Labia Minora Repair,
Labia Revision, Labia Reconstruction

By Stefan Gress

Although labia minora reduction was still considered fairly uncommon just a few years ago, it now forms part of the treatment spectrum and features on the websites of most plastic surgeons and an increasing number of gynecologists.

Since the Composite Reduction Labiaplasty  (Aesth Plast Surg (2013) 37:674-683) technique for reducing the labia minora was published, we have performed a large number of corrective procedures involving the outer female genital region, the majority of which have involved reducing the labia minora of approximately 3,200 women.

While establishing the pool of patients over the years, it became apparent that the number of revisions, i.e. corrective procedures to rectify botched operations performed previously by other surgeons, was increasing significantly at the author’s practice. These already account for 25% of all intimate surgeries performed there to date and, in some cases, serious esthetic and functional damage is involved. The total number of reconstructive procedures performed in our clinic between 2014 and 2020 following unsuccessful initial reduction of the labia minora was 702. Unsuccessful initial surgery is a substantial burden for the patients concerned.

The most common iatrogenic deformity is the overresection of the labia minora below the clitoris (segment III according to Gress)leaving behind excess tissue in the area around and above the clitoral hood. Particularly when combined with clitoral protrusion, this results in the appearance of a small penis, which can often be extremely upsetting for the patients concerned.

There are essentially two procedures that can be adopted for reconstructing the labia minora below the clitoris: the first involves reconstructing the labia minora using bilateral preputial flaps (according to Alter) and the second involves reconstructing the labia minora using vaginal skin advancement (according to Gress). It is also possible to employ a combination of both procedures paired with correction of clitoral protrusion. Surgeons may also be tasked with correcting asymmetry, frayed wound edges, contour defects, gaps, an exposed clitoris, etc., the reconstruction / revision of which depends upon the patient’s individual circumstances.

Technique

The bilateral preputial flaps approach to labial reconstruction involves using excess tissue from above the clitoris. A proximal skin flap measuring approximately 3 cm long and 0.5 cm wide is dissected lateral to the clitoral shaft up to the base of the labia at the mons pubis, which is then rotated 180 degrees downwards and trimmed as necessary to correct the defect. Reconstruction using this method is not possible if the patient has no excess tissue above the clitoris. In this case, labial reconstruction using vaginal skin would be the only viable option. This initially involves using the current labia minora as a guide for incising the skin along the entire length of the labia, from below the clitoris right down to the posterior commissure. The vaginal skin is then resected medially, approximately 3 cm into the vaginal opening and lateral to the incision line, slightly above the posterior commissure of the labia majora. A sheet of tissue can also be interposed to stabilize and add volume to the labia minora. The skin from both sides mobilized in this manner is shaped into a wall-like structure, which can then be reinforced and stabilized using an intermittent U-suture along the base of the wall. Both procedures can be combined with one another and can also be interlaced with individual sub-steps of a composite reduction labiaplasty to correct clitoral protrusion, if required.

Other reconstructions depend on the type of deformity, e.g. smoothing frayed wound edges, correcting contour defects, closing gaps, covering an exposed clitoris, reinserting the frenulum of the clitoris, revising scars, redressing asymmetry, etc. The results of these procedures have been positive and satisfactory from both a functional and esthetic perspective. They should be evaluated in relation to the starting situation in particular. However, a satisfactory result, as would have been expected from a successful initial procedure, often cannot be achieved if a patient has a very severe deformity.

An increasing number of procedures to address labial hypertrophy have been performed worldwide in recent years. Hypertrophic labia minora can be a substantial burden to the women suffering from this condition, from both a physical and psychological standpoint. The decision to undergo labia reduction is not always a quick one, and patients often think long and hard before making this choice. They tend to have high expectations when it comes to the appearance of their labia after the procedure and have an exact picture of the end result in their minds. This makes it all the more disappointing if the result differs greatly from their expectations, and even more so if mistakes are made during the procedure, causing irreparable damage or problems that are difficult to rectify.

