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httpaessagepubcomcontent3371030The online version of this article can be found at
DOI 1011771090820X13502202 2013 33 1030 originally published online 4 September 2013Aesthetic Surgery Journal
Christine A HamoriPostoperative Clitoral Hood Deformity After Labiaplasty
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httpwwwsagepublicationscom
On behalf of
American Society for Aesthetic Plastic Surgery
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Body Contouring
Aesthetic Surgery Journal33(7) 1030 ndash1036copy 2013 The American Society for Aesthetic Plastic Surgery IncReprints and permission httpwww sagepubcomjournalsPermissionsnavDOI 1011771090820X13502202wwwaestheticsurgeryjournalcom
Over the past several years there has been a 5-fold increase in the number patients seeking cosmetic surgery of the vaginal region1 The increasing vulvar visibility in the media popularity of Brazilian waxing (where all pubic hair is shaved or waxed away) and the anonymity of the Internet to view pornography have contributed to this trend2 Surgical techniques to reduce the redundancy of the labia majora minora and clitoral hood have been described3 Labiaplasty or surgical reduction of the labia minora is the most common procedure in cosmetic gynecology Basically 2 types of surgical reduction of the labia minora have been described in the literature wedge resections4 and free labial edge reductions where the scar is placed along the length of the labia minora Each technique creates aesthetic improvement of the area resulting in less protrusion of the labia minora on the standing view There is a high rate of overall patient satisfaction and improved body image with labiaplasty5 Intuitively free-edge resections seem less tech-nically demanding than wedge or deepithelization tech-niques6 Hence many gynecologists and some plastic surgeons seem to prefer this technique
In most patients free-edge trim or sculpting delivers a pleasing cosmetic result with minimal visible scarring and happy patient outcomes However in a select group of
patients where the native clitoral hood is enlarged in addi-tion to labia minora redundancy (Figure 1) the free-edge trim technique alone may result in an imbalance between the postoperatively flattened labia minora and the remain-ing more apparent clitoral hood Postoperatively in the standing position patients complain of fullness of the anterior clitoral hood despite the absence of visible labia minora and may refer to this area as having the appear-ance of a ldquosmall penisrdquo
Many women want a small less developed and petite labia minora and clitoral hood This consists of minimal if any labia minora show and youthful plump labia majora with no visible clitoral hood protruding between the ante-rior labial commissure7 (Figure 2) This nearly prepubes-cent look appears in print media and on the Internet Labiaplasty to reduce the dangling of the labia minora
Postoperative Clitoral Hood Deformity After Labiaplasty
Christine A Hamori MD
AbstractAesthetics of the female genitalia have come under increasing scrutiny with the popularity of Brazilian waxing trends and media promotion of sheer fashions Women seek to have a clean and youthful appearance of the vaginal region with minimal if any labial minora show beyond the labia majora Labiaplasty by edge resection of the redundant labia minora tends to be the preferred method of treating labia minora hypertrophy by most gynecologists and plastic surgeons This technique is effective in removing the excess circumferential rim of the labia minora thus decreasing bulk and protrusion from the introitus However in select patients with redundant clitoral hood tissue edge trim techniques may result in an imbalanced postoperative result where the hood actually looks larger These patients complain of a prominence of the clitoral hood not present prior to their labiaplasty In this case report the author describes 2 cases of excess clitoral hood prominence after free-edge resection labiaplasty Both patients were unhappy with the result of their labiaplasties and sought surgical correction Presentation anatomical findings options for treatment and avoidance of such deformity are discussed
Keywordslabiaplasty clitoral hood reduction extended wedge labiaplasty complications of labiaplasty edge trim labiaplasty body contouring
Accepted for publication March 21 2013
Dr Hamori is a plastic surgeon in private practice in Duxbury Massachusetts
Corresponding AuthorDr Christine A Hamori Cosmetic Surgery and Skin Spa 95 Tremont Street Suite 28 Duxbury MA 02332 USA Email cahchristinehamoricom
Case Report
Hamori 1031
alone may not result in the desired youthful appearance Imperative in meeting the goals and expectations of these patients is a careful preoperative discussion of the func-tional anatomy natural asymmetries and riskslimitations of surgical techniques in creating the cosmetic vision of the patient It is incumbent upon the surgeon to point out redundancy of the clitoral hood preoperatively and choose a labiaplasty technique most suited to achieving a youth-ful balanced appearance of the vulva
Wedge resection techniques popularized by Dr Gary Alter4 address the enlarged clitoral hood better than edge trim techniques The closure of the labia minora wedge defect addresses not only dangling of the labia minora inferiorly but also minimizes the projection of the clitoral hood anteriorly by placing it on posterior tension The width of the clitoral hood may be addressed by closing the wedge defect with superior dog-ear excision along either the clitoral hood8 (Figure 3) or more laterally placing the scar in the vulvar-labial sulcus Below I describe my clinical experience with 2 patients who sought reduction of the clitoral hood
PAtient DesCRiPtions
Patient 1 was a 41-year-old woman who presented 10 months after free-edge trim labiaplasty by another sur-geon (The details of her previous procedure were una-vailable) She complained of a masculine ldquopenis-likerdquo appearance of her clitoral hood In addition she stated that although her labia minora were shorter since the surgery she disliked the shape of her labia minora The unusual look of the area was bothersome to the patient who said she felt embarrassed to be nude in front of her boyfriend
