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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of fat injected will depend on the vaginal canal length and the
laxity of the vaginal walls, but overall 12 to 20 mL can be injected.
Expect to end up with mucosal irregularities, such as lumps and
changes in color when the injection is too superficial. Generally,
patients do not like these changes, so make sure to tell her these
will be present after the procedure and will be permanent.
Fat can be reabsorbed, which is also something that must be
discussed with the patient. Too much fat can result in mucosal
wall necrosis, so the area must not be overinjected. Prophylactic
antibiotics are administered, and the patient is advised to restart
activities 2 weeks postprocedure.
106.6.2 Lasers CO2, Erbium, and Diode
Although many different types of lasers can be used for vaginal
tightening, there are too few scientific studies to support their
approval by the U.S. Food and Drug Administration, which
recently issued a warning on their use—an important point to
discuss with your patient. The two types of lasers commonly
used for this procedure are CO2, erbium, and diode. Lasers come
with special vaginal pieces to introduce the laser ray inside the
vaginal canal; in some brands these pieces are disposable and
in others are reusable. They produce an increase in vasculariza-
tion and collagen fibers that thicken the vaginal walls and also
improve mucosal skin quality.
The patient must be in a lithotomy position, and the vaginal
walls must be dry. It is recommended to clean the vaginal canal
with gauze until it is dry before introducing the laser. Proceed
to introduce the vaginal handpiece and rotate it while moving
out slowly, without leaving the handpiece still at any time. No
anesthesia is needed. The laser settings will vary according to
the machine and brand being used. One to three passes can be
done with each treatment. For better results treatment must be
reapplied for three or more sessions, with intervals that can vary
between 4 and 8 weeks between sessions. No special ointments or
medications are applied after treatment, and the patient can have
sexual intercourse 3 days after the procedure.
106.6.3 5DdiRIreTuenFy 0RnRSRODr²
Multipolar
Again, as with lasers, although many different types of radio-
frequency devices have been used for vaginal tightening, there
have been too few scientific studies to date. This is an important
point to discuss with patients. Regarding the use of a monopolar
or multipolar machine, some brands refer multipolar ones have
deeper dispersion of the radiofrequency; still it is important
to remember that when we say a device is better secondary to
deeper ray penetration in the vaginal walls, altogether the four
vaginal wall layers are only millimeters thick.
Some of the radiofrequency devices come with extra safety fea-
tures that help measure the amount of heat exposure on the skin.
They also offer special devices for measuring heat delivered in the
vaginal walls. Radiofrequency vaginal-tightening devices come
with special vaginal handpieces to deliver the treatment better;
these can be reusable or disposable, depending on the individual
brand.
The patient must be in a lithotomy position, and conductive gel
must be applied to the handpiece before it is introduced into the
vagina. Proceed to introduce the radiofrequency vaginal hand-
piece and rotate it while moving out slowly, without leaving the
handpiece still at any time. No anesthesia is needed. The power
settings will vary according to each machine and brand that is
used. More than one pass must be done with each treatment.
For better results treatment must be reapplied for three or more
sessions with intervals that can vary from 4 to 8 weeks between
sessions. The patient can resume sexual activities 3 days after the
procedures. No extra posttreatment medications are needed.
106.7 Surgical Approach
106.7.1 Perineoplasty
A perineoplasty is commonly used as an option for vaginal
tightening, but it only tightens the vaginal entrance, so it will not
necessarily increase sexual gratification for the female patient.
Also, when the perineal area is overtightened, a woman can
experience constant tearing during sexual intercourse.
This procedure can be done under local anesthesia, but general
anesthesia is preferred, since having perineal muscles relaxed
during the procedure makes it easier to tighten them at the mid-
line. Ideally the patient is in a lithotomy position. Infiltration in the
area for preventing bleeding or managing postsurgical pain must
be minimized because hydrodissection in the perineal area may
produce more postsurgical pain. Identification and differentiation
between the internal and external introitus is vital; ending up
with a smaller outer introitus than the inner introitus can result
in pain and tearing during sexual intercourse.
1. Mark the midline with a vertical line that should be 0.5 cm
above the anal mucocutaneous junction on the perineum. If the
midline is drawn touching the anal mucocutaneous border, once
the perineal skin is resected, it will exceed this limit, and the
anal sphincter can be involved in the resection.
2. With two mosquito forceps, one in each hand, pinch the bor-
ders of the external introitus on the perineal area and approx-
imate them on the midline to mark the external borders of the
perineal skin resection. These external borders, once sutured
together, will conform to your new external introitus or external
vagina opening, ensuring that the outer introitus will never be
tighter than the inner introitus, thus preventing overtightening
in the perineal area, which may leave the patient prone to future
tearing in the area during sexual intercourse. The easiest way to
identify the internal introitus is to seek the hymenal remnants
(Fig. 106.1, Fig. 106.2).
3. Resect the previously marked skin. If there is scar tissue in the
area, resect it too, and perform hemostasis.
4. Dissect and identify the pubococcygeal muscles.
5. Suture them back together at the midline, putting one initial
crossed single stich at the middle and then adding two more
crossed individual stiches, one anterior and one posterior, with a
single crossed 2–0 polyglactin (Vicryl , Johnson & Johnson, New
Brunswick, NJ) suture.
6. Suture the mucosa together with 2–0 Vicryl in single crossed
sutures.
No sexual intercourse, exercise, or heavy lifting is advised for
6 weeks. Stiches, although absorbable, will be removed after 10

106 Vaginal Rejuvenation and Perineoplasty: Part 2
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to 15 days since they can be annoying for the patient while using
underwear or walking. One hundred percent cotton underwear
and no tight pants are advised for 8 days after the procedure.
106.7.2 Posterior Vaginoplasty
A posterior vaginoplasty is done when laxity of the posterior
vaginal wall is felt during the internal vaginal exam. The pos-
terior vaginoplasty generally will start with the same markings
and skin resection as a perineoplasty, but previously a hydrodis-
section is done on the posterior vaginal wall with saline solution
and epinephrine (500 mL of saline solution + 1 mL of epinephrine)
(Fig. 106.3).
Once the skin is resected on the perineum, the cervix is pulled
upward and two Allis forceps are placed on each side of the resected
skin on the external introitus. The Allis forceps are used to create a
downward-pulling traction, and a third Allis forceps is placed supe-
rior to these two and is pulled upward to facilitate a tentlike dissec-
tion. Scissors are introduced at the border of the perineal resected
skin on the external introitus (the superior border of the perineal
skin previously resected), and the mucosa on the posterior vaginal
wall is dissected. A vertical incision is made on the previously
dissected mucosa. One Allis forceps is placed distally on each side
of the dissected mucosa, and one more Allis forceps is placed on the
midline distal to the other two lateral Allis forceps. The two lateral
Allis forceps are pulled down, and the distal Allis forceps is pulled
up to provide tension and start another tentlike dissection. These
steps are repeated until the mucosa wall dissection is completed all
the way up the posterior vaginal wall until about 1.5 to 3 cm from
the cervix neck or until vaginal wall laxity is felt (Fig. 106.4).
Fig. 106.1 Determining external introitus size. Approximating two mosquito forceps on the midline and making sure the external introitus does not
end up smaller than the internal introitus.
Fig. 106.2 Perineal markings. Vertical midline without touching the
change between perineal skin and anal sphincter, lateral marking
where two mosquito forceps were placed calculating new external
introitus.

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XIII Female Genital Rejuvenation
The lateral Allis forceps are pulled away from the vagina, and
blunt lateral dissection under the dissected mucosa is done on
both sides until the dissection borders start to go around the
posterior aspect of the posterior vaginal wall (Fig. 106.5).
A vertical strip of excess vaginal mucosa is then resected on
both sides (Fig. 106.6).
Hemostasis is done. Plication of the vaginal walls is made with
2–0 Vicryl with a running crossed (locked) suture. Then a second
layer of individual cross stiches are placed with the same 2–0
Vicryl. The procedure is finished by suturing the mucosal borders
together on a running crossed (locked) suture with 2–0 Vicryl.
106.7.3 Anterior and Posterior
Vaginoplasty
An anterior vaginoplasty is performed when, during the internal
vaginal exam, the anterior vaginal wall is found to be loose. It can
also be combined with a perineoplasty. It is not uncommon that
the patient complains of urinary stress incontinence when there
is anterior wall laxity. First the anterior vaginoplasty will be done.
The procedure begins with a hydrodissection of the anterior and
posterior walls with saline solution and epinephrine. To begin
with hydrodissection of the anterior wall, the uterine cervix is
pulled down, and the solution is injected until a whitish color is
seen on the mucosa. Then the procedure is repeated on the pos-
terior vaginal wall, starting the hydrodissection of the posterior
vaginal wall while pulling the uterine cervix upward. After this
the anterior vaginoplasty is started. The uterine cervix is again
pulled downward, and 1 to 3 cm above the cervix a horizontal
1-cm incision is made. Two Allis forceps are placed on each side
of the previous horizontal incision, and one more Allis forceps
is placed more distally. The two lateral Allis forceps are pulled
down, and the distal Allis forceps is pulled up to help give tension
and start a tentlike dissection. Scissors are introduced with an
upward motion at the border of the previously done horizontal
incision, and the anterior vaginal wall mucosa is dissected. A
vertical incision is made on the previously dissected mucosa.
One Allis forceps is placed distally on each side of the dissected
mucosa, and one more Allis forceps is placed on the midline
distal to the other two lateral Allis forceps. The two lateral Allis
forceps are pulled down, and the distal Allis forceps is pulled up
to help give tension and start a tentlike dissection. These steps
are repeated until the mucosa wall dissection is done all the
way up the anterior vaginal wall. Dissection is finished where
the rough mucosa starts on the anterior vaginal wall or when
the vaginal wall laxity is reached (the dissection should never
go near the urethra). The lateral Allis forceps are pulled away
from the vagina, and blunt lateral dissection under the dissected
Fig. 106.3 Infiltrating (hydrodissection) the vaginal wall. The uterus
is pulled upward (posterior vaginoplasty) or downward (anterior
vaginoplasty) to better expose the posterior and anterior walls.
Fig. 106.4 Elevating the vaginal wall. Dissection is done in a tentlike
manner using two Allis forceps on the sides and a third forceps more
distal to the other two forceps, creating a triangular tentlike effect.
After dissection, vertical incision of the mucosa is performed.

106 Vaginal Rejuvenation and Perineoplasty: Part 2
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mucosa is done on both sides until the dissection borders start
to go around the posterior aspect of the anterior vaginal wall.
A vertical strip of excess vaginal mucosa is then resected on
both sides. Hemostasis is done. Plication of the vaginal walls is
made with 2–0 Vicryl running crossed (locked) suture, and then
a second layer of individual cross stiches is placed with the same
2–0 Vicryl. The procedure is finished by suturing the mucosal
borders together on a running crossed (locked) suture with 2–0
Vicryl. After the anterior vaginoplasty is done, the perineoplasty
and posterior vaginoplasty are started as described in the poste-
rior vaginoplasty procedure.
106.8 Concluding Thoughts
As plastic surgeons we work mainly on the external tissues;
when we perform a tummy tuck, we elevate the excess skin and
plicate the abdominal fascia to improve muscle tone. This is no
different from what we do when performing vaginal tightening
procedures. As plastic surgeons, increasing numbers of patients
are coming to us asking for a labiaplasty. Today the plastic
surgery reconstructive concept of cutting the labia minora or
majora only when they are excessive has evolved, and with it
our aesthetic plastic surgery approach toward the vulvovaginal
area. We can no longer look only at the labia; we need to look
at the entire area to deliver what is best for our patients. This
is why today plastic surgeons realize that performing only a
labiaplasty and not correcting, for example, an excessive clitoral
hood is the wrong approach. Following the same rule of treating
the entire vulvovaginal area, and knowing that when a plastic
surgeon offers aesthetic genital procedures, patients will also ask
about vaginal tightening ones, we need to obtain the knowledge,
training, and experience in surgical and nonsurgical vaginal
tightening options to be true leaders in vaginal rejuvenation.
Clinical Caveats
• Always listen to your patient; every woman’s perceptions of
and feelings about her vagina are unique.
• Female sexual gratification is based on friction on the anterior
vaginal wall; tightening only the vaginal entrance will not
improve sexual gratification for females.
• Lower patient expectations when offering nonsurgical vaginal
tightening options.
• Never hesitate to perform a surgical vaginal tightening
approach when the patient needs it.
• Vaginal walls are only millimeters thick.
• Take large portions of the pubococcygeal muscle when sutur-
ing them back on the midline during a perineoplasty.
• When performing the anterior vaginoplasty, stay away from
the midline during the plication.
• Never leave the outer introitus smaller than the inner introitus.
Fig. 106.5 Blunt dissection of the elevated lateral flaps. Blunt dissec-
tion is done with a folded piece of gauze grasped by an Allis forceps.
Fig. 106.6 Resection of the excess mucosa. After the plication, excess
vaginal mucosa is resected.

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Suggested Reading
[1] Gaviria J, Lanz J. Laser vaginal tightening (LVT)—evaluation of a novel noninvasive
laser treatment for vaginal relaxation syndrome. Journal Laser Health Acad
2012;1:59–66
[2] Grimaldi EF, Restaino S, Inglese S, et al. Role of high molecular weight hyaluronic
acid in postmenopausal vaginal discomfort. Minerva Ginecol 2012;64(4):321–
329
[3] Millheiser LS, Pauls RN, Herbst SJ, Chen BH. Radiofrequency treatment of
vaginal laxity after vaginal delivery: nonsurgical vaginal tightening. J Sex Med
2010;7(9):3088–3095
[4] Moore RD, Miklos JR. Vaginal reconstruction and rejuvenation surgery: is there
data to support improved sexual function? Am J Cosmet Surg 2012;29(2):97–113
[5] Moore C, Daneshgari F. Vaginal anatomy for the pelvic surgeon. In: Zimmern
PE, Norton PA, Haab F, Chapple CCR, eds. Vaginal Surgery for Incontinence and
Prolapse. New York, NY: Springer; 2006:3–10
[6] O’Connell HE, Eizenberg N, Rahman M, Cleeve J. The anatomy of the distal vagi-
na: towards unity. J Sex Med 2008;5(8):1883–1891
[7] Pauls RN, Fellner AN, Davila GW. Vaginal laxity: a poorly understood quality of
life problem; a survey of physician members of the International Urogynecologi-
cal Association (IUGA). Int Urogynecol J 2012;23(10):1435–1448

107 Labiaplasty and Hood Reduction Complication Avoidance and Treatment
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107 Labiaplasty and Hood Reduction Complication Avoidance
and Treatment
Michael P. Goodman
Abstract
This chapter reviews the commonly observed complications
inherent in female genital plastic/cosmetic procedures, in this
case specifically the procedures of labiaplasty and clitoral hood
reduction. It is the author’s firm belief that complications are
best avoided rather than treated, and the chapter reflects this
philosophy. The reader will further note that the chapter is writ-
ten from a “real world” pragmatic perspective, reviewing the
eventualities actually encountered in a genital plastic/aesthetic
surgery practice rather than providing a list of known labiaplasty
complications and treatment protocols for each. A summary of
what is covered is listed at the end of this chapter in Clinical
Caveats, but this author recommends a thorough perusal of this
short chapter for any surgeon endeavoring to provide labiaplasty
services for his or her patient.
Keywords
labiaplasty, labiaplasty complications, genital plastic surgery
complications, complication avoidance
107.1 Introduction
The best way to deal with a complication is to avoid it! This chap-
ter will list the various complications involving labial and clitoral
hood reduction reported by physicians and patients, will focus
on how to avoid them, and will discuss the treatment modalities
available should a complication arise.
107.2 “Buyer’s Remorse”:
The Undereducated
Consumer
´It doesn’t look like I expected.µ ´The recovery was different
than expected.” “It took longer to heal.” “I didn’t want my hood
touched.” And so on and so forth.
While not strictly a “complication,” this is a catch-all situation
that will be covered in more specific detail in later pages. These
difficulties can be avoided by working with your patient in
regards to her expectations. :hile many patients will be specific
about what they wish, the majority will not, and must be “drawn
out.” Many patients are not aware of short-term postoperative
appearance, the edema, the ecchymoses, the risks, or the specific
recovery protocol involved.
107.2.1 Expectations
Be clear both about your patient’s expectations, what her anatomy
and your technique/skill level can support, and what you can and
cannot offer and accomplish, and document this clearly in the
medical record. Fig. 107.1 portrays a typical informed consent
document for labiaplasty. each procedure (e.g., vaginoplasty, labiaplasty plus vaginoplasty,
etc.). Fig. 107.2 is a sample recovery instructions document. Both
of these will go a long way toward explaining surgery, assuring
that you and your patient are “on the same page.” Use them, or
a facsimile. This author strongly suggests that surgeons literally
review these or similar documents out loud, verbally, with their
patients, rather than leaving it to lower-level office personnel to
complete with the patient. While time consuming, it is a reliable
way for surgeons to educate their patients and avoid “buyer’s
remorse.”
Patient communication is mandatory here. Does your patient
expect a linear/trim appearance? A wedge appearance? Does she
expect a “Barbie,” a “natural look?” And what does she mean by
these terms? Does she expect to return to her job as a barista 3
days from surgery? Does she understand the risks inherent in
the procedure? Have you established a rapport, a communication
with your patient that enables her to communicate her aesthetic
expectations and plans for recovery?
Have you specifically explained her preoperative medication,
her anesthesia" How she will look during the first 1 to 2 weeks (the
“Frankenstein phase”) of her recovery with the use of photographs
showing the edema, dissymmetry, irregularity, and ecchymoses
commonly encountered during this time? Have both you and she,
with the aid of a mirror, reviewed her personal anatomy and what
you can and cannot accomplish, and documented it" Specifically,
have you considered how you will (or will not) deal with the
various aspects of her clitoral hood. What does she wish? Can you
accomplish that? Have you discussed her feelings about both hood
reduction and posterior commissure reduction in patients with
“robust” hoods and/or posterior commissure who do not plan on
having these areas reduced" Have you explained the differences
between a (curvi-)linear and wedge-type approaches. What does
she expect?
107.3 “OMG! I’ve Been
Amputated!”
Of course the very best way to deal with overresection is to avoid
it. Labial amputation (overresection) almost entirely occurs with
the linear/trim technique when the surgeon is not familiar with
the “rules.”

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XIII Female Genital Rejuvenation
Fig. 107.1 Sample informed consent document for labiaplasty/clitoral hood reduction. (© Michael P. Goodman.)
Fig. 107.2 Postoperative instructions for labiaplasty/reduction clitoral hood. (© Michael P. Goodman.)

