Labiaplasty is the most commonly performed female cosmetic genital surgery procedure. Women sought labiaplasty for aesthetic reason and/or for functional impairment. Despite increasing numbers of procedures performed, there is a lack of consensus of standards of nomenclature, of care and of outcomes. The aim of this study was to clarify the current notions and the management of these women. A systematic literature review of the last 5 years (2015-2020) was performed using the PubMed database. The search returned 111 articles; after applying inclusion criteria to identify studies evaluating classification of labia minora hypertrophy, surgical techniques, complications and outcomes, 50 articles were selected (11 reviews, 3 clinical trials, 36 prospective and retrospective studies). In this brief review the authors clarify that no consensus exists in the literature regarding the classifications of labia minora hypertrophy. Overall, 7 different techniques have been reported, and patient satisfaction rates ranged from 95 to 100 percent. The most common complication described was wound dehiscence (around 5%).
The analysis of literature clearly shows that the counselling is fundamental and women’s motivations for treatment should be carefully explored. A complete medical, sexual, psychological and gynecological history should be obtained in all patients before surgery. To achieve the best outcomes in both functionality and appearance with minimal complication rates and greatest patient satisfaction, trained surgeons must inform patients about normal variations and about the potential risks of surgery, perform psychological evaluations (multidisciplinary approach), discuss realistic expectations, and personalize the technique of surgery. Although labiaplasty was described as a safe procedure with a high satisfaction rate, current study includes few patients with short follow-up. Further clinical studies should be performed to: validate current practices, define optimal management of patients and investigate long-term outcomes.
Cosmetic genital surgery; Labial hypertrophy; Labia minora; Labiaplasty
The surgical reduction of labia minora, defined labiaplasty, was first described in literature by Hodgkinson and Hait in 1984 . About 56% of Plastic Surgeons perform labiaplasty worldwide and, over the years, this procedure has become more popular. In 2018 a total of 132.664 procedures (1.3% of total) were performed worldwide, with an increase of 25% vs 201 . In 2018 Brazil was the Country in which there are recorded the higher number of procedures, about 18.476; in USA 13.668, and in Italy 4.800 . According to data of American Society of Plastic Surgeons, 11.218 procedures were performed in 2019, up 9 percent from 2018 .
So, labiaplasty is the most commonly performed FCGS (female cosmetic genital surgery) procedure. This increase was secondary to amplified exposure to female nudity in the media and internet, which cause a definition of an ideal look of female genitalia, that, however, differs between Countries [4,5]. Women sought labiaplasty for aesthetic reason and/or for functional impairment such as irritation, pain or physical and psychological discomfort, especially in adolescent patients [6-8]. In fact, hypertrophy of labia minora can cause self-esteem reduction, insecurity when wearing tight clothing (for job or sport), dryness, irritation, tearing, chronic urinary tract infections, dyspareunia and discomfort during sexual intercourse [9,10].
Although these surgical procedures are debated for ethical aspects, about 95% of patients are satisfied with outcomes on quality of life and self-perception [11,12]. There is no consensus regarding the use of criteria to define a diagnosis of labial hypertrophy, and it has been proposed that surgery should be pursued with the presence of any chronic symptomatology. Various classifications and surgical techniques exist, with no consensus regarding their use. The lack of standards of nomenclature, of care and of outcomes have caused questions about the level of safety and efficacy of these procedures . The aim of this study was to clarify the current notions and the management of these women.
A systematic literature review of the last 5 years (2015-2020) was performed using the PubMed database with the following search algorithm: ((labiaplasty) OR (labial hypertrophy)) AND ((etiology) OR (epidemiology) OR (classification) OR (treatment)). The primary literature search returned 111 articles. The authors independently reviewed article titles and abstracts to identify all studies that assessed labial hypertrophy classification, labiaplasty techniques and outcomes. Selected articles that met these inclusion criteria then underwent full text review. Information from commentaries/replies, conferences and published abstracts was excluded. After applying inclusion criteria, of 111 articles returned, only 50 articles were selected as pertained to vaginal labiaplasty (11 reviews, 3 clinical trials, 36 prospective and retrospective studies). All articles were in English language.
Labial hypertrophy classification
The labia minora vary in length (7 mm to 5 cm), thickness, symmetry and protuberance. Women’s health care professionals play a fundamental role in helping patient to understand their normal anatomic variation [14-16]. Labial hypertrophy is most commonly congenital, but can be acquired also (androgenic hormones in infancy, topical estrogen, stretching or weight attachment, lymphedema, recidivate dermatitis, myelodysplastic diseases) . There is no consensus on classification [18,19]. The most used classification system, first described by Franco , divides 4 stages based on the distance from the base of the labia minora to the most distal tip:
- • Stage I:
- • Stage II: 2-4 cm
- • Stage III: 4-6 cm
- • Stage IV: >6 cm
Other classifications are: the Motakef classification that is based on the protrusion of the labia minora that exceeds the size of the labia majora ; the Banwell classification that categorizes the labia according to the shape and morphologic variations ; and the Chang classification that propose 4 classes of labia protrusion based on size and location . Less used classifications are described by Oranges  and by Mayer .