Figure 2 This 43-year-old woman demonstrates youthful contour of the vulvar area (No surgery has been performed on this patient)
Figure 3 Extended wedge labiaplasty Reproduced from information provided in Alter GJ Female aesthetic genital surgery In Nahai F ed The Art of Aesthetic Surgery Principles amp Techniques 2nd ed St Louis MO Quality Medical Publishing 20113097-3123
Figure 1 This 27-year-old woman has clitoral hood and labia minora redundancy
1032 Aesthetic Surgery Journal 33(7)
Upon examination in the standing position the patient had a wide clitoral hood at the anterior vulvar commissure separating the labia majora (Figure 4A) In lithotomy the patient had a large prominent clitoral hood with flattened centrally scalloped labia minora (Figure 4C) Palpation of
the clitoral area revealed no clitoromegaly but excess width and length of the clitoral hood as compared with the labia minora
Patient 2 was a 46-year-old perimenopausal woman who presented 6 months after edge trim labiaplasty by
Figure 4 (A C) This 41-year-old woman presented with an enlarged clitoral hood 10 months after labiaplasty (via an unknown technique) by another surgeon (B D) Two months after labiaplasty with inverted ldquoVrdquo clitoral hood resection and small wedge labia minora resections (E) Intraoperative view of the patientrsquos procedure
Hamori 1033
another surgeon (the details of her previous procedure were also unavailable) She complained of an excess clito-ral hood and a flattened appearance of her labia minora The standing view bothered the patient the most as the clitoral hood protruded excessively between her labia majora She stated that it was not that way prior to her
labiaplasty She felt that this problem was ldquoruining [her] sex liferdquo
In the standing position the labia majora were dwarfed by the interposition of a prominent ovoid clitoral hood (Figure 5A) In lithotomy there was an elongated ldquobish-oprsquos hatrdquo clitoral hood that widened inferiorly just above
Figure 5 (A C) This 46-year-old perimenopausal woman complained of excess clitoral hood and flattening of the labia minora 6 months after labiaplasty (via an unknown technique) by a previous surgeon (B D) One year after postlateral reduction of the widened clitoral hood and fat grafting to the labia majora (E) Intraoperative view immediately after the patientrsquos procedure
1034 Aesthetic Surgery Journal 33(7)
the irregular overshortened labia minora (Figure 5C) The labia minora appeared flattened with posterior dog ears present bilaterally
suRgiCAl teChnique
In the first case under local anesthesia the excess clitoral hood skin was addressed in an inverted ldquoVrdquo resection over the dorsum of the clitoral hood With this maneuver atten-tion must be paid to perform a very conservative dorsal hood reduction as exposure of the glans clitoris is possible The incision was conservatively marked and incised down tomdashbut not intomdashthe investing fascia of the clitoris A 2-layer closure was performed with 5-0 Monocryl (poligle-caprone 25 p-1 needle) and 5-0 Vicryl Rapide (polyglactin 910 p-1 needle) both of which are manufactured by Ethicon (Somerville New Jersey) The labia minora edge irregulari-ties were then addressed with a series of small wedge resec-tions perpendicular to the axis of the labia minora The shortening of the minora in the anterior-posterior direction and reattachment of the hanging clitoral frenulum helped retract the clitoral hood posteriorly (Figure 4A-E)
In the second case the problem with the clitoral hood was width rather than dorsal skin excess This was addressed with a lateral triangular resection placing the scar in the groove between the labia majora and the clito-ral hood Once again markings were performed and local anesthetic was injected Two triangles of lateral clitoral hood were resected 1 on either side A 2-layer closure was performed with the sutures described above In addition fat grafting of the mons pubis and labia majora was per-formed on the second patient to further conceal the prominent clitoral hood and restore a more youthful appearance to the area (Figure 5A-E)
DisCussion
Surgical procedures to improve the appearance of the female genitalia have increased dramatically over the past several years9 Labia minora protrusion beyond the majora seems to be the dominant complaint of women seeking surgery10 Conceptually labiaplasty seems simple shorten the labia minora by trimming the edge11 This technique works well in most cases but may cause disharmony in select patients who present with prominent clitoral hoods in addition to labia minora excess (Figure 6) Clitoral hood redundancy is best detected preoperatively in the standing position (Figure 7) Bulky clitoral hoods have multiple drape-like folds and tend to separate the anterior vulvar commissure when viewed standing It is only postopera-tively after edge trim labiaplasty that the patient sees the hood as redundant It is my opinion that aggressive labial trim or near-amputation may cause this imbalance to be more pronounced even in the patient with a normal-sized clitoral hood
There exists a great deal of anatomical variation in clitoral hood anatomy and since the hood is contiguous
with the labia minora procedures to reduce the labia usu-ally must address the clitoral hood as well Excess submu-cosal tissue or extra folds of the mucosa overlying the clitoris may create a thick hood that protrudes anteriorly If these anatomical variations are not taken into consid-eration preoperatively excess clitoral hood projection is worsened by trimming the labia minora alone The loca-tion of the frenulum of the clitoris is important to note at the time of labia minora reduction as well inadvertent release of this structurersquos attachments may further contrib-ute to iatrogenic clitoral hood prominence12
In patients with prominence of the clitoral hood preop-eratively the wedge labiaplasty with a lateral extension may be a better option Two cases of wedge labiaplasty
Figure 6 This 36-year-old woman has clitoral hood and labia minora redundancy
Figure 7 This 24-year-old woman has clitoral hood redundancy
Hamori 1035