107 Labiaplasty and Hood Reduction Complication Avoidance and Treatment
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107.3.1 The “Rules” for
Linear Labiaplasty
1. Always remove less than you think you should; you will always
be taking off more than you think.
2. Make sure you know how much labia your patient requests be
left.
3. When making markings, let the labium lie slack; do not “pull”
on it while marking. The lines will “spring back” and you will
remove more than expected.
4. If reducing the hood at the time of labiaplasty, decide whether
you will use a single incision line from commissure to hood, or
separate lines for the labium and hood. Avoid T incision lines;
allow a minimum of 0.5 cm (more is better) between the labial
and hood incision lines.
5. When making lines medially, always stay lateral to Hart’s line;
when laterally, always mark the interlabial fold, and allow a min-
imum of 0.5 cm between the fold and your lateral incision line at
the posterior commissure, a minimum of 1 cm between the fold
and your line midlabium, and a minimum of 1.5 cm between
the fold and incision line at the cephalic portion of your incision
laterally.
6. Unless there is a very good reason to “debulk” the subcutaneous
tissue in order to narrow a thick labium, maintain as much sub-
cutaneous (loose areolar) tissue as possible because this is part
of your ´scaffoldingµ that aids in incision healing.
7. No matter how shallow your incision, always separately close
the subcutaneous tissue with either interrupted or continu-
ous small-caliber monofilament (4–0 or 5–0) suture, burying
knots, or if running, using an imbricating technique, which, if
performed properly, will nicely bring the skin edges together. If,
when forming this layer, the surgeon includes both deep tissue
and tissue near skin edges with an “edge-to-edge; deep; edge-
to-edge” technique, this suture layer not only approximates skin
edges but eliminates “dead space,” making hematoma formation
unlikely.
107.3.2 Who Gets Amputations?
Any surgeon not well educated in the skills of aesthetic labi-
aplasty, not following the “rules,” or not paying close attention
can produce overreduction (Fig. 107.3). In practice, in this
author’s experience the overwhelming majority of labiaplasty
amputations come from Board Certified general obstetrician-
gynecologists not specifically trained in their residencies in tech-
niques for aesthetic labiaplasty. They are operating in surgical
center or hospital venues, under boilerplate privileging, which
allows them to perform a ´partial vulvectomy,µ a very different
procedure from aesthetic labiaplasty. This is a distinction that
most hospital credentialing and privileging committees are not
aware of, which places these institutions at medical-legal risk.
107.3.3 Management
Management of overresection of tissue (“amputation”) is dif-
ficult. One cannot add resected labia back. The only thing one
can do is provide emotional support, and, if amputation leads to
wound dehiscence, which it often does (to be discussed), provide
appropriate wound care until full healing is effected. After full
healing and revascularization, either an island flap (if enough
redundant clitoral hood tissue remains) or (experimentally) plac-
ing medical-grade silicone implant(s) unilaterally or bilaterally
at the vulvar vestibule/interlabial fold juncture may be aesthetic.
107.4 Wound Dehiscence
Wound separation is caused by one or more of these four things:
hematoma formation, excess separating forces secondary to
excessive tissue excision and/or inadequate subcutaneous “scaf-
folding,µ medical and social factors adversely affecting wound
healing, or injudicious activities engaged in by the recovering
Fig. 107.3 (a) Labial amputation performed by a Board Certified general gynecologist untrained in aesthetic labiaplasty or clitoral hood reduction.
Hood epithelium may be utilized for island flap revision. (© Michael P. Goodman.) (b) Labial amputation performed by a Board Certified general
gynecologist. Inadequate tissue remains for flap revision. (© Michael P. Goodman.)

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XIII Female Genital Rejuvenation
patient. The surgeon has the opportunity to influence all of these
factors to prevent this disastrous complication.
Suturing the mucosa of the vulvar vestibule to the interlabial
fold in aggressive linear labiaplasty (see earlier discussion of
“amputation”) will frequently result in wound dehiscence as
the tensile tissue dynamics produced by sutures in the strong
squamous epithelium of the interlabial fold will serve to pull the
suture free from the more fragile mucosal epithelium of the vulvar
vestibule. Overly aggressive wedge-type incisions will have a
greater tendency to separate than more judicious removal (which
carries with it the complication of leaving excess tissue, necessi-
tating a minor revision, removing the excess epithelium, which
of course is superior to removing too much). One of the major
causes of wound dehiscence in wedge-type labiaplasty is failing
to provide a subcutaneous scaffolding foundational layer for both
added support and hematoma prevention. If all the dead space of
the incision is closed with one or two foundational approximating
layers, the skin and the incision will not separate. Surgeons who
opine that wedge-type incisions are inferior because they sepa-
rate are invariably not scaffolding their incision closures properly.
Thus we have the following “rules” for V-wedge labiaplasty.
107.4.1 “Rules” for V-Wedge-Type
Labiaplasty
1. Make sure you know how you will connect and ´flowµ all the
upper (frenular, central, lateral hood) folds down into the lower
posterior commissure.
2. Understand how much the patient wants removed.
3. Remember not to go too far in mucosally; remember to “hockey-
stick” the outside curved line upward.
4. Understand how to “make a Y” out of a “V” by going cephalad
to incorporate the lateral hood or preputial fold(s) as necessary
into a single incision, “laying down” the hood redundance later-
ally, after removal of redundant hood epithelium.
5. Maintain subcutaneous tissue integrity. Don’t remove too much
subcutaneous tissue! You will use this tissue in your foundation.
6. Your subcutaneous sutures are your most important. Remember
foundation. Mindfully reapproximate V edges with three to six
subcutaneous sutures of a fine monofilament, delayed absorb-
able, such as poliglecaprone (Monocryl, Johnson & Johnson, New
Brunswick, NJ) or polydioxanone suture (PDS). Place a subcuta-
neous layer also into the base of the Y extension if appropriate,
utilizing the same technique as described earlier under “Rules
for Linear Labiaplasty.” Eliminate all “dead space!”
7. For suturing the skin, use interrupted, mostly mattress, rapidly
absorbable sutures, such as polyglactin (Vicryl Rapide, Johnson
& Johnson, New Brunswick, NJ) or plain catgut. Subcuticular
sutures may be used for hood epithelial closure.
All labiaplasty incisions and all clitoral hood reduction incisions
should be repaired with a multilayer closure technique, using
fine monofilament suture layer(s) ´underneathµ as a subcutane-
ous closure, and either a fine monofilament subcuticular closure,
or a rapidly absorbing suture, such as plain catgut, or a rapidly
absorbing multifilament suture, such as Vicryl Rapide, or a
removable skin suture to be removed at a 10 to 14 days postop.
:hile it is tempting simply to effect a skin edge closure for a
linear excision of labia or clitoral hood, this author would strongly
lobby for a subcutaneous layer that both approximates skin edges
and gathers deeper recesses of the incision so as to eliminate any
dead space areas. In regard to wedge incision closure, an inter-
rupted layer of delayed absorbable monofilament interrupted
sutures, both eliminating dead space and closely approximating
skin edges of the V, will greatly reduce any risk of wound sep-
aration. A separate subcutaneous layer should be used for any
separate or “extension” incision utilized for reduction of robust
hood epithelium.
The following specific medical and social factors significantly
increase the risk of wound disruption:
• Abnormal blood glucose
• Tobacco usage
• Vascular disease leading to inadequate tissue perfusion
• History consistent with noncompliance
The surgeon has the ability to minimize healing difficulties
secondary to these factors by refusing to perform elective proce-
dures on these patients. Personally, this author will not operate
on diabetics with hemoglobin A1C levels greater than 7 (two
separate determinations 2 months apart prior to surgery), light
cigarette smokers (2–10 cigarettes/day) who have not abstained
for 3 weeks prior to surgery, and heavy smokers (> 10 cigarettes/
day) without abstinence for 4 weeks prior to surgery. This author
notes, and records in the medical record, his advice to all smok-
ers to abstain for an additional 4 weeks postoperatively.
:hile not evidence based, any condition significantly decreas-
ing arterial flow to the labia, such as arterial narrowing secondary
to plaque, would serve to increase the risk of poor wound healing.
This is the etiology of poor wound healing among cigarette smok-
ers. There is no evidence-based literature regarding the effect of
cannabis on wound healing.
No surgeon wishes to operate on a noncompliant patient,
as noncompliance greatly increases the risk of complication,
especially wound disruption. If noncompliance is suspected, the
surgeon might consider either refusing surgery or, more likely,
taking additional time to educate the patient regarding the huge
importance of pre- and postoperative compliance, the heavy price
to be paid for noncompliance, making a detailed entry regarding
the conversation in the medical record.
Once a separation has occurred, if less than 36 hours, and argu-
ably less than 48 hours, from termination of surgery, the incision
line may be re-repaired, using horizontal or vertical mattress
sutures generously. No re-repair should be considered more than
48 hours from surgery, as reseparation of these delayed reclosures
is practically guaranteed.
107.4.2 Management of
Wound Dehiscence
First, avoid reclosure at 48 or more hours from surgery. It will
not be successful. Routine wound care for dehiscence should be
employed, along with frequent and caring emotional support.
a 3 to 4 months from surgery and should not have a revision
attempt until full revascularization has occurred after 5 to 6
months from surgery. Management of wound dehiscence consists
basically of patient reassurance, proper wound management,

107 Labiaplasty and Hood Reduction Complication Avoidance and Treatment
1583
deciding what if any revision will be performed, and whether you
are sufficiently skilled to perform the revision or whether referral
to a revision specialist is the most prudent course of action.
107.5 “(S)he Didn’t Take
(nRugK 2̵µ
107.5.1 Avoidance
Careful communication with your patient with the judicious
use of other patients’ “before and after” photos will give both
the surgeon and the patient an idea of expected results, and
the combination of careful vulvar marking at surgery and sur-
gical experience will produce reasonable, expected results. It is
imperative that the surgeon clearly represent to the patient that
labia are not smooth, regular structures, that tissue removal is an
inexact science, and that both “exact” size and exact symmetry
cannot be guaranteed.
107.5.2 Treatment
After full healing and revascularization have occurred at a 5 to
6 months, additional tissue removal may be effected by either a
linear or a wedge excision.
107.6 “My Clitoris Sticks Out”
A patient may perceive clitoral prominence either because of
clitorimegaly or robust/redundant hood epithelium, and this
difference must be shown and explained to your patient during
preoperative counseling and preparation. While redundant hood
epithelium may be reduced along with labiaplasty, clitoral body
and glans size cannot be surgically reduced, and this fact must be
discussed with the patient.
107.6.1 Avoidance
The size of the clitoris and hood epithelium must be taken into
account during surgical planning. Patients with a robust clito-
ris should be worked up for virilization, and if they are using
testosterone products in robust dosages, either under a physi-
cian’s supervision, online, or “through the gym,” they should
be withdrawn from these medications and, ideally, the clitoris
allowed to self-reduce for several months prior to surgery, while
understanding that androgen-induced clitorimegaly may never
fully resolve.
If the hood epithelium is robust and this is a “bother” to the
patient, hood reduction should be part of surgical planning. In
situations where the hood is robust and where the patient desires
aggressive labial reduction, hood reduction should be encouraged
and, if rejected, the possibility of bothersome clitoral prominence
should be discussed with the patient and documented in the
medical record.
“Reasonable expectations” are important. Patients with a
robust clitoral body, especially with modest labia majora, may not
be able to achieve the absence of any protrusion from between
the majora and should be so counseled (and documented in the
medical record) prior to surgery.
107.6.2 Treatment
This is not a problem unless the patient has been clear from the
outset that hood protrusion from between her labia majora is a
major issue for her. If the patient is dissatisfied about hood prom-
inence secondary to conservative hood removal, a surgical hood
reduction may be effected a 3 months postlabiaplasty if no labi-
aplasty incision lines will be included in the revision, or after 5 to
6 months if hood incision lines will involve previous labiaplasty
lines. An additional option in this circumstance is augmentation
of the labia majora via a filler, fat transfer, or the combination of
platelet-rich plasma and nanofat particles injected into the labia
majora.
107.7 Asymmetry
107.7.1 Prevention
Take the time to draw (and redraw as needed) careful preopera-
tive lines prior to administration of local infiltration anesthesia
and believe them. Counsel your patient using “after” photos that
she will not be exactly symmetrical, and that modest dissymme-
try is a normal and acceptable outcome.
107.7.2 Treatment
If the asymmetry is a problem for the patient, acknowledge her
concern, counseling her that it will not be until at least 3 to 4
months postoperatively that final results will be appreciated and
that, if the dissymmetry is a bother (the operative word) to her,
that you will, at or after a 5 to 6 months from surgery, when total
healing and revascularization have been realized, effect a revision
to improve symmetry, that this revision will be the only one you
will do at minimal (to cover costs) or no charge, and document.
107.8 “OMG! It Looks Awful”
(First 2 Weeks of Recovery)
Labiaplasty incisions look positively awful during early recovery
(first 1–2 weeks³´The Frankenstein Phaseµ), and it is difficult to
predict which patients will have more edema, irregularity, and
ecchymoses than others. Patient education is important here,
and the use of graphic postoperative photographs (Fig. 107.4)
during preoperative counseling will go a long way toward dimin-
ishing unnecessary patient angst and frequent patient–surgeon
interactions during this time. Edema and ecchymoses are not
complications, and they will be better endured by the patient if
she is aware of their inevitability and potential intensity.
107.9 Bruising and Excessive Edema
Similar to surgery in other areas of loose areolar tissue covered
by epithelium and devoid of musculature (e.g., blepharoplasty),
labiaplasty recovery is rife with edema and ecchymosis during
the recovery process. Significant, irregular, and not necessarily
symmetrical edema, especially during the first 1 to 2 postop-
erative weeks, but not disappearing until a 2 or more months
postoperatively, is the rule. Patients must be educated regarding

1584
XIII Female Genital Rejuvenation
this eventuality (the use of vivid first-week recovery photos is
helpful), the fact that it is not necessarily symmetrical, and that
it is normal. They should be further educated on the difference
between postoperative ecchymosis, secondary to modest subcu-
taneous postoperative venous leakage, and hematoma formation,
as well as the “danger signs” that should generate a call to their
surgeon with a photo file, or possibly a hands-on exam.
107.9.1 Prevention
Meticulous intraoperative hemostasis and restricting excessive
ambulation during the first 48 hours postoperatively will mini-
mize the risk of excessive bruising. Adding frequent ice packs (for
20 minutes every 3–4 hours) for the first 5 days postoperatively
plus maximizing supine rest with the legs elevated will mini-
mize excessive edema.
107.9.2 Treatment
Treatment of excessive ecchymosis involves differentiating the
diagnosis to rule out hematoma formation that may require
evacuation, and “watchful waiting,” informing patients that their
vivid rainbow coloration will resolve over the next week or two.
Treatment of “excessive” edema (a subjective diagnosis)
involves frequent icing and continuous use of nonsteroidal
anti-inflammatory drugs (1SAIDs; e.g., ibuprofen 600 mg every
6 hours, naproxe 400 mg every 8 hours, or ketorolac 10 mg every
6–8 hours for 3–5 days).
107.10 Hematoma Formation
107.10.1 Prevention
Meticulous hemostasis using judicious cautery on modest
venous bleeders, and suture ligation with fine-caliber mono- or
multifilament sutures, is essential for larger venous and all arte-
rial bleeders. Elimination of all dead space with one to three
layers of subcutaneous fine monofilament sutures will prevent
hematoma formation when small venous or arterial vessels ooze
during recovery.
107.10.2 Treatment
Treatment begins with identification. Patients should be coun-
seled preoperatively regarding what is “normal” (ecchymoses,
edema, and frequent variability between sides in regard to
edema) and what is abnormal and to be reported. Patients should
have an easy way to contact their surgeon throughout recovery,
but especially in the first 72 hours postoperatively. Ideally, they
will have a mechanism for transmitting a ´selfieµ of their vulva
to their surgeon in uncertain situations. If a hematoma seems
probable, the surgeon may counsel the patient to fold several
gauze pads, or a couple of clean paper towels, into a palm-sized
pad and, with the ball of her hand, apply firm pressure to the
swollen area for 5 full minutes by the clock, and then to rest in
a recumbent position for 2 hours, avoiding most ambulatory
activities for the following 24 hours. If the area refills or does not
subside, evaluation by the surgeon and possible evacuation and
suture placement if appropriate, should be elected.
Hematomas are the major cause of wound separations, and care
must be taken to avoid them via hemostasis and elimination of
dead space, and early evacuation if one occurs.
107.11 Delayed Postoperative
Bleeding
Patients should be counseled that there will (not may) be some
amount of bright red oozing from their incision line if their
surgeon takes pains to avoid cautery at the skin edge that could
Fig. 107.4 (a) Two days postoperative bilateral V-wedge labiaplasty. (© Michael P. Goodman.) (b) Seven days post–linear labiaplasty. (© Michael P.
Goodman.)

107 Labiaplasty and Hood Reduction Complication Avoidance and Treatment
1585
lead to a skin burn. This small ooze usually stops on its own and
requires no care. Patients should be counseled that if a clot forms
over the incision line, this clot should not be rubbed off/removed,
as it is “nature’s dressing,” serves to stop her oozing, and will
dissolve on its own.
107.11.1 Prevention
As for hematoma, prevention of delayed postoperative bleeding
involves meticulous hemostasis and a layered closure.
107.11.2 Treatment
Patients should be counseled to report “dripping like a faucet.”
The procedure of pressure with a folded pad, described earlier,
may be used. In the rare situation that this is not effective and
steady bleeding continues, the patient should be instructed to
return to the office or urgent/emergent care facility for incisional
reopening, location of the bleeder, and reclosure.
107.12 Cautery-Induced Skin Burn
with Secondary Surface
Necrosis
Labia are thin structures. It is not unusual to encounter minor
venous oozing at the epithelial incisional edge. Unfortunately,
electrocautery of these bleeding sites carries with it the risk of
burn injury to the overlying epithelium.
107.12.1 Prevention
Prevention mandates extreme care with cautery along the edge,
using a more pinpoint device and lowered power settings. This
author does not cauterize minor bleeders on the edge, educating
patents that there will be modest bright red oozing for several
hours to a day or two; that a narrow clot may form on the inci-
sional edge that should not be disturbed and should be allowed
to resolve in place (“nature’s dressing,” as mentioned earlier).
107.12.2 Treatment
Treatment is conservative. The burned area will develop an
eschar, which rarely needs to be débrided unless it becomes
necrotic. Education and emotional support for the patient are
essential. The eschar usually falls off within weeks, and healing
is uncomplicated unless the burned area is broad and scarified,
in which case excision and reclosure after 5 to 6 months postop-
eratively may be undertaken.
107.13 “Sutures All Over the Place
Need Removal”
107.13.1 Prevention
The use of sutures needing removal should be discouraged for
labiaplasty. :hile fine nylon sutures, removed in 7 to 10 days,
leave a very aesthetic suture line, removal is arduous for the
surgeon and quite uncomfortable for the patient. The use of
delayed absorbable mono- or multifilament sutures, such as
Vicryl, chromic, and Monocryl, through the skin that need to
be removed either for comfort reasons or to avoid “train tracks”
(to be discussed) is to be avoided. Closure with subcuticular fine
monofilament sutures or the usage of a rapidly absorbing suture,
such as 5–0 Vicryl Rapide, if through the skin, will avoid this
eventuality.
107.13.2 Treatment
Treatment is obviously delayed (after 10 days) suture removal.
107.14 Infection
Infection is rare after labiaplasty, and while prophylactic anti-
biotics may be elected, they are not necessary and may lead to
postoperative yeast infections. While some surgeons use anti-
biotic prophylaxis, most do not, and in most circumstances they
are not necessary so long as a sterile technique is followed during
surgery and patients are counseled in proper clean wound care
during their recovery. Daily clean rinses, drying, keeping the area
well ventilated, and avoiding contamination are helpful. Patients
should also be counseled in identification of possible sepsis
(increasing pain with time; spreading and “halo-like” erythema/
induration) and prompt reporting to their clinician.
107.14.1 Treatment
Antibiotic therapy with a broad-spectrum antibiotic with both
gram-positive and gram-negative coverage, such as ampicillin/
clavulanic acid, sulfamethoxazole/trimethoprim, or a first- or
second-generation cephalosporin is given for 7 days.
107.15 “Train Tracks”
Incision Line
A bumpy, grooved incision line as noted in Fig. 107.5 is produced
by tissue strangulation from too-tight, too-long-lasting, too-
large, usually interlocked, delayed absorbable suture placement.
It is easily avoided and difficult to treat.
107.15.1 Prevention
Do not use large-caliber (3–0 or larger) sutures. Do not use
delayed absorbable (e.g., those sutures taking > 2 weeks to
dissolve) sutures through the skin, unless you plan to remove
them well prior to their dissolution, and do not place a running,
interlocked skin suture line.
107.15.2 Treatment (Near Term)
If using permanent or delayed absorbable sutures, plan on
removal at or shortly after 10 days postoperatively, after the
initial edema has subsided.