Patients and methods for labia reconstruction and labia revision

Between 2014 and 2020, we operated on 702 patients who had undergone labia minora reduction elsewhere and called upon us to correct a postoperative iatrogenic deformity. On average, the labia reconstruction surgery was performed 1.8 years after the initial labia reduction procedure, ranging anywhere from 25 years after the initial surgery to just four months. For almost half of these women, a single corrective procedure was not sufficient, with two or more surgeries required in 47% of cases.

The extent of a patient’s functional and psychological impairment was recorded and documented using a questionnaire containing questions of a personal nature.

98% of patients stated that they felt psychologically impaired due to the unsightly appearance of their labia, albeit to varying degrees. Functional impairments were evident in 77% of cases.

Any perceived level of psychological impairment, ranging from very mild to very severe, was assessed as psychological distress. In 14% of cases, the women concerned even needed to seek professional help from a psychologist or psychiatrist as a result of their botched initial operation (severe cases). Even prior to the initial surgery, 84% of the patients surveyed were already suffering psychological impairment and their sexual development had been affected to some extent due to the unsightly esthetic appearance of their labia – something that was only intensified by the botched initial operation.

Any form of physical impairment of varying degrees was recorded as a functional disorder. In most cases (76%) patients suffered from pain or irritation during sexual intercourse or when subject to other mechanical stresses, e.g. when playing sport, riding a bicycle, etc. 22% of those surveyed had recurring bouts of bacterial vaginosis due to the opening to their vagina being exposed, 7% experienced reduced sensitivity, with three patients in this category stating that they had been unable to climax since the labiaplasty due to a loss of clitoral sensation. 41% of patients experienced disturbing and uncontrollable urinary stream deflection as a result of their initial operation .

The aim of the labia reconstruction was twofold – firstly, to alleviate or even eliminate the functional symptoms, and secondly, to achieve the most esthetically pleasing result possible, in line with the patient’s expectations of the end result prior to the initial operation if at all possible. There was no one standard technique as every iatrogenic deformity was different in appearance and varied greatly from patient to patient There was, however, an accumulation of errors with resulting recurring deformities:

1. Overresection of the labia minora below the clitoris

This was the most common iatrogenic deformity (63% of cases). The overresection of the labia minora below the clitoris (segment III according to Gress) with excessive shortening or even amputation of the labia leaves the vaginal opening exposed. The most common reason for this deformity is fear of causing injury to sensitive nerves, which is why the excess tissue is left in the area around and above the clitoris (segment I & II according to Gress). This results in the appearance of a “small penis” which is amplified by simultaneous clitoral protrusion.

As regards reconstructing the labia minora in the segment below the clitoris, there are essentially two options available depending on the situation:

The lateral preputial flap according to Alter or reconstruction using the vaginal skin advancement technique according to Gress, as well as a combination of the two approaches.

The lateral preputial flap technique is used if the patient has labial hypertrophy, i.e. excess tissue above the clitoris and the clitoral hood. This involves making an incision to the skin approximately 3-4 mm lateral to the midline above the clitoral shaft and extending to the base of the labia minora on the mons veneris, where it rotates downwards again and runs along the fold of the labia majora up to the level of the clitoris. Depending on the individual anatomy of the patient, a flap of varying length and width may be incised, which is then approximately 30-35 mm long and 6-8 mm wide. The flap is configured in a proximal direction, elevated, rotated 180 degrees downwards and trimmed as necessary to correct the defect. Sufficient subcutaneous tissue should be left behind to ensure that the flap, which does not have an axially defined vascular style, i.e. follows a random pattern, has a good blood supply. At the same time, it must not be cut back too far so as not to impair the sensitive nerve supply to the clitoris via its dorsal nerve. The thickness of the shaft is extremely important. In our experience, it should be at least 10 mm wide so as not to compromise circulation, particularly because after the flap has been elevated, it needs to be rotated by 180 degrees, which can significantly restrict its blood supply. On the other hand, if the base of the flap is too thick, it is not mobile enough and cannot be rotated to correct the defect. The wound is closed subcutaneously using 5-0 Vicryl sutures and cutaneously using 6-0 Monocryl sutures following a transverse technique and a continuous U-suture along the labial ridge in the segment below the clitoris in order to achieve the smoothest contour possible.