with lateral extension are shown in Figures 8 and 9 The photographs show redundancy of the clitoral hood preop-eratively which was ameliorated by performing the extended central wedge resection as described by Alter8 Free-edge resection or mucosal deepitheliazation6 tech-niques only address labia minora redundancy hence in this subset of patients the clitoral hood would have been made to appear even more prominent The posterior trac-tion placed on the clitoral hood with removal of the wedge helps reduce the anterior redundancy of the clitoral hood and the removal of the dog ear superolaterally with the extension narrows the width of the hood (Figure 8B)
In patients who present with clitoral hood prominence after labiaplasty it is important to restore balance between the clitoral hood and labia minora Treatment of iatrogenic labial deformities includes small wedge resections along the labia minora for areas of persistent redundancy reat-tachment of the frenulum of the clitoris and lateral or central reduction of the clitoral hood Care must be taken in dorsal clitoral hood reduction as this may cause
exposure of the glans clitoris (Figure 5A) If the patient complains of discomfort from an exposed clitoris the clitoral hood may be advanced forward as a V-to-Y flap Finally redundant clitoral hood tissue may be used for reconstruction of amputated labia minora by means of rotational flaps as described by Alter12
ConClusions
Surgery of the female perineummdashspecifically labia minora reduction or labiaplastymdashis on the rise Labia minora edge trim techniques have been popular among surgeons for years and provide good results in most cases but varia-tions in the size and shape of the clitoral hood should be taken into account when choosing the appropriate labial minora reduction technique Anatomy should be dis-cussed with the patient preoperatively with specific atten-tion paid to the clitoral hood size and appearance of the area in the standing position It is my opinion that
Figure 8 (A) This 29-year-old woman complained of an enlarged clitoral hood (B) Two months after wedge labiaplasty with lateral reduction of clitoral hood
Figure 9 (A) This 47-year-old woman complained of excess labia minora and clitoral hood (B) Two months after wedge labiaplasty with lateral clitoral hood reduction
1036 Aesthetic Surgery Journal 33(7)
modified wedge resections may be a better choice for patients with a prominent clitoral hood and surgeons should exercise caution when performing edge trim tech-niques in these patients
Disclosures
The author declared no potential conflicts of interest with respect to the research authorship and publication of this article
Funding
The author received no financial support for the research authorship and publication of this article
ReFeRenCes
1 Hogenboom M The rise in women seeking a perfect vagina wwwbbccouknewshealth-18947106 Accessed March 21 2013
2 Koning M Zeijlmans IA Bouman TK van der Lei B Female attitudes regarding labia minora appearance and reduction with consideration of media influence Aes-thetic Surg J 200929(1)65-71
3 Tepper OM Wulkan M Matarasso A Labiaplasty anat-omy etiology and a new surgical approach Aesthetic Surg J 201131(5)511-518
4 Alter GJ A new technique for aesthetic labia minora reduction Ann Plast Surg 199840287
5 Goodman M Placik OJ Gonzalez F et al A large multi-center outcome study of female genital plastic surgery J Sex Med 201071565-1577
6 Choi HY Kim KT A new method for aesthetic reduction of labia minora (the deepithelializaed reduction labio-plasty) Plast Reconstr Surg 2000105419-422
7 Reitsma W Mourits M Koning M Pascal A van der Lei B No (wo)man is an islandmdashthe influence of physiciansrsquo personal predisposition to labia minora appearance on their clinical decision making a cross-sectional survey J Sex Med 201182377-2385
8 Alter GJ Aesthetic labia minora and clitoral hood reduc-tion using extended central wedge resection Plast Recon-str Surg 20081221780-1789
9 Liao L Creighton S Requests for cosmetic genito-plasty how should healthcare providers respond BMJ 20073341090-1094
10 Giraldo F Gonzalez C de Haro F Central wedge nymphec-tomy with a 90-degree z-plasty for aesthetic reduction of the labia minora Plast Reconstr Surg 20041131820-1825
11 Girling R Slaisbury M Ersek R Vaginal labioplasty letters and viewpoints Plast Reconstr Surg 2005116(6)1792-1793
12 Alter G Labia minora reconstruction using clitoral hood flaps wedge excisions and YV advancement flaps Plast Reconstr Surg 20111272356-2363
Body Contouring
Aesthetic Surgery Journal33(7) 1030 ndash1036copy 2013 The American Society for Aesthetic Plastic Surgery IncReprints and permission httpwww sagepubcomjournalsPermissionsnavDOI 1011771090820X13502202wwwaestheticsurgeryjournalcom
Over the past several years there has been a 5-fold increase in the number patients seeking cosmetic surgery of the vaginal region1 The increasing vulvar visibility in the media popularity of Brazilian waxing (where all pubic hair is shaved or waxed away) and the anonymity of the Internet to view pornography have contributed to this trend2 Surgical techniques to reduce the redundancy of the labia majora minora and clitoral hood have been described3 Labiaplasty or surgical reduction of the labia minora is the most common procedure in cosmetic gynecology Basically 2 types of surgical reduction of the labia minora have been described in the literature wedge resections4 and free labial edge reductions where the scar is placed along the length of the labia minora Each technique creates aesthetic improvement of the area resulting in less protrusion of the labia minora on the standing view There is a high rate of overall patient satisfaction and improved body image with labiaplasty5 Intuitively free-edge resections seem less tech-nically demanding than wedge or deepithelization tech-niques6 Hence many gynecologists and some plastic surgeons seem to prefer this technique
In most patients free-edge trim or sculpting delivers a pleasing cosmetic result with minimal visible scarring and happy patient outcomes However in a select group of