1586
XIII Female Genital Rejuvenation
107.15.3 Treatment (Delayed)
Two treatments are available for a permanently grooved suture
line, neither of which should be attempted until healing is com-
plete at 5 to 6 months. These include re-excision of the scalloped
skin edge, or “airbrushing” the “peaks” with radiofrequency or
laser energy, essentially “grinding down” the ridges, allowing a
new, “smoother” epithelium to develop underneath the healing
eschar.
107.16 More Pain Than Expected
during Recovery
107.16.1 Prevention
Postoperative pain prevention and relief depend on a constella-
tion of factors. First is education; the patient who is well prepared
for the vicissitudes of the recovery process, who is prepared for
the appearance, for the day-by-day changes encountered during
recovery, will experience less fear, less anxiety, and therefore
less pain. Also important in pain prevention is the “early and
often” theory of postoperative pain relief. This author encourages
pain control with a combination of NSAIDs and narcotic or non-
narcotic analgesics beginning postoperatively approximately 1
hour prior to the expected diminishment of intraoperative local
anesthetic. This author suggests combinations that may include
hydrocodone tramadol or extra-strength Tylenol (acetominipgen
1000 mg) with ketoralac, ibuprofen or naproxyn with food,
every 4 to 6 hours for 24 to 36 hours postoperatively, going to as
needed thereafter.
Also important in postoperative pain prevention is the choice
of sutures and tissue handling. Using a careful plastic technique
tissue handling and fine, mostly monofilament suture material,
good careful hemostasis, and minimal cautery as necessary will
diminish postoperative edema and minimize postoperative pain.
107.16.2 Treatment
Treatment involves evaluation for unsuspected complications,
plus both verbal and medicinal anxiolytics and adequate anal-
gesic coverage.
107.17 Postoperative Sexual
DndRr 9uOYDr 3Din
Patients should be counseled that a modest amount of superficial
discomfort may be encountered during their first few/several
sexual encounters, to discuss this with their partner, and to
use a generous amount of lubrication (this author favors oil- or
silicone-based lubricants) on both partners’ sexual parts during
initial sexual intimacy.
Longer-term and ongoing sexual pain is a complication, usually
caused by excessive tissue removal (“amputation”), operating too
close to the clitoral glans on the labial frenulum, or a too-tight,
too-long-lasting suture line (see earlier discussion of “train
tracks”). Prevention is the key here, avoiding excessive removal of
labial tissue, operating outside of Hart’s line, and avoiding placing
too-long-lasting, too-tight sutures, especially ones that involve a
running interlocked suture line.
While one may hypothesize that reducing and reforming the
labial edge, or removing a large wedge of labium and closing
the incision with a large number of sutures would lead to edge
sensitivity, or edge numbness, or nerve pain via neuroma forma-
tion, the reality is that, if the “rules” for both linear and wedge
procedures are carefully and universally followed, sexual pain will
not occur.
Pudendal neuralgia, neuropathic pain most likely secondary to
scarification and ´firingµ of a pudendal nerve branch, has been
identified. This rare postoperative complication is more common
after perineoplasty surgery, especially with re-dos with excess
scar formation. However, it has been identified in labiaplasty with
excessive tissue removal, especially after significant dehiscence
with delayed healing by secondary intention and scarification.
107.17.1 Treatment
Treatment of long-lasting sexual pain secondary to amputation
or ´groovingµ is difficult and involves sexual counseling, locally
applied analgesics, and/or neuropathic pain medications, such as
gabapentin or pregabalin.
Fig. 107.5 “Choppy” incision line secondary to inadequate linear
labiaplasty with running interlocked 3–0 Vicryl suture line, performed
by the patient’s general Board Certified obstetrician-gynecologist. (©
Michael P. Goodman.)

107 Labiaplasty and Hood Reduction Complication Avoidance and Treatment
1587
107.18 SuWure 5eMeFWiRn
Fistula Formation
107.18.1 Prevention
The use of monofilament rather than multifilament suture mate-
rial will prevent most suture rejection and fistula formation,
which, in the opinion of this author (but not evidence based), will
occur after a 1:100 to 1:200 labiaplasties with the subcutaneous
usage of a multifilament delayed absorbable suture material, the
larger caliber of which will lead to a greater risk of rejection.
Additionally, careful placement of subcutaneous sutures is para-
mount, as placement too close to the skin edge will increase the
possibility of rejection and fistula formation.
107.18.2 Treatment
A fistula may be repaired by thoroughly removing the fistulous
track and all scar tissue involved a minimum of 5 to 6 months
after the original surgery.
107.19 Hypo- and Hyperesthesias,
Including Clitoral Nerve
Damage
Edge sensitivity has been reported and discussed earlier in
this chapter (see “Postoperative Sexual and/or Vulvar Pain”
and “Train Tracks”). As in skin incisions elsewhere in the body,
neuroma formation is possible but unusual. Damage to the dorsal
nerve to the clitoris has been reported occasionally and is a result
of poor technique during clitoral hood reduction, incising too
deeply beneath Camper’s and Colles’ fascias, engendering injury
to or transection of the nerve as it passes at approximately the 9
or 10 o’clock and 2 or 3 o’clock positions from the pudendal nerve
medially to the clitoris, coursing just beneath the fascia.
107.19.1 Prevention
Proper surgical technique as follows will prevent these injuries:
1. Avoid amputation, as noted earlier.
2. Avoid the use of large-caliber, delayed absorbable skin sutures,
especially placed too tightly.
3. Avoid the use of any running, interlocked suture lines.
4. Avoid any deep dissection of the paraclitoral area. Use hydrodis-
section for the plane immediately below the hood epithelium,
keeping dissection to the loose areolar layer directly below the
squamous epithelium, well above Camper’s and Colles’ fascias.
107.19.2 Treatment
There is no effective treatment for damage or transection of the
dorsal nerve to the clitoris. However, as it is known that women
with spinal cord transection may still be orgasmic secondary to
stimulation of autonomic receptors located within Graefenberg’s
area (G-spot) and within other areas of the vaginal barrel and
cervix, education on ways to effect autonomic stimulation in
these sensitive areas may prove helpful. Hyperesthesias may be
treated, as alluded to earlier under, by oral or topically applied
local anesthetics (lidocaine; benzocaine/lidocaine/tetracaine
[BLT] cream anesthetic combination) or neuroleptic medications,
such as gabapentin or pregabalin.
107.20 7Ke 'iVVDWiVÀed 3DWienW
Obviously, a grossly poor outcome equals patient dissatisfaction.
However, any experienced female genital plastic/cosmetic
surgeon will tell you that there are many women who are quite
happy with what the surgeon would opine were only “fair”
results, whereas other women who, in the surgeon’s eyes, expe-
rience excellent cosmesis, indicate dissatisfaction (too little off;
asymmetry; irregularity; “I can still see my clitoris,” etc.). Why?
And how can these patients be identified preoperatively, and at
what point might an individual surgeon decide the best course
with a specific patient is to withhold services"
Understanding this, there are some ´red flagsµ to be aware of
to identify the patient more likely to experience postoperative
dissatisfaction, given adequate results:
• Lack of eye contact during the consultation
• Excessive touching during the examination
• Brings in “before and after” photographs, or pornographic
pictures, requesting specific results ´like thisµ
• Evidence of noncompliance (late for appointments, loses pre-
scriptions, disregards instructions, etc.)
• Partner takes control of the discussion
• History of revisions of other aesthetic surgeries
• Does not listen
• Office staff reports difficulties with the patient
Understanding this and identifying such patients and either
refusing surgery or taking increased time, extra consultations,
and certainly documenting your inability to guarantee specific
results can prevent later unanticipated patient dissatisfaction.
107.21 Concluding Thoughts
Diminishing the risk of complications is directly related to
understanding the errors of both omission and commission
inherent in female genital plastic surgery. The surgeon is
responsible first in being knowledgeable in both anatomy and
technique, of the many anatomic variations, as well as the vari-
ations inherent in different sides of the individual patient. The
surgeon must be savvy in technique and suture choices, provide
careful instruction to patients regarding the importance of their
responsibilities during recovery, and have a deep understanding
of the social and sexual overtones inherent in these operations,
as well as the importance of the surgeon’s own personal comfort
in his or her discussions with the patient. This is a time for a
relaxed, in-depth, honest discussion; rushing things (the usual
demeanor of many surgical practices) will not bode well in the
arena of female genital plastics.
While avoidance of complications is key, the consummate
genital plastic/cosmetic surgeon must be aware of the sexual,

1588
XIII Female Genital Rejuvenation
anatomic, and social minefield into which she or he has stepped.
The surgeon must instruct the patient in the art of complication
avoidance, how to recognize early signs of something amiss, and
how to communicate this to her surgeon. In turn, the surgeon must
be easily available to minister to the patient. Communications
must be facile, and the patient must have the ability to send pho-
tographs of her concerns, if helpful, to the surgeon expeditiously.
That said, proper treatment (or “watchful waiting” with verbal
reassurance) is an integral part of surgical care and must be part
of the genital surgeon’s armamentarium. Additionally, complica-
tion avoidance relates to patient selection. With “discretion being
the better part of valor” (Falstaff in Henry IV, part 1, by William
Shakespeare) as a mantra, the novice surgeon may be better
served by refusing surgery or referring to a more experienced
surgeon those patients with unusual anatomy or other sexual,
body image, or social challenges.
Clinical Caveats
• Get to know your patient and her expectations. Fully discuss
“reasonable expectations” with your patient. Both modest
asymmetry and clitoral hood exposure when the legs are
adducted is an acceptable outcome; make sure she knows
this.
• Understand and master both linear and wedge-type pro-
cedures so as to choose the technique that best fits your
patient’s anatomy, her recovery realities, and her aesthetic
desires. Careful drawing of incisional lines and use of non-
reactive monofilament subcutaneous “scaffolding,” both
for support and to eliminate all dead space, is paramount
in complication avoidance. Understand the rules for both
techniques.
• Be prepared to personally give complete informed consent
and discuss appropriate recovery instructions with your
patient. Emphasize the patient’s role in her recovery.
• Remove less than you think you need in linear labiaplasty; very
carefully and completely “scaffold” wedge reconstructions.
• Do not use regular Vicryl through-and-through the skin in
labiaplasty; use fine monofilament subcutaneous/subcutic-
ular sutures (e.g., 5–0 Monocryl), and a rapidly dissolving
suture like Vicryl Rapide for skin closure if needed. Never
effect skin closure with a running, interlocked suture line;
if properly scaffolded, skin closure can be effected with
subcuticular, interrupted, or loosely applied running, rapidly
absorbing or removable sutures.
• Begin pain control every 4 to 6 hours around the clock for
24 to 36 hours prior to diminishment of local anesthesia. If
general anesthesia, use either adjunct local, or begin pain
control in the recovery room.
• Establish a good communication arrangement with your
patient. Remember, surgical care includes appropriate post-
operative availability.
• Don’t reclose labiaplasty incisions beyond 36 to 48 hours.
• Maintain subcutaneous integrity as much as possible; stay
close to the epithelium when excising the clitoral hood.
• Take great care with cautery near the skin edges.
• Understand who your “high-risk” patients are. Spend more
time with them or consider refusing an individual’s surgical
request.
• Maintain the subcutaneous tissue in labial reduction; stay
close to the epithelial surface in hood reduction. The redun-
dancy is usually epithelial, not in the loose areolar subcuta-
neous tissue.
• Understand the medical and social factors that increase the
risk of wound disruption.
• Understand how hematomas form. Maintain hemostasis and
eliminate dead space.
• Do not “strangulate” tissue.
Suggested Reading
[1] Komisaruk BR, Gerdes CA, Whipple B. ‘Complete’ spinal cord injury does not
block perceptual responses to genital self-stimulation in women. Arch Neurol
1997;54(12):1513–1520

108 Female Genital Rejuvenation: Labia Minora Revision Surgery
1589
108 Female Genital Rejuvenation: Labia Minora Revision
Surgery
Michael P. Goodman
Abstract
Aesthetic vulvar labiaplasty is a common genital plastic/
cosmetic procedure. Ideally performed by trained, experi-
enced, competent plastic or gynecologic aesthetic surgeons,
it is unfortunately also performed by general gynecologic or
plastic surgeons untrained in the “rules” for successful outcome
secondary to a proper, reproducible technique. After avoidable
or unexpected complications secondary to poor technique, non-
adherence to postoperative care and instructions, or secondary
to performance by un-/undereducated surgeons, the outcome is
occasionally suboptimal or downright awful, and a revision is
either sought or mandated.
The great majority of surgical misadventures and poor or
unwanted outcomes are discussed, and techniques for revisions
are presented, either in passing (minor revisions) or in detail
(major revisions). :hile this chapter specifically covers labia
minora revisions, the topic of labia majora and perineoplasty
revisions is briefly approached. Techniques of edge resection, V
and <-V reanastomoses, (island) flaps, and various debulking
techniques are discussed and described. This chapter serves as a
review for the trained women’s genital aesthetic surgeon, and not
as a “cookbook” for the novice.
Keywords
labiaplasty revision, labial amputation, botched labiaplasty,
avoidable unintentional female genital mutilation, clitoral hood
flaps, revision of female genital plastic/cosmetic surgery
108.1 Introduction
Occasionally, a patient will consider her result suboptimal. This
chapter explores working with such a patient through her recov-
ery, the decision whether to revise, the timing of such a revision,
and suggested techniques to adjudicate the wide variety of
minor to significant adverse outcomes encountered in patients
requesting revision.
Revision is a term that may have different meanings when it
is paired with labiaplasty. This may be anything from excision of
a small dog-ear to a major re-do of an unintentional, avoidable
labial mutilation at the hands of a surgeon naive in the ways of
plastic technique and the “rules” for successful labial and clitoral
hood reduction, or an incision opened by inadvertent disruptive
activity during recovery. Many times the defect is obvious, but
frequently it is subjective; revisions often involve as much coun-
seling as technique.
It is not rare for a surgeon to view postoperative results that
are secondary to faulty technique, poor postoperative patient
compliance, or adverse healing conditions, and think, “It could
be better.” The patient may be satisfied, as her expectations
have been met with the debulking and nonvisualization of
previously protruding labia minora. On the other hand, the
surgeon may consider the results to be excellent, only to have
the patient complain: “You know, that little edge bothers me,”
or “The right side is a little bigger than the left,” or “See that
flap there?”
It is not unusual for a patient to view her labia much more
intensively postoperatively than she did prior to surgery, and
to be dissatisfied with slight or modest asymmetries, skin
tags, discolorations, protrusions, or dog-ears. It is not rare
for your patient who preoperatively swore that her posterior
commissure or clitoral hood needed no work, either because
“it did not bother her” or to avoid extra costs associated with
a more complex procedure, to note acutely, after surgery, the
appearance of these entities, which now appear more promi-
nent to her than prior to her surgery. Secondary to either poor
technique, poor choice of suture materials, or poor choice of
postoperative activities on the part of the patient, incision
lines may dehisce. And of course, tragically, it is not at all rare
for a woman whose labial and hood size/configuration was
aesthetically and/or functionally unacceptable to be harmed
by an ill-advised technique, the choice or placement of suture
material, or a recovery or tissue-healing glitch that leaves her
with a postoperative appearance unarguably less “aesthetic”
than prior to surgery.
108.2 Circumstances Resulting in
3DWienW 5eTueVW IRr 5eYiViRn
108.2.1 Surgical and Postoperative
Factors
Several surgical situations increase the potential that a revision
may be requested. Significant edema (perhaps from excessive
use of cautery or postoperative bleeding into the incision, larger
multifilament delayed absorbable suture material, injudicious
activities by the patient, or other unknown factors) can lead to
dissymmetry. Tearing out of suture(s) may lead to gaps and heal-
ing by secondary intention, or divots in the suture line. Failure
to bevel the ends of incision lines can lead to abrupt transitions
and dog-ears. Failure to curve incision lines upward in a V-wedge
may also lead to dog-ear formation on the lateral portion of the
suture line.