The reconstruction of the labia minora using vaginal skin advancement is the only remaining option if the patient has insufficient skin above the labial segment, i.e. in the area of the prepuce (whether this is due to a previous surgery or if this is simply the patient’s anatomy) to form a flap. This procedure involves firstly smoothing the usually frayed or irregular contour of the edges of the existing labia (if present) and then making a skin incision along the scar created by the previous operation lateral to the vaginal opening on both sides. Using dissecting scissors, the vaginal skin is then detached in a medial direction, approximately 3-4 cm into the vagina, and in a lateral direction to slightly beyond the base of the labia majora . Both sections of skin mobilized in this way are then pulled tight to form a wall. Unlike the preceding description of this procedure, in modern practice we usually also lift a thin layer of tissue, pediculated at its base, consisting of the fascia of the bulbospongiosus muscle and surrounding connective tissue, which is placed between the mobilized sheets of skin to reinforce the labial wall. Reinforcement with additional tissue has been shown to counteract the formed labia’s tendency to shrink. In order to stabilize the labial wall in an upright position, penetrating U-sutures with a thickness of 4-0 Vicryl are stitched close together along its base. The labial ridge is closed using a continuous U-suture technique with 6-0 Monocryl sutures. In order for the treatment to be a success, it is essential for a compress to be placed in between the labia minora postoperatively for at least four weeks. This is necessary to continue to stabilize the labial wall and keep it in an upright position, preventing it from collapsing again and compromising the upright position of the new labium.

The two procedures can also be combined. Clitoral protrusion, which often amplifies the appearance of a “small penis”, can also be addressed as part of these two reconstructive procedures. This involves removing a diamond-shaped segment of skin from below the clitoris. By joining the edges of the wound, the clitoris is then lowered in both the lateral and frontal plane in the same manner as this sub-step of the composite reduction labiaplasty .

2. Asymmetry

Subtle asymmetries were compensated for by shortening the larger opposite side; in the case of more obvious asymmetries, the overresected side was built up by vaginal advancement or using a lateral preputial flap.

3. Frayed wound edges

This is a very common complaint, which is primarily caused by incorrect suture technique, particularly if excessively thick stitches have been used in a continuous technique to close the labial ridge. If the fraying was not too severe, it was smoothed out by making a linear incision along the labial ridge. Deep furrows, on the other hand, had to be cut open individually and closed using 6-0 Monocryl simple interrupted sutures. To avoid a rippled labia contour, the wound, i.e. the joining of the labia minora and majora below the clitoris, was closed using a 6-0 Monocryl continuous U-suture. This suturing technique is generally recommended for this area as it gives the labia a smooth contour.

4. Contour defects and gaps

These were frequently seen after wedge resection according to Alter to reduce the labia minora when the wound was closed under tension . Correction involved excision of the defect with a three-layer closure using 5-0 Vicryl sutures subcutaneously and 6-0 Monocryl cutaneously.

6. Exposed clitoris

The overresection of the clitoral hood can cause the clitoris to be exposed, which can sometimes lead to irritation or hypersensitivity. If possible, an attempt should be made to cover the clitoris, at least to some extent, using the surrounding skin from the labia.

Of the 702 patients we treated, we reconstructed the labia minora using a lateral preputial flap in 192 cases and vaginal skin advancement in 226 patients. We used a combination of the two procedures in 271 cases. Asymmetry was corrected in 87 cases, and contour defects and gaps were corrected and frayed wound edges smoothed in 106 cases. The contour of the clitoral hood was corrected and an exposed clitoris was covered in 35 cases. We also performed a series of smaller corrective procedures, which are not specified in any more detail in this document, in a further 56 cases. It was common for several of the above corrective procedures to be carried out on one single patient.