patients where the native clitoral hood is enlarged in addi-tion to labia minora redundancy (Figure 1) the free-edge trim technique alone may result in an imbalance between the postoperatively flattened labia minora and the remain-ing more apparent clitoral hood Postoperatively in the standing position patients complain of fullness of the anterior clitoral hood despite the absence of visible labia minora and may refer to this area as having the appear-ance of a ldquosmall penisrdquo
Many women want a small less developed and petite labia minora and clitoral hood This consists of minimal if any labia minora show and youthful plump labia majora with no visible clitoral hood protruding between the ante-rior labial commissure7 (Figure 2) This nearly prepubes-cent look appears in print media and on the Internet Labiaplasty to reduce the dangling of the labia minora
Postoperative Clitoral Hood Deformity After Labiaplasty
Christine A Hamori MD
AbstractAesthetics of the female genitalia have come under increasing scrutiny with the popularity of Brazilian waxing trends and media promotion of sheer fashions Women seek to have a clean and youthful appearance of the vaginal region with minimal if any labial minora show beyond the labia majora Labiaplasty by edge resection of the redundant labia minora tends to be the preferred method of treating labia minora hypertrophy by most gynecologists and plastic surgeons This technique is effective in removing the excess circumferential rim of the labia minora thus decreasing bulk and protrusion from the introitus However in select patients with redundant clitoral hood tissue edge trim techniques may result in an imbalanced postoperative result where the hood actually looks larger These patients complain of a prominence of the clitoral hood not present prior to their labiaplasty In this case report the author describes 2 cases of excess clitoral hood prominence after free-edge resection labiaplasty Both patients were unhappy with the result of their labiaplasties and sought surgical correction Presentation anatomical findings options for treatment and avoidance of such deformity are discussed
Keywordslabiaplasty clitoral hood reduction extended wedge labiaplasty complications of labiaplasty edge trim labiaplasty body contouring
Accepted for publication March 21 2013
Dr Hamori is a plastic surgeon in private practice in Duxbury Massachusetts
Corresponding AuthorDr Christine A Hamori Cosmetic Surgery and Skin Spa 95 Tremont Street Suite 28 Duxbury MA 02332 USA Email cahchristinehamoricom
Case Report
Hamori 1031
alone may not result in the desired youthful appearance Imperative in meeting the goals and expectations of these patients is a careful preoperative discussion of the func-tional anatomy natural asymmetries and riskslimitations of surgical techniques in creating the cosmetic vision of the patient It is incumbent upon the surgeon to point out redundancy of the clitoral hood preoperatively and choose a labiaplasty technique most suited to achieving a youth-ful balanced appearance of the vulva
Wedge resection techniques popularized by Dr Gary Alter4 address the enlarged clitoral hood better than edge trim techniques The closure of the labia minora wedge defect addresses not only dangling of the labia minora inferiorly but also minimizes the projection of the clitoral hood anteriorly by placing it on posterior tension The width of the clitoral hood may be addressed by closing the wedge defect with superior dog-ear excision along either the clitoral hood8 (Figure 3) or more laterally placing the scar in the vulvar-labial sulcus Below I describe my clinical experience with 2 patients who sought reduction of the clitoral hood
PAtient DesCRiPtions
Patient 1 was a 41-year-old woman who presented 10 months after free-edge trim labiaplasty by another sur-geon (The details of her previous procedure were una-vailable) She complained of a masculine ldquopenis-likerdquo appearance of her clitoral hood In addition she stated that although her labia minora were shorter since the surgery she disliked the shape of her labia minora The unusual look of the area was bothersome to the patient who said she felt embarrassed to be nude in front of her boyfriend
Figure 2 This 43-year-old woman demonstrates youthful contour of the vulvar area (No surgery has been performed on this patient)
Figure 3 Extended wedge labiaplasty Reproduced from information provided in Alter GJ Female aesthetic genital surgery In Nahai F ed The Art of Aesthetic Surgery Principles amp Techniques 2nd ed St Louis MO Quality Medical Publishing 20113097-3123
Figure 1 This 27-year-old woman has clitoral hood and labia minora redundancy
1032 Aesthetic Surgery Journal 33(7)
Upon examination in the standing position the patient had a wide clitoral hood at the anterior vulvar commissure separating the labia majora (Figure 4A) In lithotomy the patient had a large prominent clitoral hood with flattened centrally scalloped labia minora (Figure 4C) Palpation of
the clitoral area revealed no clitoromegaly but excess width and length of the clitoral hood as compared with the labia minora
Patient 2 was a 46-year-old perimenopausal woman who presented 6 months after edge trim labiaplasty by
Figure 4 (A C) This 41-year-old woman presented with an enlarged clitoral hood 10 months after labiaplasty (via an unknown technique) by another surgeon (B D) Two months after labiaplasty with inverted ldquoVrdquo clitoral hood resection and small wedge labia minora resections (E) Intraoperative view of the patientrsquos procedure
Hamori 1033
another surgeon (the details of her previous procedure were also unavailable) She complained of an excess clito-ral hood and a flattened appearance of her labia minora The standing view bothered the patient the most as the clitoral hood protruded excessively between her labia majora She stated that it was not that way prior to her
labiaplasty She felt that this problem was ldquoruining [her] sex liferdquo
In the standing position the labia majora were dwarfed by the interposition of a prominent ovoid clitoral hood (Figure 5A) In lithotomy there was an elongated ldquobish-oprsquos hatrdquo clitoral hood that widened inferiorly just above