1590
XIII Female Genital Rejuvenation
108.2.2 Patient Factors
The importance of judicious postoperative self-care cannot be
overemphasized and should be carefully discussed with the
patient (with hard copy instructions) prior to surgery. Injudicious
activities lead to excessive edema and wound separation, often
leading to desire for revision or reoperation.
108.2.3 Physician Factors
Two factors come into play here. First is a failure in the patient–
physician interaction and outcome negotiation. The physician
must listen carefully to the patient’s aesthetic goals while also
assessing anatomical realities so as to skillfully counsel the
patient regarding the propriety of her desires as they relate to her
specific anatomy, with the goal being to agree upon a reasonable
goal or compromise. This involves expectations: the surgeon
must carefully prepare the patient for an approximate, rather
than a specific, result. :hen discussed results are not forthcom-
ing, a revision is frequently on the horizon. The physician must
listen carefully to the patient’s goals and also counsel the patient
as to the best operative procedure. For example, if a patient has a
very prominent clitoral hood but only seeks a labiaplasty and no
revision of hood size, the surgeon must counsel the patient and
document in the medical record that, after surgery, her hood will
appear quite prominent, and that some mitigation of this size at
the initial procedure would be advisable.
The second physician factor of course involves surgical expe-
rience and technique. A surgeon not specifically trained in both
plastic surgical technique and the specific analysis, technique,
rules, and suture choice for aesthetic labiaplasty has no business
undertaking this procedure, and to do so is below the standards of
care. However, the dictum of primum non nocere is regularly vio-
lated by cavalier gynecologic surgeons who feel “how hard can it
be?” and provide unsuspecting fodder for the revisional aesthetic
plastic surgeon and cosmetic gynecologist, via “amputation” with
frequent wound disruption, imbalance via nonreduction of a
prominent clitoral hood, or ongoing postoperative sexual pain and
tissue grooving via inappropriate choice and placement of suture
material.
108.3 Negotiation with the Patient
and the Decision Whether
and When to Proceed
In the end, you wish your patient to be satisfied. :hile some
anxious and/or dysmorphic patients will slip your notice and
make up a portion of patients seeking revision, more often it is a
specific area that the patient finds unsatisfying that she wishes
removed or revised. It is imperative that you and your patient
reach a clear agreement as to exactly what she wishes revised,
and to document this both in writing and photographically (Fig.
108.1 provides a consent for revision form). Be clear that revi-
sions will not be ongoing, certainly if you elect not to charge a fee
(the “standard” for the majority of minor revisions performed by
the primary surgeon). Many experienced surgeons will perform
one minor revision free of charge (perhaps exclusive of facility
use/supplies), but may charge for any further “rearrangements.”
108.4 )DFWRrV ,nÁuenFing :Rmen
to Seek Revision
108.4.1 Minor Revision
Factors influencing patients’ decisions for minor revisions
include the following:
• Dog-ears, small polypoid-appearing projections along or at
the end of suture lines
• Asymmetry in labial size postoperatively
• Area(s) of darker pigmentation and/or a visible bicolored line
• Minor visible anastomosis site grooving, usually in V-wedge
procedures, secondary to minor separation of the V-wedge
anastomosis site
• Prominent frenular edges secondary to insufficient edge bev-
eling in linear labiaplasties in women with prominent frenular
fold(s)
• Removal of a portion of suture that failed to absorb after > 3
months
• Minor fistula(e) immediately adjacent to the skin edge
• Minor separation of perineoplasty anastomosis site at the
introitus
• Inadequate tissue removal during labia majoraplasty with
resultant “festoons”
Major edge grooving secondary to improper choice of suture
or faulty technique, as well as repair of deeper fistulous tract(s)
produced by extrusion of suture material, will be discussed under
“Major Revision.”
108.4.2 Major Revision
Factors influencing patients’ decisions for major revisions include
the following:
• Grossly inadequate tissue removal with primary surgery
• Excessive labial removal, either complete (aka amputation)
with mucosa sutured to the interlabial fold, or partial, with
“bald” areas (this complication may present with or without
excessive, ptotic clitoral hood folds, and most frequently
occurs in women operated upon by a surgeon not educated
in aesthetic hood reduction, leaving a robust clitoral hood
unreduced)
• Decisions to secondarily remove tissue (e.g., hood, posterior
commissure, labia majora) initially unremoved secondary
either to patient choice or the surgeon’s inadequate planning
or counseling
• Suture line dehiscence involving major breakdown of the
original procedure (e.g., major separation of a V-wedge, major

108 Female Genital Rejuvenation: Labia Minora Revision Surgery
1591
Fig. 108.1 Consent for revision. (© Michael P. Goodman.)

1592
XIII Female Genital Rejuvenation
dehiscence of curvilinear incision) secondary to surgeon
technique error, injudicious recovery choices, medical factors
influencing healing (abnormal blood sugar, hypertension,
cigarette smoking, etc.,) or a combination thereof
• Major postoperative dissymmetry
• Disfigurement or major ´groovingµ secondary to injudicious
use of large-caliber, running (± interlocked) strangulating
suture closure
• Vaginal introital “gaping” secondary to lateral vectors from
aggressive labia majoraplasty, especially when also accompa-
nied by linear labia minoraplasty
108.5 Revision “Rules”
Revision “rules” begin with preoperative counseling, something
the revision surgeon may not have had the luxury to initially par-
ticipate in, but certainly may do so during the revision process.
Women initially consult with female-genital aesthetic surgeons
or their primary gynecologist secondary to dissatisfaction over
functional and aesthetic issues arising from “bulky” labia/clitoral
hood folds, and their subjective assessment thereof. One of the
most important duties of the female-genital plastic/cosmetic
surgeon is to work carefully with the patient to share anatomic
and surgical realities as they relate to potential outcome, to set
reasonable expectations for an eventual cosmetic and functional
outcome, to carefully explain the realities of a labiaplasty recov-
ery, and to carefully and clearly delineate the rules for patient
conduct during the recovery process. Of course, the initial surgi-
cal procedure is the best time for “getting it right.” Similarly, the
revision may be the only “second chance” your patient will have
to be made aesthetically and functionally whole.
108.6 Timing of Revision
108.6.1 Communication with the
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It is imperative that the potential revision surgeon explain that
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be suggested prior to 6 weeks postoperatively, and that, while the
possibility of later revision may be discussed, it will not be until
3 to 4 months postoperatively that final results will be apparent,
and that no revision plan will be discussed until that time.
Minor revisions not involving original suture lines may be
effected at a 3 to 4 months postoperatively. These may involve
excision of minor dog-ears, polypoid projections, or minor “shave”
of protruding areas of labia not involved in original excisions.
Reduction of redundant clitoral hood folds not involved in the
original surgical procedure may be considered at this time, so long
as they do not involve a foray into original suture lines.
While more major revisions may certainly be discussed at 3 to
4 months, the revision surgeon must make it clear to the patient
that no revision will actually take place until a 6 months from the
date of the original procedure, at which time the original suture
or dehiscence lines or scarred areas have had the opportunity to
revascularize.
108.7 The “Revision Surgeon”
Who “should” perform the revision? While this may be the
patient’s original surgeon, for many reasons, including loss of
confidence in the primary surgeon, a secondary surgeon is fre-
quently consulted about performing a revision. It is this author’s
opinion that the potential revision surgeon first suggest that the
client might first consider her primary surgeon for the revision,
and document this discussion, even if it appears that this surgeon
proceeded with improper technique at the original procedure.
This documentation may include the revision consultant’s opin-
ion of the primary technique utilized and how this may inform
or disadvantage the repair or revision.
The revision surgeon must have experience commensurate
with the revision procedure at hand. If a complicated re-wedge or
flap may offer superior results, a consummate ´revisionistµ must
be both savvy and comfortable in these waters; if not, it may be
preferential to refer to a surgeon possessing the necessary skills
to accommodate the task. While of course the primary procedure
is the time for the best results, the first revision may be the only
other time to effect a viable result.
108.8 Prerevision Paperwork
A mutual decision to perform a revision should not be taken
lightly and should be negotiated with discussion regarding the
patient’s goals and what the surgeon can and cannot do. No
specific outcome promises should be made, while taking the
patient’s reasonable outcome desires into account and docu-
menting all. A sample revision informed consent is reproduced
(Fig. 108.1). Recovery instructions will vary widely depending
on the extent of revision and are very important, as they relate
to final outcome, and should be reproduced as a hard copy
explained and given to the patient.
108.9 3rRFedure (TuiSmenW
Setup, Anesthesia,
Surgical Venue
Minor revisions require only a local sterile prep and minimal
draping; usually a sterile towel and fenestrated drape will
suffice. Equipment may be limited to forceps; needle holder;
Metzenbaum, Kaye, or iris scissors; and some sort of cutting tool
(radiofrequency or laser fiber, scalpel, electrosurgical needle)
and minor cautery equipment. This is where a contact laser fiber
or radiofrequency wire/needle electrode comes in handy; both
are superior for revisions secondary to their exquisite “scrolling”
and minor cautery capacity. However, a fine-tipped electrocau-
tery device, or fine plastic surgery scissors or scalpel will often
suffice.
For major revisions of course, the standard setup for primary
labiaplasty will suffice. Anesthesia may be local infiltration,
regional, or general with endotracheal intubation (GET), as per
your choice.

108 Female Genital Rejuvenation: Labia Minora Revision Surgery
1593
108.10 SSeFiÀF 5eYiViRn 7eFKniTueV
108.10.1 Minor Revision
Dog-Ears
Dog-ears are minor protrusions along or, more frequently, at
the end(s) of incision lines that are unsightly/bothersome to the
patient. They often do not involve the incision line per se. Unless
they involve an incision line, they may be revised by a simple
elliptical excision with either scalpel, scissors, radiofrequency or
laser fiber, or electrosurgical needle, using a single-layer closure
with 5–0 nylon (to be removed in 7–10 days) or a rapidly absorb-
able mono- or multifilament small-gauge suture. The patient
should be given routine hygiene and postoperative instructions
commensurate with the revision.
Edge Shave
Edge shave repair of a minor V-wedge separation is considered if
a suture or 3 tears out of the leading edge of a V-wedge labiaplasty
incision, leaving the patient with a small to modest “groove” at
the anastomosis site. Most commonly, this is not a source of
concern, but if it is, it may be “softened” by a gentle “shave” of
the two protruding edges, with only a single-layer side-to-side
edge repair with fine 5–0 or 6–0 monofilament or multifilament
delayed absorbable suture.
Revision of Side-to-Side Dissymmetry after
Linear Labiaplasty
Again, successful revision begins with negotiation of realistic
outcome eventualities; that the “obvious” dissymmetry may be
ameliorated, but that exact symmetry cannot ever be promised.
After prepping and draping, the revision proceeds with a care-
ful drawing of the amount of tissue to be removed, followed by
excision via scissors, radiofrequency wire electrode, laser fiber,
or electrosurgical needle. Even in these small skinning revisions,
the author prefers to place a small subcutaneous layer of 5–0 or
6–0 monofilament imbricating suture prior to a 5–0 polyglactin
(Vicryl Rapide, Johnson & Johnson, New Brunswick, NJ) or inter-
rupted nylon skin closure. Nylon sutures must be removed 7 to 10
days after surgery.
“Color Line”
Not rarely your patient will encounter a pink/tan color line at
the anastomosis site of a wedge, or along the suture line of a
linear procedure. This is something that should be discussed
preoperatively and may play some part in presurgical planning
at the primary surgery. Regardless, sometimes this eventuality
is encountered as part of a potential revision. My advice is to
counsel the patient that eventually modest color disparities will
“fade in place,” over a year’s time, and will become less notice-
able than when first encountered. If this remains an issue, the
judicious use of fractional CO2 laser or radiofrequency electrode
“airbrushing” along the suture line may ease the disparity if it is
still present and bothersome after a year.
“Festoons” after Labia Majora Reduction
The degree of ptosis of the labia majora may be miscalculated
during design or a linear reduction labia majoraplasty, resulting
in minor or major festoons at the base of the reduction postoper-
atively. As in other revision attempts, this author advises waiting
5 to 6 months from the primary surgery prior to designing a
tear-drop reduction design to modify the ptosis of the festoon
(Fig. 108.2).
Minor Separation of Introital Suture after
Perineoplasty
Secondary to activity during the initial postoperative period, it
is not rare for the suture at the introitus crowning an aesthetic
perineal reconstruction to pull free, leaving a small gap. More
often than not, this is not a bother for your patient, but if it is,
after the requisite 5 to 6 months, a diamond-shaped microperi-
neoplasty wedge may be removed and resutured in a single layer
with fine nylon or delayed absorbable mono- or multifilament
suture. The patient is carefully instructed against brisk activities
during the first 2 weeks of recovery. The excision line should
encompass fibrous scar tissue, bringing ´cleanµ epithelium and
subcutaneous tissue into new approximation.
Introital Gaping Secondary to Lateral Tension
from Labia Majoraplasty
Excision of redundant labia majora epithelium produces forces
that tend to pull bilaterally outward; at the base of the labia
majora this force will dilate a lax introitus not previously appar-
ent. This “open” appearance may be additionally accentuated if
a concomitant linear labia minoraplasty has been performed,
removing epithelium that may previously have hidden the gape.
Fig. 108.2 Patient post labia minoraplasty plus majoraplasty is
unhappy with the “festoon” base of the right labium majorum reduc-
tion. A simple “teardrop” excision line is drawn for epithelial excision.
(© Michael P. Goodman.)

1594
XIII Female Genital Rejuvenation
Repair in this instance involves a simple mini-perineoplasty,
producing modest introital reclosure.
Revision of Prominent Frenular Fold Edge
Post–Linear Labiaplasty
Two schools of thought exist in regard to proximity to the clitoral
glans that the labiaplasty surgeon may stray while designing a
linear-type labiaplasty in a woman with prominent frenular
fold(s). One school’s rules state that no incision line should be
closer than 1 cm to the glans, fearing injury to the robust neu-
rovascular supply in this area; the other feels that the frenular
incision line may flow to the glans without adverse postopera-
tive pain consequences. Both schools have their experienced
acolytes; no evidence-based studies exploring this issue exist in
the literature.
Suffice it to say that a revision surgeon will encounter patients
dissatisfied with the postoperative prominence of frenular
“tag(s).” This author shies away from incision lines proximate
to the glans but can offer no reason not to ´bevelµ or ´shaveµ the
area to moderate the perceived edge protrusion, again following
the 6-month rule. Laser fiber, radiofrequency wire or needle, or
small plastic scissors may be used to trim the edge, with a minor
surgical setup, and a single-layer closure using rapidly absorbable
multifilament suture (e.g., 5–0 Vicryl Rapide) may be utilized if
needed for the repair. Frequently, leaving the small, narrow exci-
sion line open to heal by secondary intention is best.
Minor Fistula(e) Close to Surface Edge
following V-Wedge Labiaplasty
:hile major symptomatic fistula(e) are covered under ´Major
Revision,µ shallow bothersome fistulae near to the surface may be
revised by a simple curvilinear excision, taking care to completely
remove the fistulous track, repairing side-to-side. A modest divot
may result, and this should be discussed beforehand with the
patient and compared with a potentially more aesthetic result (but
with a higher risk of separation) with a small V-wedge revision (the
technique is discussed under “Major Revision”). The incision line is
usually vertical (Fig. 108.3), but if the fistula is a very small one, it
may be excised via a mini-wedge, with either linear or horizontal
closure, making sure to excise the fistulous track.
108.10.2 Major Revision
Revision of V-Wedge Separation: V, Y-V,
and Superior-Inferior Flap
Two methods exist for revision of a wedge separation: trimming
the ´loose endsµ of the separated wedge, and effecting a re-wedge
closure. The former may suffice for minor separations; for deeper
separations, a more difficult re-wedge may be the procedure of
choice.
An edge trim is relatively straightforward but may require a
concomitant trim of the contralateral side for purposes of symme-
try. The rules for this revision are the same as for a primary linear
labiaplasty: do not operate medial to Hart’s line on the medial
surface of the repair, and not closer than 0.5 cm laterally on the
lateral side, preferably leaving a minimum of 1 cm labium as the
incision proceeds cephalad (Fig. 108.4).
A more elegant, and in skilled hands more aesthetic, result may
be obtained by effecting a re-wedge, either via a modified V as orig-
inally described by Alter and later described by the same author
as a revision method (Fig. 108.5), a modification of the superior/
inferior flap technique described by Munhoz et al (Fig. 108.6), or
a hybrid, as skill and experience allow. As necessity dictates, the
superior, inferior, or both edges of the wedge may be enlarged
via a Y incision at the edges of the anastomosis to better accept
reconstruction incorporating the ipsilateral edge. For example,
Fig. 108.5b,d shows that either superior or inferior re-wedge
ends can be opened in a Y-shaped manner if additional space is
necessary to accommodate an ipsilateral edge that is larger than
the opposing edge. The rules include ≥ 6 months from original
Fig. 108.3 (a) Superficial edge fistula secondary to tissue rejection,
4–0 Vicryl. Excision lines drawn. (b) One month postoperative linear
excision fistulous track. (© Michael P. Goodman.)
Fig. 108.4 (a,b) Edge contour revision of bilateral V-wedge separation.
Edge trim was selected as the surgeon felt that re-wedging the left
side was impractical secondary to the location and scarring of the
left-sided separation flush with the vestibule. The sutures were 5–0
Monocryl subcutaneous and 5–0 Vicryl Rapide interrupted skin. (©
Michael P. Goodman.)

108 Female Genital Rejuvenation: Labia Minora Revision Surgery
1595
surgery, and incision down to viable, decently vascularized tissue
(if it doesn’t ooze, it is not vascularized). As in a primary wedge,
a 2- to 3-layer closure is mandatory to provide scaffolding for the
subcutaneous tissue, plus the generous use of mattress sutures
for the skin. Similar to the suture choice of Dr. Alter, this author
prefers the use of minimally reactive, small monofilament sutures
(e.g., Monocryl 5–0) for the subcutaneous tissue, allowing if
desired the use of a rapidly dissolving suture, such as interrupted
Vicryl Rapide for skin closure if needed. Fig. 108.5 shows the steps
in a modified V revision; Fig. 108.6 shows revision via superior/
inferior flap modification of the V-wedge technique.
5eYiViRn RI SinuV 7rDFNV DndRr )iVWuODe DIWer
V-Wedge and “Hybrid Wedge”
There is disagreement over the cause of fistulae and sinus tracks
after (usually V-wedge or the so-called more complex hybrid
type) labial reduction. :hile several different factors may be
causal, the end result is the same: blind pockets, fistulae, or
outright separation. Whether caused by occasional extrusion of
multifilament delayed absorbable subcutaneous sutures, place-
ment of subcutaneous sutures too close to the epithelium, as a
sequelae of smoking, or other undetermined cause, the result is
the same. Of course, if cigarette smoking appears to be a probable
Fig. 108.5 A 36-year-old woman 7 months after central wedge labiaplasty performed by a cosmetic surgeon. (a) Total left dehiscence with large
right perforation and stretching. (b) Marking to excise the edge of the disrupted labium. (c) Marking to excise the right perforation and stretched
labium. (d) Left side repaired, (e) Patient at end of repair. An excision of mild redundant perineal skin was also performed. (© Gary J. Alter, MD.)

