Medscape Plastic Surgery
Plastic Surgeon Says Labial Surgery Can Be Life-Changing for Patients
An Expert Interview With Jennifer L. Walden, MD
Stephanie Cajigal, Jennifer L. Walden, MD
February 11, 2013
Click here to read the article on Medscape
Labiaplasty, a procedure done to reduce the size of the labia minora in women, is one of the most common female genital aesthetic surgeries, says Jennifer L. Walden, MD, a plastic surgeon with a private practice in Austin, Texas. Dr. Walden, who has performed 25-50 labiaplasties per year since opening her practice 9 years ago, says that although the procedure can be life-changing, it is too often done by physicians unfamiliar with the latest techniques and with little experience operating on female genitalia. In this interview with Medscape, she reveals what she considers to be best practices for this procedure.
Medscape: How exactly is labiaplasty done?
Dr. Walden: It involves an excisional procedure to make the labia smaller and more cosmetically appealing. There are several ways to treat labial hypertrophy that have been described in the literature. The excisional techniques involving a wedge excision, such as a V-wedge or W-plasty, are the preferred techniques nowadays. They put the incision line on either aspect of the labia minora. An older method, which has largely been abandoned, is trimming the outer edge of the labia minora.
The V-wedge and W-plasty lead to less scar burden and to fewer problems, such as itching, burning, and painful sex, which were more common with the older procedures. They also preserve the natural border of the labia because the incision is down along the inner aspect of it, and the incision crosses and goes down the outer aspect of the midline of the labia minora.
Medscape: Is this procedure growing in popularity?
Dr. Walden: I'd say that it's become more acceptable in the past decade, and that's because techniques have improved, more doctors are now marketing that they do the procedure, and more doctors who specialize in the procedure have emerged. All of these things combined have led to it becoming less taboo and more accepted because it is not only cosmetically appealing, it's functionally appealing, too. However, when anything gains in popularity, there are always going to be hangers-on who want to jump on the trend. There are people who are less qualified to do genital surgery who do it anyway, and that's what gives cosmetic procedures a bad name. But there are a lot of very well-qualified people who are trained to surgically address these issues who produce nice results and change the quality of life for a lot of women.
Medscape: What are the main reasons why women seek this procedure?
Dr. Walden: Usually they are seeking it because they're having local irritation of the area, problems with personal hygiene when going to the bathroom or during their menstrual cycle, interference with sex, and discomfort during cycling, sitting, or walking or with tight jeans or yoga pants. What we hope is for the labia minora to be housed within the labia majora because the labia majora have a different quality to the skin and are designed to protect the inner labia minora. When the labia minora protrude outside of the labia majora, it's essentially a part of the female anatomy that's not protected, and it can be very irritating. Therefore, one of the main benefits is just an improvement of discomfort.
Women can also have a general concern with the appearance of their labia, so they want it to look as nice as possible. And that's OK. It's not a bad thing for women to want to look as good as possible.
Medscape: Are these benefits documented in the medical literature?
Dr. Walden: There have been a lot of well-done studies on this procedure, and there also have been a lot of case reports and small series, not just in the plastic surgery literature but in the obstetrics and gynecology literature.[1-3] In many different specialties, this is a well-documented procedure.
My labiaplasty patients are some of my happiest patients because it's a relatively straightforward and short procedure that's done on an outpatient basis. Within about an hour, it can be kind of life-changing.
Medscape: There are some physicians who feel that this procedure should only be done for reconstructive purposes, such as for prolapsed organs. How do you feel about this criticism?
Dr. Walden: When you're doing something to improve discomfort or to improve pain with sex or with sitting, then that in and of itself makes it not purely an aesthetic procedure. I think it's a misnomer to just qualify this as an aesthetic procedure because nearly all the time, the patient also has a functional concern.