Figure 5 (A C) This 46-year-old perimenopausal woman complained of excess clitoral hood and flattening of the labia minora 6 months after labiaplasty (via an unknown technique) by a previous surgeon (B D) One year after postlateral reduction of the widened clitoral hood and fat grafting to the labia majora (E) Intraoperative view immediately after the patientrsquos procedure
1034 Aesthetic Surgery Journal 33(7)
the irregular overshortened labia minora (Figure 5C) The labia minora appeared flattened with posterior dog ears present bilaterally
suRgiCAl teChnique
In the first case under local anesthesia the excess clitoral hood skin was addressed in an inverted ldquoVrdquo resection over the dorsum of the clitoral hood With this maneuver atten-tion must be paid to perform a very conservative dorsal hood reduction as exposure of the glans clitoris is possible The incision was conservatively marked and incised down tomdashbut not intomdashthe investing fascia of the clitoris A 2-layer closure was performed with 5-0 Monocryl (poligle-caprone 25 p-1 needle) and 5-0 Vicryl Rapide (polyglactin 910 p-1 needle) both of which are manufactured by Ethicon (Somerville New Jersey) The labia minora edge irregulari-ties were then addressed with a series of small wedge resec-tions perpendicular to the axis of the labia minora The shortening of the minora in the anterior-posterior direction and reattachment of the hanging clitoral frenulum helped retract the clitoral hood posteriorly (Figure 4A-E)
In the second case the problem with the clitoral hood was width rather than dorsal skin excess This was addressed with a lateral triangular resection placing the scar in the groove between the labia majora and the clito-ral hood Once again markings were performed and local anesthetic was injected Two triangles of lateral clitoral hood were resected 1 on either side A 2-layer closure was performed with the sutures described above In addition fat grafting of the mons pubis and labia majora was per-formed on the second patient to further conceal the prominent clitoral hood and restore a more youthful appearance to the area (Figure 5A-E)
DisCussion
Surgical procedures to improve the appearance of the female genitalia have increased dramatically over the past several years9 Labia minora protrusion beyond the majora seems to be the dominant complaint of women seeking surgery10 Conceptually labiaplasty seems simple shorten the labia minora by trimming the edge11 This technique works well in most cases but may cause disharmony in select patients who present with prominent clitoral hoods in addition to labia minora excess (Figure 6) Clitoral hood redundancy is best detected preoperatively in the standing position (Figure 7) Bulky clitoral hoods have multiple drape-like folds and tend to separate the anterior vulvar commissure when viewed standing It is only postopera-tively after edge trim labiaplasty that the patient sees the hood as redundant It is my opinion that aggressive labial trim or near-amputation may cause this imbalance to be more pronounced even in the patient with a normal-sized clitoral hood
There exists a great deal of anatomical variation in clitoral hood anatomy and since the hood is contiguous
with the labia minora procedures to reduce the labia usu-ally must address the clitoral hood as well Excess submu-cosal tissue or extra folds of the mucosa overlying the clitoris may create a thick hood that protrudes anteriorly If these anatomical variations are not taken into consid-eration preoperatively excess clitoral hood projection is worsened by trimming the labia minora alone The loca-tion of the frenulum of the clitoris is important to note at the time of labia minora reduction as well inadvertent release of this structurersquos attachments may further contrib-ute to iatrogenic clitoral hood prominence12
In patients with prominence of the clitoral hood preop-eratively the wedge labiaplasty with a lateral extension may be a better option Two cases of wedge labiaplasty
Figure 6 This 36-year-old woman has clitoral hood and labia minora redundancy
Figure 7 This 24-year-old woman has clitoral hood redundancy
Hamori 1035
with lateral extension are shown in Figures 8 and 9 The photographs show redundancy of the clitoral hood preop-eratively which was ameliorated by performing the extended central wedge resection as described by Alter8 Free-edge resection or mucosal deepitheliazation6 tech-niques only address labia minora redundancy hence in this subset of patients the clitoral hood would have been made to appear even more prominent The posterior trac-tion placed on the clitoral hood with removal of the wedge helps reduce the anterior redundancy of the clitoral hood and the removal of the dog ear superolaterally with the extension narrows the width of the hood (Figure 8B)
In patients who present with clitoral hood prominence after labiaplasty it is important to restore balance between the clitoral hood and labia minora Treatment of iatrogenic labial deformities includes small wedge resections along the labia minora for areas of persistent redundancy reat-tachment of the frenulum of the clitoris and lateral or central reduction of the clitoral hood Care must be taken in dorsal clitoral hood reduction as this may cause
exposure of the glans clitoris (Figure 5A) If the patient complains of discomfort from an exposed clitoris the clitoral hood may be advanced forward as a V-to-Y flap Finally redundant clitoral hood tissue may be used for reconstruction of amputated labia minora by means of rotational flaps as described by Alter12
ConClusions
Surgery of the female perineummdashspecifically labia minora reduction or labiaplastymdashis on the rise Labia minora edge trim techniques have been popular among surgeons for years and provide good results in most cases but varia-tions in the size and shape of the clitoral hood should be taken into account when choosing the appropriate labial minora reduction technique Anatomy should be dis-cussed with the patient preoperatively with specific atten-tion paid to the clitoral hood size and appearance of the area in the standing position It is my opinion that
Figure 8 (A) This 29-year-old woman complained of an enlarged clitoral hood (B) Two months after wedge labiaplasty with lateral reduction of clitoral hood
Figure 9 (A) This 47-year-old woman complained of excess labia minora and clitoral hood (B) Two months after wedge labiaplasty with lateral clitoral hood reduction