1596
XIII Female Genital Rejuvenation
culprit, it is mandatory that the patient discontinue ingestion or
inhalation of tobacco products for a minimum of 1 month prior
to and 1 month following revision.
The surgical technique for this revision is basically the same as
the re-wedge techniques described earlier. Care must be taken to
completely excise fistulous tracks down to viable epithelium.
Revision of Labial Amputation
As a result of overly aggressive trimming labiaplasties, many
women present with either unilateral or bilateral total or
significant absence of the labia minora (aka amputation; Fig.
108.7). This is one of the most commonly encountered major
complications resulting from labiaplasty and is tragic and
iatrogenic, most commonly produced by a surgeon unschooled
in proper technique for aesthetic linear reductive labiaplasty,
who unintentionally removes the entire labium minus, usually
suturing the mucosa of the vulvar vestibule to the interlabial
fold. Adding insult to injury, if the surgeon uses a single-layer
closure or if the sutures are placed into mucosal epithelium
medially and squamous epithelium laterally, the tensile forces
will tend to pull sutures from the fragile mucosa, frequently
resulting in a dehiscence, necessitating closure by secondary
intention. The resulting scarred area, in addition to appearing
unaesthetic, frequently is the cause of pain, both at rest and
especially during sexual activities, both from the exteriorization
of the vulvar mucosa and the neurogenic pain produced by the
scarring. Additionally, as the majority of these surgeons, most
Fig. 108.6 A 26-year-old woman with disruption of the right labium and significant labial stretching after posterior wedge labiaplasty performed
by a gynecologist. (a) Deformity of labia minora and posterior introitus. (b) Marking to excise and repair the right labium. (c) Marking to excise
the stretched left labium. Right labium repaired. (d) Four months after repair. Posterior introitus is not ideal with “notch” at right base. (e,f) Seven
months after labia repair and 3 months after repair of the posterior introitus. (© Gary J. Alter, MD.)

108 Female Genital Rejuvenation: Labia Minora Revision Surgery
1597
commonly Board Certified obstetrician-gynecologists, have not
been trained either in their residencies or via standalone training
programs in either plastic technique or the ´fineriesµ of clitoral
hood reduction or how to work aesthetically with the frenular
fold, their resultant amputation frequently leaves bulky hood
epithelium intact and/or an abrupt edge to the frenular fold.
While not evidence-based in peer-reviewed literature, it is
this author’s opinion that the daily application of compounded
estradiol + testosterone (0.05%/0.3–0.5%) in the form of an absorb-
able cream to the area is helpful. Whether this is secondary to
tissue-enhancing effects of the active ingredients, to the mechan-
ical action of daily massage, as an aid in epithelial metaplasia of
mucosa to squamous epithelium, or the psychological balm of
touch and massage to an area that has received so much negative
self-attention is unknown. While in the author’s hands this has
been effective in diminishing discomfort and promoting pliability,
aesthetic issues remain.
Two possibilities exist for aesthetic revision, entirely depen-
dent on the amount of redundant clitoral hood or posterior
commissure epithelium available for reconstruction. Redundant
hood (usual) or posterior commissure (less likely) epithelium
may be brought down (or up) to cover the denuded amputated
area by either a modified V-wedge or a <-V procedure, if enough
epithelium remains at the posterior commissure to attach to the
cephalad portion of the reconstructed area (Fig. 108.6b–e). Or a
labium may be developed by bringing down hood epithelium via a
flap procedure (Fig. 108.8, Fig. 108.9). This major revision, termed
an island flap, was first designed and now refined by the ´fatherµ
of reconstructive labiaplasty, Gary J. Alter, MD, of Los Angeles,
California.
Flaps
The “carving out” of an island of viable tissue to be rotated/
moved to a nearby location with a portion of its blood supply
intact is termed a flap, or an island flap, and is a mainstay of plas-
tic surgery training and technique, but not a technique that other
surgical specialists (e.g., gynecologists) are taught in residency
training. Short of the experimental and not evidence-based
implants briefly discussed later in the chapter, these flaps are
the mainstay of reconstruction for revision of labial amputation,
provided enough tissue remains nearby (e.g., from the clitoral
hood) to allow flap rotation.
:hile every flap must be individually designed attendant with
anatomy, tissue available, and the size of the denuded area of the
vulvar vestibule to be covered, the basic technique is reproducible.
Utilizing a variety of tools (scalpel, touch laser, radiofrequency
wire needle electrode, dissecting scissors, electrosurgical needle),
a finger of nearby available epithelium matching the desired
epithelial surface to be covered, usually from the clitoral hood, is
dissected on three of its four sides and rotated in such a manner
as to retain the integrity of its blood supply, and tacked down over
a similarly sized finger of previously denuded area on the vulvar
vestibule at the site of the amputated ipsilateral labium.
There are rules, and there is art. The rules include the following:
(1) There must be adequate tissue harvesting availability from the
nearby hood, or on occasion the posterior commissure. (2) Sharp
dissection of the donor flap must include adequate subcutaneous
tissue containing the vascular supply from the portion of the flap
left intact. This is crucial, as flaps containing only epithelium have
a significantly poorer chance of survival. Of course, great care
must be taken to not dissect below fascial planes to avoid injury
to the dorsal nerve to the clitoris. (3) The rotation, as shown and
described elegantly by Alter (Fig. 108.8, Fig. 108.9), must contain
an adequate vascular supply and be clockwise on the left and coun-
terclockwise on the right side (if harvest is from the clitoral hood).
Of course, as in all descriptions of technique, sides are determined
from the patient’s perspective, not from the view of the operating
surgeon. (4) The flap must be secured both subcutaneously to
eliminate dead space and peripherally to secure edges. Delayed
absorbable, preferably monofilament, suture is used underneath,
taking care not to dimple or buttonhole, working from the vascu-
lar pedicle toward the end of the flap, and edges are secured with
either a subcuticular or through-and-through suture line, using
either fine monofilament (5–0 or 6–0 poliglecaprone >Monocryl,
Johnson & Johnson, New Brunswick, NJ]—Alter’s choice) or 5–0
Vicryl Rapide or 5–0 nylon (this author’s choice) for edge closure.
(5) The recipient area must be properly dissected, removing all
devitalized fibrous/scar down to viable tissue in an area roughly
similar to the shape and size of the donor graft. (6) Adequate and
clear postoperative instructions to the patient are imperative.
This is the only chance remaining to “make things right” for the
patient. Rest and elimination of any activities that would tend to
put undue tension on the flap over the first 3 weeks of healing are
imperative.
The ´artµ is evident in Alter’s two figures. Additionally, the
revision surgeon must know when to say “no” and must design
each flap, both harvest and recipient site, individually and shape
the superior and inferior incisions roughly equally.
Silicone Lip Implant Reconstruction
:hile repair via V or <-V advancement or flap rotation from
redundant clitoral hood epithelium is a superior method for
reconstruction after labial amputation, not rarely the revision
surgeon does not have the benefit of enough redundant hood
epithelium to bring down a usable flap. In these cases, while
vertical undermining with attempts to develop a useful strip
Fig. 108.7 Patient post labiaplasty performed by her general gynecol-
ogist, resulting in bilateral labial amputation. Fortunately, adequate
tissue remains from her untouched clitoral hood for an acceptable
“island flap” revision. (© Michael P. Goodman.)

1598
XIII Female Genital Rejuvenation
of aesthetic faux labia is tempting, these procedures have not
resulted in reproducible anatomic labia.
A new and theoretical revision method exists for women expe-
riencing amputation who have no excess clitoral hood or posterior
commissure epithelium from which to fashion a usable flap. Peter
Raphael et al, have described the potential use of preformed
medical-grade silicone lip implants (Perma-Lips and Perma Facial
Implant; SurgiSil, Plano, TX) for aesthetic facial lip augmentation.
The implants come in three sizes, although only the largest
(5 × 65 mm), placed singly or potentially stacked to provide better
elevation, may be warranted to provide an aesthetic boundary
between the vulvar vestibule and the interlabial fold, providing
a “faux labium” (Fig. 108.10). The implants may be placed via
a small tendon passer in a barely developed vertical tunnel just
lateral to the vulvar vestibule to elevate the skin and provide a
more aesthetic appearance of the introitus. Unanswered are the
rejection rate, the performance with sexual activities, and whether
the elevation produced by stacking would stand the test of time.
Debulking
Redundant Hood Epithelium with and without
Labial Reduction
Women whose labiaplasty was performed by a surgeon naive to
the technique of hood reduction, or who eschew advice by their
surgeon to reduce redundant hood at the time of labiaplasty, or
whose surgeon is perhaps a bit too carefully conservative, or for
other reasons, may after recovery find themselves ´unbalanced,µ
with a hood that “sticks out like a little penis,” or with more tissue
Fig. 108.8 A 54-year-old woman 5 years after a trimming labiaplasty performed by a gynecologist. (a,b) Abrupt end of the right clitoral hood and
frenulum with an absent right labium minus except for a small posterior labium. The left labium is scalloped and irregular. (c) Marking for the right
clitoral hood flap with excision of a painful right introital scar. (d) The right clitoral hood island flap is based on random vessels at the medial labium
majus and lateral clitoral hood. The flap will be rotated 180° counterclockwise on the right. (e) The clitoral hood flap is inset. It is attached to the
frenulum and the lower labial remnant. Markings for wedge excisions on the left to make it symmetric to the right side and to eliminate some
protrusions and scalloping. (f,g) The patient at the end of the procedure. The posterior lip excess tissue was also excised, and the posterior introitus
was reconstructed. (h) Three months postoperative. The right lower lateral clitoral hood can be reduced to match the left if of concern to the patient.
(© Gary J. Alter, MD.)

108 Female Genital Rejuvenation: Labia Minora Revision Surgery
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remaining than they wish. Revision is far “easier” and more likely
accomplished in women with too much after labiaplasty than in
women with too little.
Reduction here may be performed in the standard manner
for hood reduction, via bilaterally placed paramedian elliptical
incisions, gathering up and excising redundant tissue (Fig.
108.11). If unreduced at the time of primary surgery, redundant
labial, including frenular, folds may be incorporated into the
reduction.
Fig. 108.9 A 31-year-old woman who had trimming labiaplasty performed as a teenager. (a) Abrupt termination of the frenula and clitoral hood
with absent upper two-thirds of the labia minora. The patient has adequate remaining clitoral hood. (b,c) Markings for bilateral clitoral hood flaps
along with excision of the right labiaplasty scar. (d) The right clitoral hood flap is inset and attached to the lower labium. The right flap is a random,
island flap on vessels from the lateral lower clitoral hood and labium majus. It is elevated with as much subcutaneous tissue as possible. The right
side is rotated 180° counterclockwise, and the left side will be rotated clockwise. Marking for a wedge excision of the lower labium to reduce its
protuberance to match the left side. (e) Both clitoral hood flaps are inset, the right wedge is completed, and excess perineal tissue has been excised.
(f) Four months postoperation. (© Gary J. Alter, MD.)

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XIII Female Genital Rejuvenation
Via Mini-Wedges and Linear Resection
Not rarely, the job is simply not performed aggressively enough
for the patient’s taste, with inadequate tissue removal via
either the curvilinear or the wedge technique. Here, basically,
a re-wedge or re-linear resection is performed as per standard
technique to debulk and further minimize size. The revision
surgeon must be flexible and willing to envision a multiplicity
of techniques and hybrids to work with the specific individual
situation encountered. Alter presents a novel approach to this
situation. Fig. 108.12 shows the technique of a mini re-wedge
curving upward in the manner of a primary modified V-wedge
reduction. Goodman shows a more traditional linear reresection
plus clitoral hood reduction (Fig. 108.13).
Revision of “Grooves” Secondary to
,mSrRSer SuWure 7eFKniTue
Inexperienced labial reconstructive surgeons may close incisions
with large-caliber, tightly placed running or running interlocked
suture line, resulting in a scalloped appearance (Fig. 108.14).
Besides being aesthetically unappealing to the patient, these
grooved areas can produce ongoing discomfort.
Two methods exist for their aesthetic reconstruction. Data are
insufficient to determine whether one is superior to the other for
resolution.
If sufficient remaining tissue allows, by far the best revision
technique here is a careful reexcision of the offending scalloped
edges via either a linear or a wedge excision. As with primary
labiaplasty, the rule of staying outside of Hart’s line mucosally,
and allowing a minimum of 0.5 cm of lateral edge at the posterior
commissure, and 1 to 1.5 cm epithelium nearer to the superior
portion of the labium from the interlabial fold laterally is absolute,
as the patient does not wish to trade a scalloped appearance for
that of an amputation. Alter, the creator of V-wedge modification
techniques, prefers a re-wedge (Fig. 108.15) if anatomy allows.
Goodman has utilized a curvilinear revision for the anatomy in
Fig. 108.16.
Red Alinsod, MD, has described at meetings his technique of
“feathering” to mitigate the grooved, scalloped appearance in
cases where the labial length is insufficient to allow for a retrim.
While his technique is reproducible, and the results are quite
pleasing, the recovery is frankly brutal, and evidence-based
results have thus far not graced the literature.
Fig. 108.10 Two medical-grade silicone permanent lip implants, 60
and 65 mm, stacked together via small-caliber Gore-Tex sutures.
Implants would be stacked for vertical placement, sutured in place in
their tunnel with slow-absorbing monofilament suture (5–0 Monocryl)
anticipating scarification within the tunnel to theoretically prevent
collapse of stacked implants. (© SurgiSil, Plano, TX)
Fig. 108.11 Bilateral paramedial incision lines for reduction of redun-
dant clitoral hood epithelium. Vertical dotted line denotes the midline;
bilateral ellipses denote excision lines. (© Michael P. Goodman.)

108 Female Genital Rejuvenation: Labia Minora Revision Surgery
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Dr. Alinsod’s technique involves “airbrushing” the surface,
removing the jagged peaks using a radiofrequency wire needle
electrode on bipolar cutting power and relatively low (10–12
watts) power, to sand or ´airbrushµ off the jagged epithelium.
The surface is left open and unsutured and left to heal by sec-
ondary intention. Postoperative self-care includes oral analgesics
(hydrocodone, tramadol), topical analgesia with benzocaine/lido-
caine, tetracaine, 20–8–8% (BLT) cream), hydration with Aquaphor
(Beiersdorf, Wilton, CT) or an equivalent, and daily cleansing with
Cetaphil cleanser (Galderma Laboratories, Fort Worth, TX) or an
equivalent. The use of Telfa covering (Medtronic, Dublin, Ireland)
marks the approximately 3- to 4-week convalescence, but the
postoperative results are frequently quite pleasing (personal
communication; meeting presentations).
Revision of Introital “Gaping” Secondary
to Labia Majoraplasty
The lateral tension produced by labia majoraplasty, especially
when the patient’s labia majora redundancy extends well down
caudad to the perineum, or when a teardrop technique is nec-
essary to fully decompress the patient’s redundancy and ptosis,
produces forces that act to produce introital gaping. While this
is something that should be addressed in presurgical planning
for the primary procedure, it often is not, or the patient, often
for financial reasons, elects not to have a minor perineoplasty
performed concomitant with her labia majoraplasty.
This revision consists simply of a minor perineoplasty, remov-
ing a diamond-shaped wedge of vulvar vestibule, introitus, and
distalmost posterior vaginal mucosa plus underlying scar tissue,
rebuilding the introitus and perineal body in an aesthetic manner.
A common mistake in these procedures is excessive conservatism:
Fig. 108.12 A 32-year-old woman with deformities after trimming
labiaplasty by a plastic surgeon. (a) Labia minora with scalloping and
protruding frenula. (b,c) Wedge markings to excise the lower frenula
and upper labia minora, which includes many scallops. (d) The patient
at the end of the procedure. A small wedge to excise a concavity from
a scallop was also performed inferior to the larger wedge on each side.
The frenula were bulky bilaterally, so they were trimmed longitudinally.
(© Gary J. Alter, MD.)
Fig. 108.13 (a,b) A 34-year-old s/p linear revision, seeking additional
reduction, plus reduction of an underreduced clitoral hood. The
patient underwent recurvilinear resection, 5–0 Monocryl subcutane-
ous layer plus 5–0 Vicryl Rapide subcuticular skin closure, plus separate
bilateral elliptical excisions for the hood. (© Michael P. Goodman.)
Fig. 108.14 (a,b) “Train tracks” produced by application of a too large
and too tight delayed absorbable, frequently running interlocked
suture line producing a postoperative pseudopolypoid grooved
appearance. (© Michael P. Goodman.)

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XIII Female Genital Rejuvenation
not going deep enough, or removing an inadequate amount of
introital/distal vaginal tissue.
108.11 Concluding Thoughts
Labiaplasty revisions appear to fall into three categories:
1. Revision of labiaplasty when “too much” tissue remains
2. Revision of labiaplasty when “too little” remains (e.g.,
amputation)
3. Revision of labiaplasty procedures involving dehiscence of orig-
inal suture lines
Revision of “too much” is more successful than revision involv-
ing “too little.” Labiaplasty revision surgery is a separate branch of
aesthetic vulvar/labial plastic procedures. The consummate labi-
aplasty surgeon is mandated to be aware of the different anatomic
findings and potential revision techniques for each, so as to be
able to choose the correct procedure(s) for each variation, and to
match it as much as possible to the patient’s expectations. The
revision surgeon should be savvy as to timing of a revision, taking
into account individual situations, using appropriate suture mate-
rials, counseling the patient appropriately while understanding
individual anatomic situations, and knowing when and to whom
to refer out when not up to the task at hand.
Clinical Caveats
• For your patient inquiring about a revision: don’t even talk
about it until 6 weeks postop; do not make any final evaluation
until 3 to 4 months postop, and do not perform the revision
until at least 5 to 6 months postop, unless the revision does
not include previous incision lines, in which case revision may
be performed after 3 to four months postop.
• Be candid and honest about what can and what cannot be
achieved with a revision on your individual patient.
• Be clear that you are not responsible for the first outcome,
and that this outcome influences any revision.
• When in doubt, opt for the simplest procedure.
Fig. 108.15 A 19-year-old woman who had a trimming labiaplasty
performed by a gynecologist. (a) Asymmetrical labia minora with
severe scalloping. (b) Markings to excise a wedge from an enlarged left
labium and lateral clitoral hood, which includes the worst scalloping.
(c) Marking to excise a similar wedge on the right. The left side is
completed. (d) The appearance after both wedges are completed along
with a smaller wedge containing a large scallop. (© Gary J. Alter, MD.)
Fig. 108.16 (a) A 17-year-old young woman had a “trimming”
labiaplasty by her family gynecologist, who used a large-caliber,
delayed absorbable, running suture closure, macerating and grooving
remaining inadequately removed labia as well as leaving a robust hood
untouched. (b,c) Medial and lateral lines for curvilinear revision include
reduction of the prominent clitoral hood epithelium. Two-layer closure
with running, imbricating 5–0 Monocryl underneath; interrupted 5–0
Vicryl Rapide for the epithelium. (d) Six-week outcome. (© Michael P.
Goodman.)