In almost all cases, the procedure was performed under local anesthesia on an outpatient basis. It was performed under general anesthesia in a handful of cases. We always used a high-frequency unit to incise and resect the skin, not a scalpel. The wound was closed subcutaneously with 4.0 or 5.0 Vicryl sutures and the skin was closed with 6.0 Monocryl sutures using various techniques. Antibiotics and pain medication were administered orally in the majority of cases. Patients were monitored regularly after surgery. The dressing consisted of an unfolded, moistened compress that had to be worn in between the labia for 14 days. In the case of labia reconstruction, this compress was worn for four weeks in order to stabilize the new labial wall for as long as possible. In most cases, patients had also been told to apply pressure to the labia after two weeks over a period of one month. This pressure was applied to the corrected or reconstructed labia twice a day with the tip of the index finger and the thumb to prevent tissue swelling from draining and to achieve the best possible scar healing.

Skin grafts were not used for labia reconstruction as they do not regain sensation and have a different skin color, which is not esthetically pleasing.

Results for labia reconstruction and labia revision

The result was assessed solely by the patient themselves six months after the completion of their treatment by means of an anonymous questionnaire. Of the 702 patients who underwent reconstruction and correction of the labia minora, the questionnaire was completed in full and returned to us in 544 cases. This questionnaire recorded patient satisfaction with the outcome of their operation as well as their assessment of esthetic and functional improvement.

The most common complication associated with reconstructive procedures is a wound healing disorder, which occurred in 37% of cases (e.g. wound dehiscence requiring correction, irregularities of the labia contour). Skin necrosis, mainly due to reconstruction of the labia minora by using a lateral preputial flap or by vaginal skin advancement, occurred in 7% of cases. This also included superficial skin necrosis, mainly as a result of venous congestion, whereby the skin did subsequently regenerate. For patients who underwent labia reconstruction using the lateral preputial flap method, complete flap necrosis occurred in 12 cases. There were no reports of infections or the worsening of a patient’s capacity for sexual stimulation. Further corrections requiring two or more surgeries were necessary in 43% of cases.

The development of existing psychological and functional disorders was related to the patient’s situation after the initial surgery and not to the time leading up to it, despite the fact that these impairments were already present before the initial procedure in most cases. The vast majority of patients (64%) stated that their psychological distress improved substantially after labia reconstruction, with 23% experiencing only minor improvement. The psychological situation remained the same compared to the starting situation in 6% of cases and even worsened for 7% of patients.

The correction of the initial result completely eliminated functional symptoms in 40% of cases, and there was at least a substantial improvement in 43% of cases. Functional symptoms did not worsen for any patients (0%), whilst 17% did not experience any change in their situation.

Patient satisfaction with the overall result achieved when compared to the starting situation before the initial procedure was scored at 4.6 out of a maximum of 10 points. The overall satisfaction with the result achieved in relation to the patient’s situation caused by the damage resulting from the initial operation was rated as 7.1

Discussion

Iatrogenic deformities are the root cause of the vast majority of revisions performed at our practice following an initial labia reduction carried out elsewhere. There are several reasons for this, including the surgeon adopting an incorrect or unsuitable surgical technique, executing the procedure in an imprecise or even careless manner due to lack of experience, underestimating the scope of the operation or not having sufficient expertise, particularly as regards detailed anatomical knowledge. The spectrum of deformities is extremely varied, ranging from a minor irregularity requiring correction through to complete mutilation. Reconstruction is often very difficult and a single corrective procedure does not suffice in most cases.

It is thanks to modern media and the penetrating power of the Internet that trends and developments in the field of medicine, including knowledge about the possibilities relating to intimate surgery, are spreading further and faster today than ever before.

The fact that, in our Western world at least, an increasing number of surgeons are performing procedures in the realm of female intimate surgery, is a positive development for the women concerned. On the other hand, however, an ideal surgical treatment is not always available in every case. However, this comparatively sudden launch of intimate surgery into the day-to-day practice of plastic surgeons does come with a dangerous drawback – a lack of training, standards and experience. Surgery on the nose or female breast, for example, has evolved over many decades, is taught at major institutions and has been a key talking point at conferences and further training events since the very beginning. This is not the case with intimate surgery. It is very rarely taught, and even when it is, it is assigned the very last slot for discussion at conferences. However, as many surgeons are keen to secure their position in this growing market, they operate at their own discretion without the necessary training, guidelines or surgical experience in this field. The results are often indicative of this. At the very least, they would have a selection of published surgical techniques  to follow.