1036 Aesthetic Surgery Journal 33(7)
modified wedge resections may be a better choice for patients with a prominent clitoral hood and surgeons should exercise caution when performing edge trim tech-niques in these patients
Disclosures
The author declared no potential conflicts of interest with respect to the research authorship and publication of this article
Funding
The author received no financial support for the research authorship and publication of this article
ReFeRenCes
1 Hogenboom M The rise in women seeking a perfect vagina wwwbbccouknewshealth-18947106 Accessed March 21 2013
2 Koning M Zeijlmans IA Bouman TK van der Lei B Female attitudes regarding labia minora appearance and reduction with consideration of media influence Aes-thetic Surg J 200929(1)65-71
3 Tepper OM Wulkan M Matarasso A Labiaplasty anat-omy etiology and a new surgical approach Aesthetic Surg J 201131(5)511-518
4 Alter GJ A new technique for aesthetic labia minora reduction Ann Plast Surg 199840287
5 Goodman M Placik OJ Gonzalez F et al A large multi-center outcome study of female genital plastic surgery J Sex Med 201071565-1577
6 Choi HY Kim KT A new method for aesthetic reduction of labia minora (the deepithelializaed reduction labio-plasty) Plast Reconstr Surg 2000105419-422
7 Reitsma W Mourits M Koning M Pascal A van der Lei B No (wo)man is an islandmdashthe influence of physiciansrsquo personal predisposition to labia minora appearance on their clinical decision making a cross-sectional survey J Sex Med 201182377-2385
8 Alter GJ Aesthetic labia minora and clitoral hood reduc-tion using extended central wedge resection Plast Recon-str Surg 20081221780-1789
9 Liao L Creighton S Requests for cosmetic genito-plasty how should healthcare providers respond BMJ 20073341090-1094
10 Giraldo F Gonzalez C de Haro F Central wedge nymphec-tomy with a 90-degree z-plasty for aesthetic reduction of the labia minora Plast Reconstr Surg 20041131820-1825
11 Girling R Slaisbury M Ersek R Vaginal labioplasty letters and viewpoints Plast Reconstr Surg 2005116(6)1792-1793
12 Alter G Labia minora reconstruction using clitoral hood flaps wedge excisions and YV advancement flaps Plast Reconstr Surg 20111272356-2363
Hamori 1031
alone may not result in the desired youthful appearance Imperative in meeting the goals and expectations of these patients is a careful preoperative discussion of the func-tional anatomy natural asymmetries and riskslimitations of surgical techniques in creating the cosmetic vision of the patient It is incumbent upon the surgeon to point out redundancy of the clitoral hood preoperatively and choose a labiaplasty technique most suited to achieving a youth-ful balanced appearance of the vulva
Wedge resection techniques popularized by Dr Gary Alter4 address the enlarged clitoral hood better than edge trim techniques The closure of the labia minora wedge defect addresses not only dangling of the labia minora inferiorly but also minimizes the projection of the clitoral hood anteriorly by placing it on posterior tension The width of the clitoral hood may be addressed by closing the wedge defect with superior dog-ear excision along either the clitoral hood8 (Figure 3) or more laterally placing the scar in the vulvar-labial sulcus Below I describe my clinical experience with 2 patients who sought reduction of the clitoral hood
PAtient DesCRiPtions
Patient 1 was a 41-year-old woman who presented 10 months after free-edge trim labiaplasty by another sur-geon (The details of her previous procedure were una-vailable) She complained of a masculine ldquopenis-likerdquo appearance of her clitoral hood In addition she stated that although her labia minora were shorter since the surgery she disliked the shape of her labia minora The unusual look of the area was bothersome to the patient who said she felt embarrassed to be nude in front of her boyfriend
Figure 2 This 43-year-old woman demonstrates youthful contour of the vulvar area (No surgery has been performed on this patient)
Figure 3 Extended wedge labiaplasty Reproduced from information provided in Alter GJ Female aesthetic genital surgery In Nahai F ed The Art of Aesthetic Surgery Principles amp Techniques 2nd ed St Louis MO Quality Medical Publishing 20113097-3123
Figure 1 This 27-year-old woman has clitoral hood and labia minora redundancy
1032 Aesthetic Surgery Journal 33(7)
Upon examination in the standing position the patient had a wide clitoral hood at the anterior vulvar commissure separating the labia majora (Figure 4A) In lithotomy the patient had a large prominent clitoral hood with flattened centrally scalloped labia minora (Figure 4C) Palpation of
the clitoral area revealed no clitoromegaly but excess width and length of the clitoral hood as compared with the labia minora
Patient 2 was a 46-year-old perimenopausal woman who presented 6 months after edge trim labiaplasty by
Figure 4 (A C) This 41-year-old woman presented with an enlarged clitoral hood 10 months after labiaplasty (via an unknown technique) by another surgeon (B D) Two months after labiaplasty with inverted ldquoVrdquo clitoral hood resection and small wedge labia minora resections (E) Intraoperative view of the patientrsquos procedure
Hamori 1033
another surgeon (the details of her previous procedure were also unavailable) She complained of an excess clito-ral hood and a flattened appearance of her labia minora The standing view bothered the patient the most as the clitoral hood protruded excessively between her labia majora She stated that it was not that way prior to her
labiaplasty She felt that this problem was ldquoruining [her] sex liferdquo
In the standing position the labia majora were dwarfed by the interposition of a prominent ovoid clitoral hood (Figure 5A) In lithotomy there was an elongated ldquobish-oprsquos hatrdquo clitoral hood that widened inferiorly just above
Figure 5 (A C) This 46-year-old perimenopausal woman complained of excess clitoral hood and flattening of the labia minora 6 months after labiaplasty (via an unknown technique) by a previous surgeon (B D) One year after postlateral reduction of the widened clitoral hood and fat grafting to the labia majora (E) Intraoperative view immediately after the patientrsquos procedure