108 Female Genital Rejuvenation: Labia Minora Revision Surgery
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• If redoing a wedge, use standard wedge rules: scaffold the
subcutaneous tissue well, eliminate any dead space, be
careful not to remove too much, and excise all preexisting
devitalized scar tissue.
• If doing a re-linear revision, be careful to stay at least 0.5 to
1.5 cm away from the interlabial fold laterally and outside of
Hart’s line medially.
• For a flap revision of a previous labial amputation, carefully
measure both the donor and the recipient sites and excise all
devitalized scar tissue from the recipient site.
• This is the only chance your patient will get. Be clear and firm
about her responsibilities during recovery.
• Consider less-reactive, fine monofilament, delayed absorb-
able sutures underneath and rapidly absorbable fine sutures
for skin closure if needed.
• If using a radiofrequency “airbrushing” technique to minimize
grooved scars, adequate topical cleansers, moisturizers, and
topical and systemic analgesics must be supplied.
Acknowledgments
I acknowledge the contributions to this chapter from Gary Alter,
MD. A pioneer in the field, whose contributions to the literature
since 1998 have enriched us all, most importantly Dr. Alter is an
artist and a “rescuer” for many women who have endured the
not rare disfigurement and sexual sequelae of cosmetic labial
surgery gone wrong. I thank Gary for his openness and willing-
ness to share his innovations and techniques with others.
Suggested Reading
[1] Alter GJ. A new technique for aesthetic labia minora reduction. Ann Plast Surg
1998;40(3):287–290
[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 G-. Labia minora reconstruction using clitoral hood flaps, wedge excisions,
and [4] 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
[5] Raphael P, Harris R, Harris SW. Five-year experience with Perma Facial Implant.
Plast Reconstr Surg Glob Open 2014;2(5):e153

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Part XIV
Gender-Affirming Surgery
XIV

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109 &OiniFDO 'eFiViRn 0DNing IRr Gender-Affirming Surgery
Wilmina N. Landford, Paula M. Neira, and Devin O’Brien Coon
Abstract
Gender dysphoria affects a significant number of transgender
individuals, approximately 1.4 million in the United States alone,
representing a significant psychosomatic a̧iction that justifies
medical intervention. Surgical procedures that alter physical
appearance to align with a person’s gender identity fall under the
category of gender-affirming surgery (GAS), which encompasses
a broad range of interventions that include genital, facial, chest,
and voice/thyroid cartilage surgery. Accordingly, GAS requires
individualized treatment planning due to the variability of the
patient’s medical necessity, anatomical profile, ethnic back-
ground, and overall desires. Although several operative tech-
niques may be applicable, clinical decision making prior to any
surgical intervention must be executed to enhance the potential
for a maximal beneficial outcome.
Keywords
gender dysphoria, gender-affirming surgery, vaginoplasty,
phalloplasty, chest masculinization, breast augmentation, facial
feminization surgery, thyroid chondroplasty, voice surgery
109.1 Understanding
Gender Dysphoria
109.1.1 Gender Dysphoria
Transgender is an umbrella term for a heterogeneous group of
individuals whose gender identity does not conform with their
sex assigned at birth. Among the transgender population, gender
identities and expressions are remarkably diverse. Some individ-
uals identify within a male–female binary and use terms (e.g.,
transman, transwoman) that reflect a gender identity opposite of
the sex they were assigned at birth, whereas others may identify
outside the binary notions of gender (Table 109.1). Consequently,
the dichotomy between an individual’s self-identity and soci-
ety’s perception of gender can have significant implications on
overall well-being and thus result in a degree of psychological
impairment. The Diagnostic and Statistical Manual of Mental
Disorders, fifth edition (DSM-V) defines gender dysphoria as a
persistent psychological and emotional distress created by an
incongruence between one’s experienced or expressed gender
and one’s assigned gender. It is, however, important to empha-
size that varying degrees of dysphoria exist. Individuals might
experience only a minimum of distress, or no distress at all;
therefore, decisions for treatment must also be individualized.
109.1.2 Diagnostic Evaluation
of Gender Dysphoria
A comprehensive evaluation by a multidisciplinary team of
mental health professionals, endocrinologists, surgeons, and
medical specialists provides an encompassing level of support for
individuals with gender dysphoria. Establishing a clinical diag-
nosis and management plan includes a thorough examination
of psychosocial functioning, identifying personal and financial
support systems, and formation of an individualized treatment
plan, as specific needs and goals for gender expression may
vary from patient to patient. Given the potential for medical or
mental health comorbidities, a qualified mental health or med-
ical professional with training and experience in working with
transgender patients and diagnosing gender dysphoria should
complete a psychosocial assessment to determine readiness
and appropriateness of treatment before initiating hormonal
or surgical interventions. This is particularly important before
undertaking gender-affirming surgery (GAS) due to its irrevers-
ible nature. In addition, a thorough medical assessment by a
primary care provider or endocrinologist for those interested in
hormone therapy or surgery is recommended.
Multidisciplinary centers provide support for a myriad of
interventions, such as psychotherapy, social gender transitioning,
hormonal therapy, and GAS. Importantly, through a supportive
network, individuals are able to find a gender identity or expres-
sion that is comfortable for them following social or medical
transitioning. The multidisciplinary team can address any con-
cerns with the pre- and postoperative care following surgical
intervention. Ultimately, this supportive team approach improves
surgical outcomes, reduces complications, and helps to meet
patient expectations.
109.2 Medical Therapy
109.2.1 Psychotherapy, Counseling,
and Hormone Therapy
Psychotherapy and Counseling
The overarching goal of psychotherapy and counseling is to help
patients find an equilibrium in their psychological state and
quality of life. Although not an explicit requirement by the World
Professional Association for Transgender Health Standards of
Care (WPATH-SOC), psychotherapy can provide numerous bene-
fits to patients that aim to optimize the patient’s ´psychological
well-being, quality of life and self-fulfillment.µ Some may suc-
cessfully integrate into their appropriate gender identity without
the need for any hormone therapy or surgical intervention.

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XIV Gender-Affirming Surgery
Hormone Therapy
Hormone therapy plays an important role in inducing the sec-
ondary sex characteristics associated with a patient’s gender
identity while minimizing those of their natal gender. The physi-
cal effects of hormone therapy develop gradually over months to
years and are variable from patient to patient. Hormone therapy
can be tailored to a patient’s transition goals, but one must also
consider their medical comorbidities and be familiar with the
side effects associated with hormone use, including but not
limited to, the risk of thromboembolism, electrolyte imbalances,
drug interactions, effects on organ function, and possible malig-
nancy. The WPATH-SOC recommends that providers complete
a psychosocial assessment and obtain informed consent before
initiating hormone therapy.
Feminizing Hormone therapy
The current approach to hormone therapy in transgender women
is to feminize patients by blocking androgen production in con-
junction with estrogen supplementation at physiologic doses. As
a result, notable physical changes include breast development,
redistribution of facial and body fat, reduction of muscle mass,
loss in facial and body hair quantity and thickness, changes in
sweat and odor patterns, slowing or reversal of scalp hair loss,
reduction in erectile function, reduced sperm count and ejacu-
latory fluid, reduced testicular size, and changes to libido. The
extent to which these physical changes begin to surface upon
initiating estrogen therapy varies across patients and may take
up to 18 to 24 months to occur. Laser hair removal or electrolysis
is often required, as feminizing hormone therapy alone will not
eliminate all unwanted facial hair. Breast development occurs but
frequently not to the extent the patient would like; hence these
realities should be discussed prior to initiating treatment. Some
individuals assigned male at birth and who identify as nonbinary
may seek feminizing hormone therapy to make their bodies less
masculine and more androgynous. The greatest concern with
feminizing hormones in the perioperative period is the increased
deep venous thrombosis rate associated with estrogens. There
are too few data to base practice on, and surgeons may require
anywhere from 1 to 6 weeks of hormone cessation prior to
surgery. The senior author (DC) requires all patients undergoing
general anesthesia procedures to stop estradiol 14 days before
surgery and resume 7 days postoperatively. This practice was
developed in concert with endocrinologists and balances the
thrombosis risk against the side effects of hormone cessation;
many patients will report undergoing a “menopause-like” symp-
tomatology, including hot flashes and mood lability.
Masculinizing Hormone Therapy
Testosterone therapy suppresses female secondary sex charac-
teristics and masculinizes transgender men. Within 3 months
of initiating testosterone therapy, patients notice amenorrhea,
increased facial and body hair, skin changes and increased acne,
changes in fat distribution, increased muscle mass, and increased
libido. Some individuals assigned female at birth and who iden-
tify as nonbinary may seek masculinizing hormone therapy to
make their bodies less feminine and more androgynous. Again,
the senior author (DC) requires all patients undergoing general
anesthesia procedures to stop testosterone 14 days before
surgery and to resume 7 days postoperatively. The data for pre-
operative testosterone cessation are weaker and based largely
on the concept that the consistently higher hematoma rates seen
in men versus women across plastic surgery procedures may
produce a similar risk in patients taking exogenous testosterone.
Table 109.1 Terminology and definitions
Term
'eÀniWiRn
Transgender
An all-inclusive term that refers to individuals whose gender identity does not align with the sex they were assigned
at birth
Transsexual
An older medical/psychological term that may be used by some transgender people. It is not an umbrella term and
specifically refers to individuals who have had, or seek to have, medical interventions such as hormone therapy or
surgery to align their bodies with their gender identity. This term should not be used to describe a patient unless
they use the term to describe themselves (GLAAD, 2016)
Gender identity
An individual’s deeply rooted perception of their own gender. A person may identify as male, female, or in a
nonbinary manner. One’s gender identity may or may not align with the sex assigned at birth (GLAAD, 2016;
Human Rights Campaign, 2018)
Gender nonconformity
An individual whose behavior or gender expression does not fit the societal descriptions of masculine or feminine
Gender dysphoria
Distress that is clinically significant caused by the incongruence between an individual’s gender identity and the sex
they were assigned at birth (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; Human Rights Campaign,
2018)
Gender-affirming surgery
A set of surgical procedures that are performed by a multispecialty team to help align physical appearance and
functional abilities to the patient’s gender identity. The phrase “sex change” should never be used to describe
gender-affirming surgery or the process of transition
Transgender man/transman
A male assigned female at birth
Transgender woman/transwoman
A female assigned male at birth
Nonbinary/genderqueer
Terms that may be used by individuals whose gender identity or gender expression falls outside a male–female
binary (GLAAD, 2016)
Transition
The process of living aligned with one’s gender identity rather than aligned with the sex assigned at birth. This is a
highly individualized experience and generally encompasses a social, legal, and (often) medical dimension (GLAAD,
2016)

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1609
109.3 Gender-Affirming Surgery
109.3.1 The Preoperative Evaluation
GAS includes a set of procedures that help align the body with
the person’s own gender identity (Fig. 109.1). Surgical options
include facial feminization/masculinization surgery, chest mas-
culinization or breast augmentation (“top surgery”), and genital
reconstruction (“bottom surgery”). In preparation for surgery,
the WPATH-SOC highlight several criteria to meet prior to
undergoing any breast/chest or genital operations (Table 109.2).
Although there is no distinct order in which operations are per-
formed, these guidelines help provide optimal care for patients.
The WPATH-SOC recommend documentation of persistent
gender dysphoria by a qualified mental health professional, with
one referral letter to be written for breast/chest reconstruction
and two letters for those undergoing genital reconstructions.
Moreover, surgeons are advised to take on an ethical and legal
responsibility in carrying out an informed consent process in
order to assess the patient’s understanding of the procedure.
Several relative recommendations that are not explicitly required
include a minimum of 12 months of feminizing hormone therapy
Table 109.2 Criteria for gender-affirming surgery
Term
'eÀniWiRn
Chest reconstruction
One referral letter from a qualified mental health professional
Persistent, well-documented gender dysphoria
Capacity to make informed consent for treatment
Age of majority
Well-controlled medical and mental health comorbidities
12 months of feminizing hormone therapy to maximize breast growtha
Genital reconstruction
Two referral letters from a qualified mental health professional
Persistent, well-documented gender dysphoria
Capacity for informed decision making and consent
Age of majority
Well-controlled medical and mental health comorbidities
12 months of hormone therapy prior to gonadectomya
12 months of social transitioning (for phalloplasty or vaginoplasty candidates)a
a Not required, only a recommendation.
Source: Adapted from the WPATH-Standards of Care, 7th ed.
Fig. 109.1 Road map of gender-affirming surgery.

1610
XIV Gender-Affirming Surgery
use prior to breast augmentation to obtain better surgical results,
a medical transition period of 12 continuous months of hormone
therapy prior to gonadectomy to introduce a period of reversible
estrogen or testosterone suppression, and 12 continuous months
of a social transition period that is congruent with the person’s
gender identity (for metoidioplasty, phalloplasty, or vagino-
plasty). It is also an unfortunate reality that in the United States,
insurance preauthorization requirements vary dramatically by
payor and may mandate much more stringent and lengthy lists
of requirements, frequently including things with no apparent
medical basis (e.g., requiring a year of testosterone before mas-
tectomy though the two have no relationship).
During the initial consultation, it is of utmost importance for
surgeons to do the following:
• Build rapport with patients by addressing them by their
chosen name and pronoun
• Establish a clear understanding of what characteristics the
patient perceives as feminine or masculine
• Delineate the operations that best suit the patient’s desires
• Establish realistic expectations
• Ensure that patients understand the irreversibility of surgery
• Discuss risks and complications
A discussion regarding any relative contraindications, such as
nicotine use and elevated body mass index, must be conducted
in addition to addressing the need for gender-specific laboratory
tests (e.g., urine human chorionic gonadotropin testing) for
patients who may already have undergone GAS as well as the
need to follow oncologic screening recommendations.
Furthermore, surgeons must reevaluate the diagnosis of gender
dysphoria and comorbidities that may impact surgical outcome,
and assess the patient’s readiness for surgery. Careful reading of
the mental health readiness letters can save tremendous future
problems for both surgeon and patient.
It is important to emphasize that not all transgender patients
desire or pursue these medical interventions. Some may be
limited by financial constraints or find that less invasive therapies
sufficiently alleviate their stresses of gender dysphoria. In addi-
tion, patients may not necessarily want to fully request a mascu-
line or feminine body type. Many individuals, in fact, might opt to
undergo only some of the surgical procedures currently available,
while others opt to receive the full array of treatments.
109.3.2 Clinical Decision Making for
Feminizing Procedures
Facial Feminization Surgery
Facial feminization surgery (FFS) encompasses a set of cranio-
maxillofacial procedures that include forehead contouring,
blepharoplasty, cheek augmentation, rhinoplasty, lip aug-
mentation, mandibular border reduction, and genioplasty.
Procedures may also include hair transplantation, reduction
thyrochondroplasty, fillers or neuromodulators, and feminizing
speech therapy. When evaluating, diagnosing, and planning a
patient’s feminization process, one must understand the gender
differences in the face. Assessment must include a global eval-
uation of the facial profile as well as specific anthropometric
measurements. On clinical evaluation, the face is divided into
horizontal thirds. In the upper third of the face, the forehead,
nasoglabellar angle, as well as the hairline and eyebrows are
evaluated. The middle third focuses on nasal projection and tip,
the malar prominence, and the length of the upper lip. The lower
third includes the chin and mandibular body and angle.
To attain an objective view prior to surgery, preoperative radio-
logic imaging with the use of CT scans with three-dimensional
reconstruction is invaluable to discuss the potential changes to
the bony skeleton with patients and allow them to participate
in the decision as to which changes are most important to them.
Regardless of whether or not a surgeon performs all FFS proce-
dures, it is vitally important to maintain facial harmony. One of
the most unfortunate but common reasons unhappy FFS patients
present to the senior author (DC) for revision is performance of
an isolated procedure—most commonly rhinoplasty—in which
the surgeon compensates for the limited scope of the surgery by
making the nose exceptionally feminine. This exacerbates the
problem and creates a highly abnormal appearance by placing a
female-sized nose on a male facial structure. When performing
isolated procedures, it is essential to undercorrect to maintain
harmony with the other parts of the face that will not be changed.
It must always be remembered that the great majority of patients
will judge their result based on a combination of both femininity
and attractiveness.
Transfeminine Top Surgery
Chest reconstruction in transgender women significantly
increases subjective feelings of femininity. Patients are recom-
mended to undergo a year of hormone therapy prior to augmen-
tation mammoplasty to maximize the extent of breast growth
with hormone therapy. Preoperative planning must consider
the anatomical differences between natal men and women.
Natal men have wider chests, larger pectoralis muscles, and a
greater distance between the nipple–areola complexes (NACs) in
addition to a shorter distance from the inframammary crease to
the NAC. While feminizing hormone therapy may result in breast
growth, a majority of patients still seek breast augmentation to
achieve the desired outcome. All postoperative measures used
for natal women also apply to transgender women who have
undergone breast reconstruction.
Transfeminine Genital Surgery
Vaginoplasty
Several important functional differences exist between a
neovagina and a natal vagina that patients must keep in mind.
The ideal neovagina possesses intrinsic self-lubricating qualities,
clitoral stimulation, a lack of hair growth, and elastic capabilities
with an ideal depth of at least 10 cm and a diameter of 3 cm. In an
effort to attain a similar profile, several issues must be addressed
prior to performing penile inversion vaginoplasty or intestinal
vaginoplasty (Fig. 109.2).

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Neovaginal Depth and Diameter
Reconstructive options to achieve an appropriate neovaginal
depth and diameter should be properly discussed during pre-
operative visits. Patients should be counseled on the variable
results due to differences in body type and tissue availability. Of
note, as patients increasingly begin to choose pubertal suppres-
sion, it is important to advise patients on the likelihood of not
having enough penile skin for a penile inversion vaginoplasty
and the possible use of a skin graft. In addition, patients should
understand that the size of the natal phallus plays a key role in
providing skin for the neovagina when undergoing penile inver-
sion vaginoplasty. Inadequate penile shaft skin can be addressed
with the use of a scrotal flap, nongenital skin graft/flap, or pedi-
cled intestinal flap.
Depilatory Procedures
Genital hair removal via laser or electrolysis is recommended to
optimize surgical results and to prevent hair growth within the
neovagina, which can lead to bezoars, infections, and a buildup
of secretions inside the neovagina. Moreover, yearly speculum
exams are recommended for assessment and removal of any
buildup in the neovagina.
Dilation Exercises
Upon the construction of a neovagina, patients should be pre-
pared as to the frequency in which the neovaginal pouch must
be regularly dilated in order to maintain its caliber and prevent
vaginal stenosis. Healing can take up to 12 weeks postopera-
tively, at which time vaginal intercourse can begin if desired.
Alternatively, patients who wish to avoid invasive surgery, life-
long dilation, or may be uninterested in vaginal intercourse may
elect for a zero-depth vaginoplasty in which a dimple is formed
in place of the introitus.
Thromboprophylaxis
Estrogen use, length of surgery, and postoperative bedrest are
all factors that can significantly increase the incidence of a
thromboembolic event in these patients. As already mentioned,
we recommend hormone use be stopped 2 weeks prior to sur-
gery and restarted 1 week after surgery. For pelvic surgery, we
administer preoperative subcutaneous heparin and continue it
throughout the period of bed rest.
Bowel Preparation Protocol
The use of a modified bowel preparation protocol varies from
surgeon to surgeon in penile inversion vaginoplasty. In intestinal
vaginoplasty, a full mechanical bowel prep and oral antibiotics
are recommended.
Ancillary Procedures
The timing during which procedures such as bilateral orchi-
ectomy and labiaplasty should occur is based on the patient’s
decision. Bilateral orchiectomy can be performed concurrently
with vaginoplasty or can occur at an earlier stage of transition,
with the goal of reducing androgen production. Similarly, labi-
aplasty is often performed concurrently with vaginoplasty but
can be delayed as a second-stage procedure after healing of the
first procedure has occurred.
Oncologic Screening
No formal oncologic screening guideline exists for transgender
women who retain their prostate gland after GAS. Although
studies have not shown an increase in incidence when taking
cross-sex hormones, patients should receive annual digital
prostate exams in addition to measuring serum prostate-specific
antigen, as some may develop benign prostatic hyperplasia or
acquire prostate cancer at the age of 50.
109.3.3 Clinical Decision Making for
Masculinizing Procedures
Facial Masculinization Surgery
Relatively few patients present requesting facial masculinization,
as most will develop significant facial hair due to testosterone
and report that this provides adequate facial virilization. Facial
masculinization procedures that can be offered include thyroid
cartilage augmentation, forehead augmentation, genioplasty,
and mandibular angle implants.
Fig. 109.2 Penile inversion vaginoplasty. (a) Preoperative evaluation of anatomic landmarks and available soft tissue for reconstruction. (b)
Photographic representation of postoperative result. (c) Postoperative result at 12-month follow-up.

