The documented origin of labioplasty dates back to the Pharaos in Egypt [1]. This practice, although modified, has persisted in the African continent with variations as minor as modification of the labia minora up to extensive resection of all external female genital organs including labia majora and minora as well as the clitoris.

Amongst the earliest modern medical references discussing labioplasty is that of Hodgkinson and Hait [2] where they discuss the functional and aesthetic standpoints. Over the years, multiple procedures by Alter [3], Rouzier [4], Choi [5], and others were devised with varied outcomes and complications inherent to the different techniques used. Although less commonly used, the term labioplasty may encompass the augmentation or reduction of the labia majora .

A common nonaesthetic indication for labioplasty is dyspareunia, which usually occurs in women with labial hypertrophy due to the labia being pulled on significantly during intercourse. Other indications include vulvar irritation and discomfort with the use of underclothes or during ambulation or exercise. Some patients report an inimical impact on hygiene, especially when menstruating. The negative psychological impact of the “unnatural” or abnormally appearing labia, even if subjective, is also a frequent reason to consult a physician.

When performing a labioplasty, the essential goals should include the reduction of the hypertrophied labia minora with maintenance of the neurovascular supply, preservation of the introitus, optimal color/texture match, and minimal invasiveness [6, 7].

While many systems to stage the severity of this condition exist, there is still no consensus on how best to define and classify labial hypertrophy. One system divides the classification into three stages: none (no edges protruding beyond the labia majora ), mild (1–3 cm beyond the labia majora edges), severe (>3 cm). Another system described by Felicio [8] divides labial hypertrophy into four stages: I (<2 cm), II (2–4 cm), III (4–6 cm), IV (>6 cm). Franco and Franco [9] describe a similar classification. However, Rouzier [4] considered that the normal maximal length of the labia minora should not exceed 4 cm, whereas Radman [10] considers it to be 5 cm (Fig. 25.1).

A myriad of surgical techniques have been reported in the literature, including simple resection, wedge resection with modification of excisions, VY and Z-plasties, and de-epithelialization (Figs. 25.2a–c and 25.3a–c).

In simple resection, the excess or protuberant labial tissue is removed using scissors, a scalpel, or even a laser, in an elliptical or straight line [11]. The edges are thereafter reapproximated with sutures, preferably simple interrupted, to ensure appropriate healing while maintaining the new contour. Depending on the defect or abnormality, the resection is preferably made while preserving a regular labia minora edge. Some surgeons suggest a remnant minimal labia minora depth of 1 cm [2, 12]. A novel technique called “Lazy S” reported by Warren is reported to assist in reducing the likelihood of contractures and phimosis of the labia minora [13]. This technique involves marking the area to be resected in an S shape—rather than an ellipse or straight line—prior to infiltration with local anesthetic and then resecting along the broadly wavy tract. It is reported that once healing occurs, the wavy line would take a relaxed appearance with little tension at the periphery of the tissue, giving a more “natural” and aesthetic look.

Another technique is wedge resection, which is reported to reduce hypersensitivity and contour irregularities upon healing. The wedge system targets the most hypertrophied region in the labia minora and resects it all the way to its base in a V or wedge form. This in turn allows for a smaller exposed healing area; however, depending on the resection required, it might be deep enough that it reaches the proximity of the labia majora . Multiple variants of this procedure have been devised including Z-plasty and VY and the Matarasso modification/Star wedge resection [6]. The initial description of the technique involved a V-shaped wedge resection of the area with the most excess tissue identifiable [3]. Maas and Hage reported the wedge technique to strictly involve a W-shaped resection margin in the labia minora with no involvement of the clitoral dorsal hood, prepuce, or fourchette [12]. The advantage of this technique (also known as the Zig-Zag technique) was reported to be the lower likelihood of dyspareunia and introital obliteration. This technique is reported by some to induce loss of the pigmentation along the border of the labia minora despite the more natural contour being generated. In 2008, Alter published the extended central wedge technique, a modification of his previous wedge resection, producing a more aesthetic look, with the possibility of resection of excess tissue in the clitoral hood [14]. This was based on the follow-up of previously operated patients. Among the modifications was one reported by Munhoz and colleagues where the wedge is resected from the inferior aspect of the labia minora and a superior pedicle flap is developed [15]. This is reported to provide a better aesthetic look due to a more homogenous tinting of the labia.