1034 Aesthetic Surgery Journal 33(7)
the irregular overshortened labia minora (Figure 5C) The labia minora appeared flattened with posterior dog ears present bilaterally
suRgiCAl teChnique
In the first case under local anesthesia the excess clitoral hood skin was addressed in an inverted ldquoVrdquo resection over the dorsum of the clitoral hood With this maneuver atten-tion must be paid to perform a very conservative dorsal hood reduction as exposure of the glans clitoris is possible The incision was conservatively marked and incised down tomdashbut not intomdashthe investing fascia of the clitoris A 2-layer closure was performed with 5-0 Monocryl (poligle-caprone 25 p-1 needle) and 5-0 Vicryl Rapide (polyglactin 910 p-1 needle) both of which are manufactured by Ethicon (Somerville New Jersey) The labia minora edge irregulari-ties were then addressed with a series of small wedge resec-tions perpendicular to the axis of the labia minora The shortening of the minora in the anterior-posterior direction and reattachment of the hanging clitoral frenulum helped retract the clitoral hood posteriorly (Figure 4A-E)
In the second case the problem with the clitoral hood was width rather than dorsal skin excess This was addressed with a lateral triangular resection placing the scar in the groove between the labia majora and the clito-ral hood Once again markings were performed and local anesthetic was injected Two triangles of lateral clitoral hood were resected 1 on either side A 2-layer closure was performed with the sutures described above In addition fat grafting of the mons pubis and labia majora was per-formed on the second patient to further conceal the prominent clitoral hood and restore a more youthful appearance to the area (Figure 5A-E)
DisCussion
Surgical procedures to improve the appearance of the female genitalia have increased dramatically over the past several years9 Labia minora protrusion beyond the majora seems to be the dominant complaint of women seeking surgery10 Conceptually labiaplasty seems simple shorten the labia minora by trimming the edge11 This technique works well in most cases but may cause disharmony in select patients who present with prominent clitoral hoods in addition to labia minora excess (Figure 6) Clitoral hood redundancy is best detected preoperatively in the standing position (Figure 7) Bulky clitoral hoods have multiple drape-like folds and tend to separate the anterior vulvar commissure when viewed standing It is only postopera-tively after edge trim labiaplasty that the patient sees the hood as redundant It is my opinion that aggressive labial trim or near-amputation may cause this imbalance to be more pronounced even in the patient with a normal-sized clitoral hood
There exists a great deal of anatomical variation in clitoral hood anatomy and since the hood is contiguous
with the labia minora procedures to reduce the labia usu-ally must address the clitoral hood as well Excess submu-cosal tissue or extra folds of the mucosa overlying the clitoris may create a thick hood that protrudes anteriorly If these anatomical variations are not taken into consid-eration preoperatively excess clitoral hood projection is worsened by trimming the labia minora alone The loca-tion of the frenulum of the clitoris is important to note at the time of labia minora reduction as well inadvertent release of this structurersquos attachments may further contrib-ute to iatrogenic clitoral hood prominence12
In patients with prominence of the clitoral hood preop-eratively the wedge labiaplasty with a lateral extension may be a better option Two cases of wedge labiaplasty
Figure 6 This 36-year-old woman has clitoral hood and labia minora redundancy
Figure 7 This 24-year-old woman has clitoral hood redundancy
Hamori 1035
with lateral extension are shown in Figures 8 and 9 The photographs show redundancy of the clitoral hood preop-eratively which was ameliorated by performing the extended central wedge resection as described by Alter8 Free-edge resection or mucosal deepitheliazation6 tech-niques only address labia minora redundancy hence in this subset of patients the clitoral hood would have been made to appear even more prominent The posterior trac-tion placed on the clitoral hood with removal of the wedge helps reduce the anterior redundancy of the clitoral hood and the removal of the dog ear superolaterally with the extension narrows the width of the hood (Figure 8B)
In patients who present with clitoral hood prominence after labiaplasty it is important to restore balance between the clitoral hood and labia minora Treatment of iatrogenic labial deformities includes small wedge resections along the labia minora for areas of persistent redundancy reat-tachment of the frenulum of the clitoris and lateral or central reduction of the clitoral hood Care must be taken in dorsal clitoral hood reduction as this may cause
exposure of the glans clitoris (Figure 5A) If the patient complains of discomfort from an exposed clitoris the clitoral hood may be advanced forward as a V-to-Y flap Finally redundant clitoral hood tissue may be used for reconstruction of amputated labia minora by means of rotational flaps as described by Alter12
ConClusions
Surgery of the female perineummdashspecifically labia minora reduction or labiaplastymdashis on the rise Labia minora edge trim techniques have been popular among surgeons for years and provide good results in most cases but varia-tions in the size and shape of the clitoral hood should be taken into account when choosing the appropriate labial minora reduction technique Anatomy should be dis-cussed with the patient preoperatively with specific atten-tion paid to the clitoral hood size and appearance of the area in the standing position It is my opinion that
Figure 8 (A) This 29-year-old woman complained of an enlarged clitoral hood (B) Two months after wedge labiaplasty with lateral reduction of clitoral hood
Figure 9 (A) This 47-year-old woman complained of excess labia minora and clitoral hood (B) Two months after wedge labiaplasty with lateral clitoral hood reduction
1036 Aesthetic Surgery Journal 33(7)