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XIV Gender-Affirming Surgery
Transmasculine Top Surgery
Chest masculinization involves the removal of breast tissue,
reduction and repositioning of the NAC, and obliteration of the
inframammary fold through various surgical approaches (Fig.
109.3). Masculinizing hormone therapy provides patients with
chest hair and an increase in muscle mass, resulting in a more
masculine appearance.
Techniques include the “double incision” elliptical mastectomy
with free nipple grafting, periareolar mastectomies, and hybrid
techniques with variation on skin excision. The decision for a
particular technique depends on the size of the breast, size of the
NAC, and grade of breast ptosis. In our experience the majority of
patients will present with a preference or desire for a particular
technique. It is important to discuss the patient’s desires and
explain the advantages or disadvantages involved. Patients should
be counseled on the initial appearance of the surgical incisions,
the potential use of drains, and any additional postoperative care.
Transmasculine Bottom Surgery
The ideal neophallus looks cosmetically like a penis while having
tactile and erogenous sensation, a competent neourethra with
the ability to stand during micturition, and enough girth to
accommodate a prosthetic device. Reconstructive procedures
for transgender men include vaginectomy, metoidioplasty or
phalloplasty, scrotoplasty, and placement of an erectile device.
The removal of female reproductive organs by hysterectomy and
bilateral salpingo-oophorectomy prior to genital reconstruction
is an optional decision for some transgender men. Some find
discomfort in having internal female reproductive organs,
whereas others remove them entirely in order to decrease the
risk of developing cervical, endometrial, and ovarian cancer.
Alternatively, others may retain their vaginal introitus for sexual
gratification. At the time of phalloplasty or metoidioplasty,
patients may undergo full or partial vaginectomy and colpo-
cleisis (removal of the vaginal epithelium with closure of the
perineum) in order to cease vaginal discharge, which increases
during sexual arousal and may be disturbing to transgender
men. Vaginectomy should generally not be offered without prior
or concomitant hysterectomy, as colpocleisis would prevent Pap
smear surveillance of the remaining cervix.
Preoperative planning includes a thorough history and a
physical examination that evaluates the abdomen, mons, external
genitalia, and any potential donor sites as well as the body habitus
and body mass index for surgical decision making. In patients
undergoing radial forearm phalloplasty, an Allen test is performed
at the palmar arch to assess vascularity. Additionally, hair removal
at these donor sites may be cosmetically helpful and is vital in any
areas that will become neourethra.
Metoidioplasty
Metoidioplasty offers patients an alternative to phalloplasty
whereby patients are able to maintain intact erogenous sen-
sation with a lower complication rate than with phalloplasty.
Following testosterone therapy, the hypertrophied clitoris is
then surgically released and elongated. “Simple” metoidioplasty
involves only release of the urethral plate and suspensory liga-
ment to elongate the neophallus, whereas “full” metoidioplasty
also involves urethral lengthening out to the tip of the neophal-
lus. The goal for most patients undergoing the latter is to stand
during micturition. They will be typically unable to perform
penetrative intercourse. Scrotoplasty can also be performed with
either. Metoidioplasty is perhaps the most anatomy-dependent
of gender surgery procedures and requires significant clitoral
hypertrophy to achieve an acceptable result.
Fig. 109.3 Chest masculinization. (a–c) Preoperative and (d–f) postoperative depiction of reconstructive transformation.

 &OiniFDO 'eFiViRn 0DNing IRr Gender-Affirming Surgery
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Phalloplasty
Numerous phalloplasty techniques have been described,
including radial forearm free flaps, anterolateral thigh pedicled
or free flaps, latissimus dorsi flaps, suprapubic or abdominal
flaps, groin-based flaps, and osteocutaneous fibular free flaps.
The method in which to reconstruct the neophallus may involve
the use of radiological imaging, such as CT, to evaluate the main
perforators, physical examination, and patient understanding of
the risks and benefits of each flap.
Donor-site morbidity is an important topic to discuss with
patients who will be undergoing phalloplasty. Reported problems
after radial forearm or fibular osteocutaneous free flaps include
bone fracture, limited range of motion, decreased pinch and grip
strength, and sensory changes.
Complication rates with phalloplasty are exceptionally high
due to the tremendous complexity of the surgery, which com-
monly includes intricate microsurgery, long-distance urethral
lengthening and placement of a penile prosthetic cylinder with-
out the tough tunica sheath found in a natal penis that typically
protects it from extrusion. Most patients present for consultation
already aware of these challenges, but it is important to screen
carefully to ensure that the patient is mentally, financially, and
physically ready for a protracted reconstruction that could span
many operations.
Patients who retain their female reproductive organs should be
encouraged to undergo cancer screening during the recommended
intervals for natal women, as no current recommendations exist
for transgender men.
109.4 Concluding Thoughts
Transgender surgery represents a subspecialty of reconstruc-
tive surgery with a unique set of cultural and psychological
considerations and skills that the surgeon must master prior to
conducting the actual operations. Ultimately, however, in the
senior author’s (DC) experience, in properly selected candidates
these procedures represent uniquely complex functional recon-
structive surgery and can produce among the most happy and
grateful patients we see.
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110 Gender-Affirming Surgery 3DWienW SeOeFWiRn Dnd
Preoperative Considerations
Ara A. Salibian, Steven Lamm, and Rachel Bluebond-Langner
Abstract
Gender-affirming surgery is an important part of the overall
transition of transgender men and women. There are a wide vari-
ety of gender-affirming procedures, each with its own unique
challenges. All these procedures, however, require appropriate
preoperative evaluation and patient selection. Preoperative care
is the beginning of a multidisciplinary approach that will lon-
gitudinally follow patients through their surgical timeline. The
World Professional Association for Transgender Health Standards
of Care provide important guidelines that should be followed in
all gender-affirming procedures. Adjustment of hormone ther-
apy, early involvement of social services, mental health support,
knowledge of insurance coverage, cancer screening, and patient
education are all necessary aspects of comprehensive preopera-
tive care of transgender patients.
Keywords
gender-affirming surgery, gender-confirmation surgery, trans-
gender, gender nonconforming, gender dysphoria, vaginoplasty,
phalloplasty
110.1 Introduction
Gender-affirming surgery includes a group of procedures that
align an individual’s anatomy with the expressed or identified
gender of the patient. These masculinizing or feminizing oper-
ations include genital reconstruction, breast augmentation
surgery, mastectomy or chest contouring, body contouring, and
facial feminization/masculinization, among others (Table 110.1).
Gender-affirming surgery improves overall quality of life and
is a critical aspect of many patients’ transition. Rates of gender-
affirming procedures have significantly increased over the last
several years. This is due to increased understanding of the treat-
ment of gender dysphoria as well as expansion of insurance cover-
age. Major advances were made after 2014, when the exclusion of
transgender surgical services from Medicare coverage since 1981
was overturned.
While these procedures have been performed for decades and
the number of patients seeking surgery has increased, the tech-
niques are continuing to evolve as we aim to improve functional
and aesthetic outcomes as well as find better methods of evaluat-
ing quality of life and functional outcomes for these procedures.
These outcomes are significantly influenced by proper patient
selection, workup, and counseling. A multidisciplinary approach,
engaging the patient throughout all stages, is critical to the suc-
cess of gender-affirming procedures.
110.2 Considerations for Care
110.2.1 Terminology
Assigned sex is the gender marker designated at birth, typically
determined based on natal genitalia. A patient’s gender identity,
on the other hand, is their core sense of being male, female,
elements of both, or neither. Transgender patients therefore
have an incongruence between their assigned sex and their
self-identified gender, which may differ by varying degrees.
Transgender men have an assigned female sex and identify as
male, and may undergo masculinizing gender-affirming proce-
dures. Transgender women have an assigned male sex and iden-
tify as female, and may undergo feminizing gender-affirming
procedures.
Gender dysphoria is defined by strong, persistent feelings of
identification with a gender other than the sex assigned at birth,
which may result in significant distress, though not all transgen-
der patients experience gender dysphoria. Gender dysphoria is
assigned an International Classification of Disease (ICD-10) code
under gender identity disorders (F64.0-9) and is thus considered
a treatable condition, which some insurers will cover. The World
Professional Association for Transgender Health (WPATH) guide-
lines have appropriately recommended refraining from treating
gender dysphoria as a pathologic diagnosis in order to disassociate
the label from mental illness. Instead, a patient’s gender identity
can be solely recognized as demographic information.
Table 110.1 Common gender-affirming proceduresa
Male-to-female
Facial feminization
Female-to-male
Facial masculinization
Forehead contouring
Hairline advancement
Brow lift
Rhinoplasty
Rhytidectomy
Cheek augmentation
Lip lift
Genioplasty
Mandibular angle reduction
Thyroid chondroplasty
Augmentation mammaplasty
Body contouring
Orchiectomy
Genital reconstruction
Vaginoplasty
Clitoroplasty
Labioplasty
Forehead lengthening/augmentation
Rhinoplasty
Mandibular angle implants
Genioplasty
Thyroid cartilage enhancement
Chest contouring
Mastectomy
Liposuction
Body contouring
Hysterectomy/oophorectomy
Genital reconstruction
Phalloplasty
Metoidioplasty
Scrotoplasty
Testicular implants
Urethroplasty
a Several variations of procedures also exist for a spectrum of gender-nonconforming
patients.

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XIV Gender-Affirming Surgery
It is imperative for providers to use language that is affirming
and to accurately reflect this information while documenting
in the electronic medical record (EMR). Consistent and detailed
documentation promotes improved accessibility of affirming care
for every professional working with the patient. At our institution,
chosen names and pronouns are additionally included on oper-
ating room schedules, clinic appointment summaries, and case
bookings to minimize the incidence of misgendering.
110.2.2 WPATH Guidelines
All medical and surgical care of transgender patients should
follow the Standards of Care set forth in the WPATH guidelines.
These standards provide recommendations for all health care
providers to offer safe, responsible, and affirming care for
transgender individuals. The :PATH guidelines provide specific
criteria on patient evaluation for gender-affirming procedures.
All patients should have documentation of persistent gender
dysphoria, be able to make fully informed decisions, and consent
to treatment. Any significant medical or mental health concerns
should be identified and well controlled. Patients should under-
stand the risks, the benefits, the potential complications, and
recovery required.
Patients pursuing chest or breast surgery require one referral
letter from a qualified mental health professional. Individuals
undergoing breast augmentation require a minimum of 12 months
of continuous feminizing hormone therapy. Hormone therapy is
not required for individuals undergoing chest masculinization/
mastectomy procedures. All patients undergoing either trans-
masculine or transfeminine genital reconstruction require a
minimum of 12 months of continuous hormone therapy as well
as 12 continuous months of living in their identified gender.
Furthermore, two distinct referral letters from different mental
health professionals are required for patients undergoing gen-
ital surgery. Copies of the referral letters should be saved in all
patients’ EMRs and fulfillment of the :PATH criteria confirmed
and documented in the preoperative consultation.
110.3 Preoperative Evaluation
As with any operation patients undergoing gender-affirming sur-
gery require a full history and physical (Table 110.2). Common
risk factors for postoperative complications, such as high body-
mass index, smoking, and diabetes, should be screened for and
optimized prior to surgery. Human immunodeficiency virus
(HIV) is not a contraindication to surgery, but viral load and
CD4 count should be optimized. This history is important in
counseling patients preoperatively, selecting good candidates for
gender-affirming procedures and providing accurate estimates
of risks for different complications.
The date of social transition, the date of initiation of hormones,
and the contact numbers for the mental health provider and
hormone provider should be included in the documentation.
Support networks for postoperative care should be identified and
established. An organ inventory should be created to document
organs that have been removed and those that remain in order to
guide future preventive care and cancer screening. Using “organ
inventoryµ instead of ´women’sµ or ´men’sµ templates is effective
in documenting the information needed and helps to uphold
trans-affirming language.
110.3.1 Hormone Therapy
Patients’ current hormone therapy regimens, including start
dates, are queried, and the contact of their hormone provider is
documented in the EMR. Hormone adjustments are often needed
prior to and following certain gender-affirming procedures and
should be coordinated with the patient’s current hormone therapy
provider. In our practice, estrogen therapy is usually stopped 3 to
4 weeks prior to both top and bottom surgery due to an increased
risk of thromboembolic events. Testosterone therapy is typically
stopped 2 weeks prior to surgery. The timeline of resuming
hormone therapy postoperatively should also be discussed with
patients and the patients’ hormone providers preoperatively.
110.3.2 Mental Health Evaluation
Mental health is a critical longitudinal component of gender-
affirming surgery. Aside from the requirements of the :PATH
Standards of Care, mental health providers support individuals
during and after transition. Depression and anxiety have been
found to be higher in transgender populations, likely due to
social stigmas, discrimination, and abuse these persons have
experienced secondary to their gender identity. Therapy sessions
in the preoperative period should focus on establishing postop-
erative support systems, setting expectations, and arranging
finances and time off from work. Continued mental health care
postoperatively is advised; postoperative anxiety and depression
are not uncommon.
110.3.3 Cancer Screening
Appropriate cancer screening plays an important role in both
pre- and postoperative patient care. Cancer screening should
be based on organs present, the patient’s age, and the length of
time on hormones. Transgender patients have been shown to
avoid cancer screening due to worsening of gender dysphoria,
embarrassment, or discomfort with actual procedures. For
example, cervical screening can be physically painful in trans
men with vaginal mucosal atrophy due to testosterone, as well
as emotionally difficult due to gender dysphoria. Screening
should be individualized to provide patients with a comfortable,
respectful, and inclusive environment.
Table 110.2 Preoperative considerations in gender-affirming surgery
WPATH Standards of Care
Multidisciplinary team approach
Gender identity and preferred name documentation
Hormone therapy adjustment
Organ inventory
Mental health evaluation and support
Cancer screening
Adequate social support
Insurance coverage
Patient education and shared decision making
Abbreviation: WPATH, The World Professional Association for Transgender Health.

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Screening mammography is recommended for trans men who
have not had a mastectomy, starting at 40 years of age and every 2
years thereafter. This may be adjusted based on personal or family
history. For trans women, screening mammography begins at age
50 and after 5 to 10 years of hormone therapy. If a patient begins
estrogen at 55, screening mammography is not indicated until
60 or 65. Transgender women should also undergo screening for
prostate cancer according to the guidelines for cisgender (people
whose gender identity matches the sex that they were assigned
at birth) men. If the patient underwent vaginoplasty surgery,
the exam should be done through the neovagina. Cervical cancer
screening in trans men should follow recommendations for cis
women.
110.3.4 3rRFedure-SSeFiÀF (YDOuDWiRnV
Gender-affirming procedures include a myriad of different
operations, such as facial feminization, body contouring, breast/
chest surgery, and genital procedures. Each of these has its own
important factors in preoperative evaluation. The following
sections review important considerations for the most common
top (chest/breast) and bottom (genital) procedures (Table 110.3).
Female-to-Male
Mastectomy
Personal and family history of cancer or cancer risk factors
should be reviewed as well as any history of prior breast surgery,
including reduction, mastopexy, and augmentation. Recent
mammography, if age appropriate, should also be reviewed and
included in the patient’s record. The surgeon should counsel the
patient that some breast tissue may be left behind and clinical
exams are still recommended postoperatively. A history of
current or prior chest binding is relevant because binding can
decrease skin elasticity, which may exaggerate ptosis or cause
rashes and skin changes.
Physical examination includes a standard breast exam as well
as assessment of size, ptosis, and symmetry, including sternal
notch-to-nipple, nipple-to-inframammary fold, and breast width,
areolar diameter, nipple projection, internipple distance measure-
ments, as well as chest or breast asymmetry. Glandular volume,
skin elasticity, and degree of ptosis will guide the surgeon’s choice
of technique. Inability to breastfeed and changes in nipple sensa-
tion should be reviewed with the patients preoperatively.
Phalloplasty
Phalloplasty is a complex operation with multiple components. It
is important to discuss and understand the patient’s goals with
regard to sensation, ability to stand to void, ability for penetrative
intercourse, and donor site morbidity. These goals in addition to
the patient’s body habitus will guide donor site selection (e.g.,
forearm, thigh, back, abdomen). There are many components to
a phalloplasty (creation of the phallus, innervation of the phal-
lus, urethral lengthening, vaginectomy, scrotoplasty, testicular
implants, and erectile devices), and not all patients will elect
for every component. Phalloplasty is often done in stages, and
timing as well as commitment should be discussed.
Phalloplasty has high complication rates, including total or
partial flap loss, urethral strictures and fistulas, loss of the erectile
device, and donor-site complications. These complications must
be appropriately communicated to and understood by the patient.
Patients who are traveling should plan to stay within the area for
several weeks following surgery
Male-to-Female
Augmentation Mammaplasty
Patients undergoing augmentation mammaplasty should be
aware of the short-term and long-term risks of implant place-
ment. These include capsular contracture, implant rupture, mal-
position, rippling, changes in nipple sensation, and the need for
revision procedures. If textured implants are being considered,
the rare but serious risk of breast implant–associated anaplastic
large-cell lymphoma must also be discussed.
It is important to elicit a history of free silicone injections,
which can cause overlying skin changes, painful masses, and
deformity of the breast mound, and which may increase the risk
of infection or capsular contracture. Features of the chest that are
difficult to change with augmentation include wide-set nipples
and a wide sternum. These characteristics should be pointed out
in the preoperative exam, and realistic expectations should be set.
Implant sizing is determined by skin laxity, skin pinch, chest wall
measurements, and patient preference.
Vaginoplasty
Patient evaluation for vaginoplasty includes assessment of
penile length and quantity of scrotal skin to determine the need
for extragenital graft harvest if penile inversion vaginoplasty is
being performed. Patients’ sexual health, including the ability
to orgasm, preferred partner, and preferred type of intercourse
should also be assessed. Urinary symptoms including hesitancy,
Table 110.3 Procedure-specific considerations in gender-affirming
surgery
Mastectomy
Breast cancer history and screening
Binding history
Incision selection
Preemptive discussion of postoperative cancer screening
Phalloplasty
Desired neophallus size
Donor site selection
Urethral lengthening
Testicular and/or penile implants
Focused discussion on potential for flap loss and urethral complications
Augmentation mammaplasty
Discussion of short and long-term implant complications
Assessment for prior free silicone injections
Implant and incision selection
Vaginoplasty
Assessment of adequate genital skin (penile inversion vaginoplasty)
Sexual health history
Preoperative discussion on need for lifelong dilation
Communication of risks: bowel/bladder injury, neovaginal stenosis/
stricture