In 2000, a technique was devised by Choi and Kim so as to maximally help preserve tint, texture, sensation, and the neurovascular supply to the labia minora [5]. This technique involved the central de-epithelialization of both labia minora on both sides with suturing of the new edges together.

In 2011, Alter described the use of YV advancement flaps for the reconstruction of either absent, abruptly terminated, distorted, or scalloped labial edges [16]. Being the closest match to labial tissue, clitoral hood tissue is mobilized in such a manner as to release two parallel folds—including the Dartos fascia and blood supply—from around the clitoris and rotating them on each side to form the labia minora.

Composite reduction refers to labial reduction as well as enhancement of the clitoral hood. Described first by Gress in 2013, it allows for uniform reduction of the labia and the tissues covering the clitoris [17]. The study, which consisted of 812 patients, reported high patient satisfaction and an increase in patient excitability in 35% of patient undergoing the correction of clitoral protrusion.

The perineal area seems less susceptible to infection compared to other regions of the body but the potential for abscess formation does exist, and it is mandatory to follow the universal guidelines for surgical site cleansing prior to initiating surgery. Although no definitive recommendations for labioplasty have been set by any society, routine administration of surgical antibiotic prophylaxis is advisable.

The possibility of contractures , tissue breakdown along the suture line, flap necrosis, edge necrosis, irregular resorption, phimosis of the clitoral hood, new onset of dyspareunia, loss of sensation or hyperalgesia may occur in the resection areas.

Close care following surgery whether immediately postoperatively or a few weeks out is mandatory. No set criteria are available in the literature denoting particular postoperative wound care. However, it is advisable that postoperative patients avoid trauma to the surgical site and observe pelvic rest, such as by avoiding intercourse and use of tampons and sexual toys, for a minimum of 4–6 weeks so as to ensure adequate healing. Felicio reports that ice packs and NSAIDs are ideal for postoperative edema and swelling [20]. He also recommends ensuring that labioplasty is not concurrently performed with perineoplasty due to the intense swelling resulting in prolonged discomfort persisting up to 6 months. In addition to discomfort, the likelihood of suture-line breakdown is much higher with swelling. Thus, staging the enhancement procedure would be advisable for both patient care and outcome.

Generalized flap degeneration or necrosis is more commonly seen in patients with sutures that have been placed tightly across the edges or when there is excessive traction on the attached tissue or flaps. It is crucial that when a flap is to be mobilized, the surgeon needs to ensure the persistence of the blood supply to allow the flap to survive as well as incorporate appropriately into the transposition site. Distal flap necrosis and subsequent gap formation in the labia may ensue if the vascular supply is not preserved. Additionally, in YV advancement flaps, the devascularization due to extensive undermining or extreme skinning prior to mobilization particularly endangers the survival of the transposed flap. Thus, ensuring minimal vessel distortion when mobilizing tissue with the least possible rotation/torque applied allows for better tissue survival. The development of a wound dehiscence is particularly ominous in esthetic surgery.​

Hemorrhage and the possibility of hematomas may be encountered based on the vessels severed. Arterial blood vessels usually require active control by cautery or suture ligation, whereas venous bleeders may need less aggressive management including pressure applied to the area involved or simple application of hemostatic agents.

The acute worsening of pain postoperatively may indicate the expansion of a hematoma, particularly in highly vascularized areas such as the labia majora . In addition to the psychological impact on a patient, the formation of a hematoma could potentially require drainage as well as prolonged courses of antibiotics, and ultimately exploration to control the bleeding vessel. This can be attempted initially by freeing the suture line and then evacuating the hematoma. Since not all hematomas are associated with arterial bleeding, the use of fibrin clotting agents could be useful at times when persistent minimal venous oozing is noted. While multiple agents exist, there are no studies identifying the benefit of one compared to. another in the setting of labial hematomas .

Postoperative dyspareunia is known to occur more with wedge excisions as well as simple resection of labial tissue due to the newly formed exposed labial edge. Multiple studies have been done to assess the innervation in hypertrophied labia compared to normal sized ones with no evidence of variability demonstarted relative to size [23–25]. However, postoperative hyperalgesia has been noted to occur, especially with associated infection, severe inflammation, or when severe edema ensues postoperatively. If swelling occurs and the tissue perfusion is impacted, the possibility of labial retraction and contracture (called phimosis if involving the clitoral hood) may occur as the healing process continues. This contracture may in turn cause severe dyspareunia that may require reoperation if resulting in inability to achieve penetration.