Labial reduction is a term used to describe any surgical procedure that is intended to reduce the size and volume of the labia minora. The criteria for labial reduction are either functional or aesthetic, though in the majority of cases the latter is predominant. This is surprising in view of the fact that the ideal female vulva does not exist, rather a wide range of labial lengths and widths, as well as clitoral sizes.
What are the Labia?
The labia minora are the small folds of thin and delicate skin that lie on each side of the actual vaginal introitus. They are about 0.4 to 6.4 cm in length, and about 2 cm wide, on average. It is important to note that the actual range is much wider, with normal variants being anywhere from 1.2 to 10 cm in length and 0.7 to 5 cm in width. interestingly, the two labia of the same woman are very often of different lengths. This shows that significant variations in labial size from one side to the other, as well as between different women, are perfectly normal and should never be interpreted as hypertrophy or abnormal in any way.
The clitoris is also between 0.2 to 3.5 cm long, and up to 1 cm wide. Contrary to popular thought, a larger clitoris is associated with greater enjoyment and a higher chance of experiencing sexual climax.
Labial hypertrophy has been attempted to be defined in terms of labial length. Felicio’s classification categorizes it into four:
- Type 1: Less than 2 cm
- Type 2: 2-4 cm
- Type 3: 4-6 cm
- Type 4: Over 6 cm.
Others define labial hypertrophy as anything over 4 or 5 cm and advocate correction if desired, but acknowledge that most cases are congenital in origin, which implicitly means it is a normal variant. A minority of cases may have acquired hypertrophy which is possibly due to:
- Exposure to exogenous androgens in infant life
- Application of estrogen preparations causing overgrowth of the labia
- Stretching by manual means or by attaching weights as in some aboriginal tribes for the sake of cultural beauty norms
- Chronic dermatitis
- Vulvar lymphedema
- Bone marrow infiltration
- Stretching in pregnancy, which is still a doubtful etiology
Indications for Labial Reduction
The guidelines for labial reduction are very vague, as mentioned above. It is obvious that most surgery of this type is done on the basis of a woman’s dissatisfaction with her labia rather than any concrete functional or surgical reason for intervention. For this reason, some authors have tried to define labial hypertrophy as an anatomical entity to justify this operation.
Surgery for labial reduction should be recommended or supported only if there are chronic symptoms due to labial irritation, abnormal odor or genuine difficulty in sexual penetration. These are so uncommonly due to labial hypertrophy as to be unlikely. It has also been established that modern society prefers women to have small labia resembling those of prepubertal girls.
Many techniques have been devised to achieve labial reduction, which include:
- De-epithelialization which removes some tissue from the labia but does not change the shape, and is thus suited to slim down the labia rather than trim their length or width
- Direct excision or trimming which cuts off the excessive length, but is not ideal as it leaves a horizontal scar, causes scalloping of the edges, removes the natural contour and may leave the labia fibrous and firm
- Wedge resection removes a V-shaped piece of skin with underlying subcutaneous tissue to reduce labial volume but preserve more skin. The incision at first left a horizontal scar and an overhanging hood. The modified extended wedge incision is made in such a way as to leave an invisible scar in the crease between the labia majora and minora. It leaves the edge intact and does not alter the pigmentation.
- Z-plasty is another modification which uses a Z-shaped incision to further reduce the incidence of post-operative tightness or scarring.
- Composite reduction is a still further central wedge resection which extends the lateral incision to tailor the contour of the clitoris as well by removing lateral clitoral tissue and shortening the clitoral hood. However, it is also easier to botch this correction and it has a higher rate of complications and of revision surgery.
- W-plasty and laser labiaplasty are among the most recent modifications of this surgery.
Whatever the technique, it should be clear to the patient that psychological problems similar to those of body dymorphic disorder cannot be solved or even alleviated by having a medical professional to perform physical alterations on her body. Some experts have strongly opined that professional counseling should be made available after clarifying that the female genitalia does not fit the one-size-fits-all approach, but there are almost as many variants as there are women in the world.
Either general or local anesthetic may be used, but the former is preferred. The skin is closed meticulously using fine sutures in layers to maximize the chances of healthy healing without a visible scar.
The procedure takes about a couple of hours at most, and most patients are discharged by the next day. Postoperative care is important to optimize wound healing.
After a labia reduction procedure, the woman must keep the area dry and clean. She should also wear loose underwear and clothes, avoid friction between the wound and overlying cloth, avoid sexual intercourse, and use sanitary pads if needed during this time.
A labia reduction surgery is usually uneventful, but complications do occur in a small number of patients, including wound dehiscence, wound hematomas, chronic pain, unsightly scarring, and infection of the wound, as well as flap necrosis. Injury to the neurovascular supply may impair future sexual enjoyment.
A poor outcome may necessitate future revision surgery.
The patient satisfaction rate with the appearance is usually high, however, though long-term studies are not available as to the improvement in sexual satisfaction following the surgery.
Is Labia Reduction a Form of Female Genital Mutilation?
An interesting point of view has been raised for clarification by some researchers into medicolegal issues, namely: what is the difference between a cosmetic labia reduction surgery and female genital mutilation, which is currently a criminal offence in developed countries? It is suggested that the fact that the patient consents to labia reduction while the child who is mostly the subject of female genital mutilation does not, is not a valid difference between the two procedures. The mostly cultural value attached to the desired appearance of the external genitalia would appear to be the motivating factor in both, and to be equally invalid as an indication for surgical intervention in both situations.