The Deutsche Gynäkologische Fachgesellschaft (German Society of Gynecology) has itself warned against performing intimate surgeries and describes procedures involving the labia as obsolete In Switzerland, there is even talk in the political sphere about banning them entirely.

However, a ban is not the right way to go. Operations performed in an incompetent and incorrect manner must not be used as the basis for evaluating a surgical treatment or be allowed to stand in the way of medical progress. On the contrary. As with any other surgical procedure, we need to change our way of thinking in favor of a more respectful and professional approach to intimate surgery, combined with the possibility of enhancing knowledge of this field of medicine when plastic surgeons are in training at the very least, including teaching specific anatomical details and surgical techniques with indications, possibilities and risks.

A lack of knowledge of anatomical details combined with the fear of leaving a patient with sensory disturbances, in particular, results in the most common iatrogenic deformity associated with labia reduction that we see in our practice – the appearance of a “small penis”.

This is caused by the overresection of the labia minora below the clitoris, with excess tissue left behind in the area around the clitoral hood and above the clitoris. This is amplified further if the patient also has clitoral protrusion. This deformity is extremely distressing for the women concerned, and could be avoided by choosing the correct surgical technique which addresses the entirety of the labia minora, including the size and position of the clitoris, e.g. by using the composite reduction labiaplasty technique.

It is not uncommon for minor follow-up corrective procedures to be required after the initial operation. The genital region in particular is significantly affected by the mechanical friction caused by walking or sitting. It is not really possible to immobilize the area that has been operated on, which is why wound healing disorders are fairly common. Having said that, many complications can be avoided preemptively – major asymmetry can be prevented by precisely marking the incision line prior to injecting the local anesthesia. The use of a high-frequency radiofrequency surgical device makes it possible to make precise incision lines that cannot be achieved using a scalpel or scissors, and the use of the correct sutures and suture technique prevents the formation of a frayed labial contour. Clear guidelines concerning postoperative conduct and care, such as avoiding friction (e.g. sexual intercourse, jogging, cycling) also help the patient to heal without any complications.

The evaluation of the result of a reconstruction is unique, as the ultimate result needs to be assessed in relation to the patient’s starting situation and their expectations of the outcome of their initial operation, as well with regard to the degree of severity of the iatrogenic impairment.

On the one hand, patients are extremely happy with the improvement in their situation, but on the other hand, they are also disappointed if it ultimately proved impossible to achieve the result they were hoping for prior to the initial operation. This is particularly pertinent with regard to the external appearance of the labia. This is reflected in the evaluation of the results, which, compared to an initial operation, was substantially worse in the assessment of general patient satisfaction relating to the starting situation before the initial operation, scoring 4.6 points, than in the assessment of the initial procedures associated with a composite reduction labiaplasty, for example. In this case, the evaluation of the overall result, also with regard to the esthetic appearance achieved, scored an average of 9.4 on a scale of 0-10.

The elimination of functional impairments in 40% of cases, however, is very gratifying, and patients’ symptoms were at least alleviated or improved in 43% of cases. This factor, along with an ultimately acceptable esthetic result, may have contributed to the fact that the evaluation of the overall result in relation to the severity of the deformity can conclusively be rated as extremely satisfactory, scoring 7.1 out of 10.

Conclusion

Female intimate surgery, especially labia reduction, has become firmly established in the treatment spectrum of many plastic surgery practices and centers due to an increasing demand for this kind of surgery in our Western world. The demand for the best possible medical and surgical treatment should, however, also apply to these procedures, just as it does to any other operation. The harsh reality that the number of patients experiencing poor outcomes and mutilations is on the rise requires us to urgently change our approach and take action – specifically by introducing operative standards and including this subfield as an option in the training to become a plastic surgeon at the very least. The reconstruction of mutilations, e.g. fully amputated labia minora, is not easy and often only leads to a mediocre result in many cases. The prevention of errors with an appropriate initial operation must therefore be given top priority.

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