incontinence, it is important to inform her that
although a vaginal rejuvenation treatment can help her with these
symptoms, stress incontinence should not be the main reason for
having the procedure.
Once this has been addressed, it is time to proceed to the exam
room, where it is important to provide the patient with a mirror
so she can show us what bothers her. The patient should first be
examined standing and then in the lithotomy position both in
front of and with a handheld mirror. The standing position and
the mirror are very important for addressing the genital area and
all external vaginal rejuvenation procedures.