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frequency, dribbling, weak stream, and sensation of incomplete
emptying should be assessed. Important preoperative discussion
points include the need for daily vaginal dilation postoperatively
to prevent neovaginal stenosis and collapse. Patients must also
be aware of the very low but still possible risks of bowel or blad-
der injury, incontinence, loss of erogenous sensation, and ability
to orgasm.
110.4 Preoperative Considerations
110.4.1 Insurance Issues
Insurance coverage for gender-affirming surgery has signifi-
cantly increased over the last several years, including Medicare
and Medicaid in some states. Many third-party insurance pro-
viders and federal health insurance programs offer coverage for
chest and genital surgery. There remain state-based differences
in insurance coverage, and certain procedures, such as facial
feminization, are considered by many insurers to be cosmetic
and thus are not covered. Both patients and providers should
be familiar with the insurance policies in their state and obtain
authorization prior to surgery. Criteria for coverage is often
based on WPATH guidelines; therefore adherence to the WPATH
Standards of Care and appropriate documentation are strongly
recommended.
110.4.2 Social Support
Adequate support systems are critical to safe and successful
postoperative recovery. Involvement of social work early in the
preoperative process is useful in evaluating a patient’s external
support system and establishing the necessary services to assist
patients postoperatively. Some transgender patients have lost
friends and family as a result of transition and discrimination.
Potential isolation puts these patients at risk for further mental
and physical burdens postoperatively. Social work services are
therefore an integral part of the multidisciplinary team to ensure
that patients are receiving optimal postoperative support to aid
in their recovery.
110.4.3 Patient Education
The well-informed patient prior to surgery is the best set up for
success after surgery. It is the provider’s responsibility not only
to explain relevant information, including risks, benefits, goals of
the operation, and aftercare involved, but to ensure that patients
comprehend this information and retain the knowledge. This
process requires shared decision making in which both the pro-
vider and the patient formulate treatment plans together, with
each party providing important information, asking questions,
and contributing to decisions. Gender-affirming procedures
improve quality of life and can be lifesaving. Thorough and
responsible preoperative evaluation and preparation will max-
imize the benefits of gender-affirming surgery.
110.5 Concluding Thoughts
Gender-affirming surgery plays a critical role in the transition of
transgender patients and in treating gender dysphoria. Success of
gender-affirming procedures requires a standardized approach
to caring for transgender patients that starts with the initial
consultation and continues through a multidisciplinary team
that is incorporated longitudinally in both pre- and postopera-
tive care. Adherence to :PATH guidelines, delivery of affirming
care, focus on patient education, and comprehensive support
throughout these processes will maximize the success of these
invaluable procedures.
Clinical Caveats
• All surgical care should follow the WPATH Standards of Care
guidelines, and compliance should be appropriately docu-
mented in preoperative consults.
• Hormone therapy regimes should be documented and
stopped appropriately prior to gender-affirming surgery
through discussion with a patient’s hormone provider.
• Mental health support should be provided early and through-
out the care of patients undergoing gender-affirming surgery.
• Patients should undergo age-appropriate cancer screening
preoperatively and should be counseled on the need for con-
tinued cancer screening postoperatively based on remaining
organs and current guidelines.
• In-depth discussion and confirmation of patient understand-
ing of procedure risks is imperative, particularly in complex,
multistaged operations, such as phalloplasty.
• Establishment of a social support system with the assistance
of social work services is an integral component in the overall
care of patients undergoing gender-affirmation surgery.
Suggested Reading
[1] Andréasson M, Georgas K, Elander A, Selvaggi G. Patient-reported outcome mea-
sures used in gender confirmation surgery: a systematic review. Plast Reconstr
Surg 2018;141(4):1026–1039
[2] Baker KE. The future of transgender coverage. N Engl J Med 2017;376(19):1801–
1804
[3] Berli JU, Knudson G, Fraser L, et al. What surgeons need to know about gender
confirmation surgery when providing care for transgender individuals: a review.
JAMA Surg 2017;152(4):394–400
[4] Bluebond-Langner R, Berli JU, Sabino J, Chopra K, Singh D, Fischer B. Top surgery
in transgender men: how far can you push the envelope? Plast Reconstr Surg
2017;139(4):873e–882e
[5] Callahan EJ, Sitkin N, Ton H, Eidson-Ton WS, Weckstein J, Latimore D. Introducing
sexual orientation and gender identity into the electronic health record: one
academic health center’s experience. Acad Med 2015;90(2):154–160
[6] De Roo C, Tilleman K, T’Sjoen G, De Sutter P. Fertility options in transgender
people. Int Rev Psychiatry 2016;28(1):112–119
[7] Deutsch MB, Green J, Keatley J, Mayer G, Hastings J, Hall AM; World Professional
Association for Transgender Health EMR Working Group. Electronic medical
records and the transgender patient: recommendations from the World Profes-
sional Association for Transgender Health EMR Working Group. J Am Med Inform
Assoc 2013;20(4):700–703
[8] Dhejne C, Van Vlerken R, Heylens G, Arcelus J. Mental health and gender dyspho-
ria: A review of the literature. Int Rev Psychiatry 2016;28(1):44–57

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[9] Green J, McGowan S, Levi J, Wallbank R, Whittle S. Recommendations from the
WPATH consensus process for revision of the DSM diagnosis of gender identity
disorders: implications for human rights. Int J Transgenderism 2011;13(1):1–4
[10] Selvaggi G, Giordano S. The role of mental health professionals in gender reas-
signment surgeries: unjust discrimination or responsible care? Aesthetic Plast
Surg 2014;38(6):1177–1183
[11] Smith YL, Van Goozen SH, Kuiper AJ, Cohen-Kettenis PT. Sex reassignment: out-
comes and predictors of treatment for adolescent and adult transsexuals. Psychol
Med 2005;35(1):89–99
[12] The World Professional Association for Transgender Health. Standards of Care for
the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th
Version. 2011; Transfer/
SOC/Standards of Care V7 - 2011 WPATH.pdf
[13] Weigert R, Frison E, Sessiecq Q, Al Mutairi K, Casoli V. Patient satisfaction with
breasts and psychosocial, sexual, and physical well-being after breast augmenta-
tion in male-to-female transsexuals. Plast Reconstr Surg 2013;132(6):1421–1429
[14] :eissler -M, Chang BL, Carney M-, et al. Gender-affirming surgery in persons
with gender dysphoria. Plast Reconstr Surg 2018;141(3):388e–396e

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XIV Gender-Affirming Surgery
111 Gender-Affirming Surgery )DFiDO Surgery
Ara A. Salibian and Rachel Bluebond-Langner
Abstract
Facial feminization and masculinization involve a set of
gender-affirming procedures that align the facial features of
transgender patients with aesthetic ideals of the natal female
and male face, respectively. Facial feminization of the upper
facial third includes scalp advancement, forehead contouring,
and hair transplantation. Middle facial third procedures include
feminizing rhinoplasty and zygoma contouring. Lower facial
third procedures include lip lift, genioplasty, mandibular angle
reduction, and chondrolaryngoplasty. Facial masculinization
procedures include thyroid cartilage augmentation, supraorbital
and nasal augmentation, and genioplasty. When performed
properly in the appropriate patients, these procedures result in
high patient satisfaction and can have a significant impact on
treating gender dysphoria,
Keywords
facial feminization, gender-affirming surgery, gender-confirmation
surgery, transgende, tracheal shave, forehead contouring
111.1 Introduction
The face is a focal point of human interaction and social percep-
tion and therefore an integral component of how we perceive
gender difference. Facial feminization and masculinization sur-
gery consists of a group of gender-affirming procedures that alter
both bony and soft tissue structures of the face to develop facial
contours and proportions more aligned with accepted natal fem-
inine and masculine norms, respectively. While not as common
as other gender-affirming surgeries, such as augmentation mam-
maplasty and chest masculinization, these procedures have an
important role in treating gender dysphoria. Facial feminization
in particular has demonstrated high patient satisfaction as well
as significant psychological and social benefits.
Facial gender-affirming surgery has seen a recent increase after
recognition of the important role surgical intervention can play
in the treatment of gender dysphoria. These procedures were first
pioneered by Dr. Douglas Ousterhout in the late 1980s. At this
time, the primary anthropometric differences between the male
and female facial skeleton addressed were forehead contour, nasal
dorsum, and chin dimensions. Since then, indications have been
expanded to include a variety of refined operative techniques that
safely and effectively feminize and masculinize the natal male and
female face.
111.2 The Male and Female Face
Male and female faces have a multitude of distinct differences
in skeletal and soft tissue structures that convey an overall per-
ception of masculinity or femininity. The female forehead lacks
the supraorbital bossing of the male forehead (attributed to the
size of the frontal sinus and thickness of the supraorbital ridge)
and instead has a gentle continuous curve from the hairline to
the radix. Additionally, the female hairline has been described
as ´O-shapedµ versus ´M-shapedµ in the male. Brow differences
between males and females have been well described, with the
female brow more arched and sitting above the supraorbital rim
compared to a straight brow at the level of the supraorbital rim
in men.
The female face has a more prominent malar eminence com-
pared to a flatter zygoma in males. Females usually have a smaller
nose and narrow nasal bridge with a more obtuse glabellar angle
and nasolabial angle (increased tip rotation). The nasal dorsum
tends to be straight or more concave in females with a narrower
alar base width and increased tip projection. The female upper lip
also has a shorter cutaneous distance from the nasal base to the
vermilion border.
With regard to the lower facial third, the female chin is nar-
rower, more pointed, and less projected than the male chin. The
mandibular angle is also less prominent in females, who typically
have a shorter bigonial distance. Males also have a more prom-
inent thyroid cartilage secondary to a more acute angle at the
laryngeal prominence.
111.3 Preoperative Considerations
As with other gender-affirming procedures, facial feminization
operations should be performed in accordance with the World
Professional Association for Transgender Health Standards of
Care. Important guidelines include assessment and documenta-
tion of persistent gender dysphoria, the capacity to make fully
informed decisions, and the good control of significant medical
and/or mental comorbidities. Though referral letters from
mental health professionals are not required for facial femini-
zation surgery, early involvement of mental health professionals
is invaluable in providing the appropriate support for patients
undergoing these procedures. In addition, though facial femini-
zation procedures have a tremendous impact on treating gender
dysphoria, they are often categorized as aesthetic procedures by
insurance providers. Coverage issues and cost should therefore
be discussed preemptively with patients.
111.4 Common Facial Feminization
Procedures
111.4.1 Forehead Contouring and
Hairline Advancement
The upper facial third has been suggested to be the most import-
ant component of the face in conveying the appearance of a
female gender. Forehead contouring is a common procedure that

 Gender-Affirming Surgery )DFiDO Surgery
1621
modifies the frontonasal–orbital complex to reduce the prom-
inence of the supraorbital rim and frontal sinus while creating
a softer curve to the forehead (Fig. 111.1). Different approaches
have been proposed, including an anterior hairline incision
as well as a modified bicoronal incision. The former allows for
concomitant forehead advancement while the latter affords
the opportunity for follicular grafting from an excised strip of
scalp. There are also several different methods of recontouring,
including burring, removal of the anterior table with back table
contouring and refixation, creation of bony islands, and combi-
nations of these procedures.
Patient satisfaction rates after forehead contouring and hairline
modification are usually high. These procedures, however, can
have serious complications, including mucocele secondary to
frontonasal duct disruption as well as malunion of osteoplastic
segments. Alopecia and unfavorable scarring at incision sites must
also be discussed with the patient preoperatively. Appropriate
preoperative planning is critical and includes the use of different
imaging modalities to evaluate the thickness of the anterior cal-
varium and the size of the frontal sinus.
111.4.2 Rhinoplasty
Male-to-female gender-affirming rhinoplasty addresses the
overly “male” characteristics of the nose using standard open
and closed rhinoplasty techniques. Nasal reduction includes
component dorsal hump reduction to reduce the nasal dorsum
in profile and increase the nasofrontal angle. 1asal bone osteot-
omies and infracturing are also used to narrow the bony nasal
vault. Refinement of the tip is an equally critical component
of feminization rhinoplasty. Cephalic tip rotation is achieved
with cephalic trim and tip rotation sutures with the addition of
columellar strut grafts to maintain tip support. Caudal septal
resection can also effectively shorten the nose while providing
cartilage for grafts. Operative plans must be tailored to each
individual patient to feminize the nose while always considering
aesthetic ideals for rhinoplasty.
111.4.3 Lip Lift
The indirect lip lift, originally designed for lip rejuvenation,
translates well to lip feminization as both procedures share the
goal of shortening the cutaneous upper lip, or distance from the
columellar–labial junction to the vermilion border. The lip lift
additionally increases vermilion show and upper lip pout, both
of which have been found to be more aesthetically pleasing.
The subnasal bullhorn lift allows for varying degrees of lip lift
while concealing the scar at the nasal base. Lip lifts can also be
combined with lip augmentation with various fillers or autolo-
gous grafts. Patient selection and meticulous surgical technique
are critical for successful outcomes with regard to scarring and
amount of lateral lip lift (based on alar base width).
111.4.4 Genioplasty
Genioplasty is performed to narrow the width of the chin and
decrease its height. Use of traditional osteotomies typically lends
better results than more conservative burring/contouring. An
intraoral approach is used through a labial sulcus incision, sim-
ilar to aesthetic genioplasty, taking care to preserve the mental
nerves during dissection. Narrowing the chin is achieved by mid-
line vertical osteotomies with removal of a predetermined width
of bone. Reduction in vertical height is similarly performed, and
segments are stabilized with miniplaste fixation. Complications
include mental nerve damage, mentalis dysfunction secondary
to inadequate resuspension, damage to tooth roots, and mal-
union or nonunion of osteotomized segments.
111.4.5 Chondrolaryngoplasty
(Tracheal Shave)
A variety of different techniques have been proposed to reduce
the laryngeal prominence of the thyroid cartilage. Our preferred
technique includes an incision at the cervicomental junction
for scar concealment, a meticulous hemostatic dissection, and
careful burring (Fig. 111.2).
In addition, we use a hypodermic needle to pierce the thyroid
cartilage and subsequently visualize the needle on bronchoscopy
to ensure that the level of cartilage reduction is being performed
superior to the vocal cords to minimize the risk of destabilization.
111.4.6 Other Procedures
Several other procedures are also used to feminize the transgen-
der female face. In the upper third of the face, these include brow
lift and hair transplantation. In the middle third, osteotomies
Fig. 111.1 Forehead recontouring. (a) Preoperative photograph. (b)
Postoperative photograph. Note the absence of supraorbital bossing
and the gentle sloping curve to the forehead postoperatively.
Fig. 111.2 Chondrolaryngoplasty. (a) Preoperative lateral photograph.
(b) Postoperative photograph.

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XIV Gender-Affirming Surgery
and implants are used to increase zygoma projection. In the
inferior third, mandibular angle reduction is used to decrease
bigonial distance.
111.5 Common Facial
Masculinization Procedures
Facial masculinization is less described in the literature than is
facial feminization. The majority of reports focus on masculin-
ization of the cisgender face, pioneered by Dr. Ousterhout. These
techniques, however, can be readily adapted and applied for
transgender masculinization procedures.
111.5.1 Thyroid Cartilage Augmentation
A visible and prominent thyroid cartilage creates a masculine
neckline that becomes the focal point of the head and neck.
Augmentation grafts most commonly use cartilage harvested
from the ribs to provide an adequate block of cartilage for
shaping into a pyramidal structure that mimics the largyngeal
prominence. The submental approach for graft placement is
similar to that described for chondrolaryngoplasty, after which
the cartilage graft is secured to the native thyroid cartilage with
permanent suture, and the incision is closed in layers.
111.5.2 Other Procedures
Other facial masculinization procedures typically address the
forehead, nose, and jawline. Masculinization of the forehead is
aimed at creating a more protruding supraorbital forehead with
glabellar bossing. Augmentation of the supraorbital bar can
be achieved using different materials as onlays, such as meth-
ylmethacrylate shaped to particular dimensions for a specific
patient. Masculinization rhinoplasty involves increasing the
dorsal projection of the nose, again with the use of single onlay
grafts or diced cartilage through an open rhinoplasty approach.
Finally, osseous genioplasty can be used to widen and increase
the height of the chin. Methylmethacrylate implants used in
cisgender genioplasty can also be used to create a broad and
projected masculine chin.
111.6 Concluding Thoughts
Facial gender-affirming surgery encompasses a variety of proce-
dures aimed at better aligning the soft tissue and bony structures
of the face with accepted natal feminine and masculine norms.
These procedures commonly include forehead recontouring,
hairline advancement, rhinoplasty, lip lift, genioplasty, and
chondrolaryngoplasty, among others. Expected cosmetic results
and the extent of changes in appearance must be thoroughly
discussed with patients preoperatively prior to any facial femi-
nization procedure. It is important to remember that feminiza-
tion should include an overarching goal to stay within or move
toward known aesthetic ideals for each aspect of the face to offer
patients the best outcome for this gender-affirming surgery.
Clinical Caveats
• The female face lacks supraorbital bossing, has prominent
malar eminences, a smaller nose and narrower bridge with
increased tip rotation, a shorter cutaneous upper lip, and a
narrower, more pointed and less projected chin
• The World Professional Association for Transgender Health
Standards of Care must be followed for all facial feminization
procedures, with coverage issues and costs discussed pre-
emptively with the patient.
• Appropriate preoperative planning is key in forehead
recontouring, particularly with regard to the use of different
imaging modalities to evaluate the thickness of the anterior
calvarium and the size of the frontal sinus.
• Patient selection and meticulous operative technique are key
to reducing visible postoperative scarring in lip lifts.
• Chondrolaryngoplasty incisions should be hidden in the
cervicomental junction to avoid visible scarring.
• Rib cartilage grafts are a useful technique for thyroid cartilage
augmentation to masculinize the neck.
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