It's also a procedure that should be done by qualified surgeons who have knowledge of the anatomy and the ramifications of operating near the vagina and near the clitoris, because there are true problems that can develop in surgical scarring that can be equally as painful or dysfunctional as the preoperative problem. But, if done conservatively and according to documented literature by the experts on these procedures, of which we have several in different fields, including plastic surgery, then there should be a relatively low likelihood of these problems.
Medscape: Can you specify what some of the complications may include?
Dr. Walden: With the older technique, surgeons would take a scissor and trim the edge of the labia, which, as you could imagine, would lead to a scar in a bad location. And so, with that, you could have a fragile or stiff suture line associated with irritation, discomfort with walking, contraction around the vagina, contraction of the scar around the clitoris, and problems such as diversion of the urinary stream, which is rare but could occur with certain techniques.
Medscape: What would make someone a qualified physician to do this procedure?
Dr. Walden: A qualified physician is someone who's certified by the American Board of Plastic Surgery and who's familiar with the techniques and is comfortable with operating on that part of the female anatomy. Gynecologic surgeons certainly are qualified to operate on the female anatomy.
Medscape: What sort of criteria do you review before performing surgery on a patient? Do you ever refuse to do surgery on certain patients?
Dr. Walden: Most of my patients have been realistic and of an adequate age to undergo the procedure. I can't recall turning someone away because they didn't have the anatomic problem that they described they had. But, certainly, if someone presented to me and they did not have what they described they had -- in other words, if they had some form of body dysmorphic disorder or a psychological problem that I could identify -- then I would turn that person away. I also wouldn't perform the surgery on a minor.
Also, if a patient presented with any other anatomic issue, like a vaginal scar condition or any other related anatomic problem that I'm not suitable to deal with, I'd refer her to a gynecologist.
Medscape: What kind of long-term follow-up and care are necessary?
Dr. Walden: Usually patients who undergo this procedure have a strict set of postoperative orders that include keeping the area clean with sitz baths and antibiotic cream and refraining from sex, riding a bike, and major exercise for about 6 weeks to let the suture line heal. The area actually heals very quickly, so after that whole process has occurred, it usually looks as if surgery hasn't been performed. Just as you can imagine, if you made an incision on the inner lip, because of the well-vascularized nature of the inner lip mucosa, it heals extremely well. I usually see patients several times in the early postoperative period and then at about 3 months, 6 months, and 1 year, and they're welcome to come back annually thereafter. Most people don't, just because they do fine and they kind of forget that they even had it done.
Medscape: Are there any misperceptions about the procedure that you would like to set straight?
Dr. Walden: There's a lot of controversy surrounding it, and it's for good reason. There have been providers in the past who may have performed the procedure in such a way so as not to promote the best incision line and postoperative results.
There are also surgeons who advertise for "designer vaginas," and I have to worry about my gender when I see an ad like that. When people in my profession see ads that border on appealing to people's emotional senses and to the unrealistic, then we have to take pause. We have to always be able to describe to patients what the procedure is that we are recommending, why we recommend it, and emphasize that this is surgery, and even if the surgery is for the sake of appearance, it has true consequences and potential complications.
Also, I don't think that surgery for labial reduction is a form of genital mutilation or of making women more subservient by altering their anatomy. I think that's a very extreme misperception because we have women performing the procedure on other women. I think it should be taken for what it's worth in that this procedure is done to alleviate certain symptoms in women and to make them feel better about themselves, which is really the definition of plastic surgery.
- Mass SM, Hage JJ. Functional and aesthetic labia minora reduction. Plast Reconstr Surg. 2000;105:1453-1456.
- Alter GJ. Labia minora reconstruction using clitoral hood flaps, wedge excisions, and YV advancement flaps. Plast Reconstr Surg. 2011;127:2356-2363.
- Murariu D, Jackowe DJ, Parsa AA, Parsa FD. Comparison of wedge versus straight-line reduction labiaplasty. Plast Reconstr Surg. 2010;125:1046-1047.