In 2016, 2017 and 2020 ACOG Committee (American College of Obstetricians and Gynecologists) recommended that the women should be informed about normal variations and physical changes, that the patient’s physical and emotional development had to be evaluated, and that consultation about non-surgical technique should be provided [26-29]. In fact, counselling is fundamental to ensure that women have reliable information about normal variations and physiological changes in the external genitalia over the lifetime and about possible complication of surgery, especially in adolescents [30-34]. Many women desire the labia minora roughly symmetric, non-exposed or invaginated under of the labia majora. Women’s motivations for treatment should be carefully explored. A complete medical, sexual, psychological and gynecological history should be obtained [35-38]. In fact, principal contraindications are: body dysmorphic syndrome, enhancing sexual lives and orgasm .
When performing a labiaplasty, 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 [40-45]. Although many surgical techniques have been reported in the literature, (including deepithelialization,  direct excision,  W-shaped resection,  wedge resection, [49-53] composite reduction, [54-55] Z-plasty,  and laser labiaplasty [57,58], few studies have defined an algorithm for choosing the optimal surgical procedure according to the degree of deformity. Patient-specific techniques chosen based on the patient’s anatomy and applied with a realistic approach can increase patient satisfaction and reduce complication rates. Overall, the different techniques reported can be categorized into three groups: edge resection; wedge resection; and central resection.
In this technique, the excess of labial tissue is removed by resecting the most protruding part. This excision can be performed either in a line that follows the curve of the labia, in an S-shaped line, or in a W-shaped resection. The S-shaped resection, or the double-W-shaped incision or the Z-plasty is widely used technique to increase the length of the scar and to reduce the effects of scar contraction [48-58].
Wedge resection is the most popular labiaplasty technique. It includes various adaptations that have been made to improve aesthetic results (such as preserving the shape and colour of the labia) or to prevent loss of sensation or necrosis. The location of the wedge can be adjusted to the most bulging part of the labia minora. The central wedge resection can be performed with or without first identifying and preserving the main labial artery .
Giraldo et al.,  perform a 90° Z-plasty in order to prevent scar contraction. When reduction of the clitoral hood is also desired, a central wedge can be combined with a “lateral anterior curved excision of redundant lateral labium and excess lateral clitoral hood” . The wedge can also be placed posteriorly in a posterior wedge resection , or inferiorly with a superior pedicle flap.
Central resection is used to maintain the original texture, contour, and pigmentation of the labial edge and includes de-epithelialization  and fenestration . Choi et al.,  described a de-epithelialization technique using a triangle-shaped marking centred in the labia minora. Ostrzenski et al.,  marked the amount of tissue to be removed centrally in the labia minora in a ‘bicycle helmet’ shape. Excision is performed, and the inner and outer surface of the labia minora are sutured separately, without suturing the erectile tissue between them.
A. Direct excision; B. Deepithelialization; C. Central wedge resection; D. W-resection.
In current literature there isn’t any comparative analysis of all reported labiaplasty techniques to establish a standard operative planning. Ellsworth et al.,  proposed this algorithmic approach: patients with Franco type I and type II may be treated most effectively with the deepithelialization technique. Patients with Franco type III or type IV may be more appropriate candidates for either the direct excision or the wedge resection technique. However, future larger studies should validate this approach.
Each technique offers its own advantages and disadvantages . Although direct excision is a simple technique, yet it removes the natural contour, coloration, and texture of the free edge of the labia minora and may lead to visible scar formation. In contrast, deepithelialization may preserving the natural border of the labia minora and its neurovascular supply, but it may be unsatisfactory for wider labial width. Wedge resection retains the natural contour and coloration of the free edge of the labia minora; however, it may create an abrupt contrast in the coloration where tissues are sutured. Composite reduction is a technique that addresses both labial protrusion and clitoral hooding with excellent aesthetic outcomes. However, the complication and reoperation rate for this technique is also the highest described in the literature (about 17 percent) .
In current literature, few studies report on the surgical outcomes of labiaplasty with a patient satisfaction rates ranged from 95 to 100 percent [62-68]. The most common complications are dehiscence, hematoma, unsatisfactory scarring, infections, flap necrosis, fistulas, clitoral hood excess and pain [69-71]. Most reviewed studies stated that resection should not reduce the width of the remaining labia minora less than 1 cm to avoid distortion of the urethral orifice. Moreover, the resection should not extend to the posterior fourchette to avoid distorting the vaginal introitus [69,70]. More work needs to be done to validate each of these methods, better compare the available techniques, the risks and benefits for each method, and validate treatment paradigms, and to perform recommendations for perioperative patient management.
The request of female aesthetic genital surgery increases rapidly. Although the aesthetic labiaplasty is becoming a commonly performed surgery with exceptional patient satisfaction rates, the current literature is rather limited. With this safe, consistent and reproducible procedure, both function and beauty are becoming researched together. To achieve the best outcomes in both functionality and appearance with minimal complication rates and maximum patient satisfaction, trained surgeons must inform patients about normal variations and about the potential risks of surgery, perform psychological evaluations (multidisciplinary approach), discuss realistic expectations and individualize the technique of surgery. Further clinical studies should be performed to: validate current practices, define optimal management of patients, investigate long-term outcomes examining the impact of labiaplasty on a woman’s self-image and quality of life, and compare outcomes between various labiaplasty techniques.
The authors declare that there is no conflict of interest regarding the publication of this paper.