modified wedge resections may be a better choice for patients with a prominent clitoral hood and surgeons should exercise caution when performing edge trim tech-niques in these patients
Disclosures
The author declared no potential conflicts of interest with respect to the research authorship and publication of this article
Funding
The author received no financial support for the research authorship and publication of this article
ReFeRenCes
1 Hogenboom M The rise in women seeking a perfect vagina wwwbbccouknewshealth-18947106 Accessed March 21 2013
2 Koning M Zeijlmans IA Bouman TK van der Lei B Female attitudes regarding labia minora appearance and reduction with consideration of media influence Aes-thetic Surg J 200929(1)65-71
3 Tepper OM Wulkan M Matarasso A Labiaplasty anat-omy etiology and a new surgical approach Aesthetic Surg J 201131(5)511-518
4 Alter GJ A new technique for aesthetic labia minora reduction Ann Plast Surg 199840287
5 Goodman M Placik OJ Gonzalez F et al A large multi-center outcome study of female genital plastic surgery J Sex Med 201071565-1577
6 Choi HY Kim KT A new method for aesthetic reduction of labia minora (the deepithelializaed reduction labio-plasty) Plast Reconstr Surg 2000105419-422
7 Reitsma W Mourits M Koning M Pascal A van der Lei B No (wo)man is an islandmdashthe influence of physiciansrsquo personal predisposition to labia minora appearance on their clinical decision making a cross-sectional survey J Sex Med 201182377-2385
8 Alter GJ Aesthetic labia minora and clitoral hood reduc-tion using extended central wedge resection Plast Recon-str Surg 20081221780-1789
9 Liao L Creighton S Requests for cosmetic genito-plasty how should healthcare providers respond BMJ 20073341090-1094
10 Giraldo F Gonzalez C de Haro F Central wedge nymphec-tomy with a 90-degree z-plasty for aesthetic reduction of the labia minora Plast Reconstr Surg 20041131820-1825
11 Girling R Slaisbury M Ersek R Vaginal labioplasty letters and viewpoints Plast Reconstr Surg 2005116(6)1792-1793
12 Alter G Labia minora reconstruction using clitoral hood flaps wedge excisions and YV advancement flaps Plast Reconstr Surg 20111272356-2363
1032 Aesthetic Surgery Journal 33(7)
Upon examination in the standing position the patient had a wide clitoral hood at the anterior vulvar commissure separating the labia majora (Figure 4A) In lithotomy the patient had a large prominent clitoral hood with flattened centrally scalloped labia minora (Figure 4C) Palpation of
the clitoral area revealed no clitoromegaly but excess width and length of the clitoral hood as compared with the labia minora
Patient 2 was a 46-year-old perimenopausal woman who presented 6 months after edge trim labiaplasty by
Figure 4 (A C) This 41-year-old woman presented with an enlarged clitoral hood 10 months after labiaplasty (via an unknown technique) by another surgeon (B D) Two months after labiaplasty with inverted ldquoVrdquo clitoral hood resection and small wedge labia minora resections (E) Intraoperative view of the patientrsquos procedure
Hamori 1033
another surgeon (the details of her previous procedure were also unavailable) She complained of an excess clito-ral hood and a flattened appearance of her labia minora The standing view bothered the patient the most as the clitoral hood protruded excessively between her labia majora She stated that it was not that way prior to her
labiaplasty She felt that this problem was ldquoruining [her] sex liferdquo
In the standing position the labia majora were dwarfed by the interposition of a prominent ovoid clitoral hood (Figure 5A) In lithotomy there was an elongated ldquobish-oprsquos hatrdquo clitoral hood that widened inferiorly just above
Figure 5 (A C) This 46-year-old perimenopausal woman complained of excess clitoral hood and flattening of the labia minora 6 months after labiaplasty (via an unknown technique) by a previous surgeon (B D) One year after postlateral reduction of the widened clitoral hood and fat grafting to the labia majora (E) Intraoperative view immediately after the patientrsquos procedure
1034 Aesthetic Surgery Journal 33(7)
the irregular overshortened labia minora (Figure 5C) The labia minora appeared flattened with posterior dog ears present bilaterally
suRgiCAl teChnique
In the first case under local anesthesia the excess clitoral hood skin was addressed in an inverted ldquoVrdquo resection over the dorsum of the clitoral hood With this maneuver atten-tion must be paid to perform a very conservative dorsal hood reduction as exposure of the glans clitoris is possible The incision was conservatively marked and incised down tomdashbut not intomdashthe investing fascia of the clitoris A 2-layer closure was performed with 5-0 Monocryl (poligle-caprone 25 p-1 needle) and 5-0 Vicryl Rapide (polyglactin 910 p-1 needle) both of which are manufactured by Ethicon (Somerville New Jersey) The labia minora edge irregulari-ties were then addressed with a series of small wedge resec-tions perpendicular to the axis of the labia minora The shortening of the minora in the anterior-posterior direction and reattachment of the hanging clitoral frenulum helped retract the clitoral hood posteriorly (Figure 4A-E)
In the second case the problem with the clitoral hood was width rather than dorsal skin excess This was addressed with a lateral triangular resection placing the scar in the groove between the labia majora and the clito-ral hood Once again markings were performed and local anesthetic was injected Two triangles of lateral clitoral hood were resected 1 on either side A 2-layer closure was performed with the sutures described above In addition fat grafting of the mons pubis and labia majora was per-formed on the second patient to further conceal the prominent clitoral hood and restore a more youthful appearance to the area (Figure 5A-E)
DisCussion
Surgical procedures to improve the appearance of the female genitalia have increased dramatically over the past several years9 Labia minora protrusion beyond the majora seems to be the dominant complaint of women seeking surgery10 Conceptually labiaplasty seems simple shorten the labia minora by trimming the edge11 This technique works well in most cases but may cause disharmony in select patients who present with prominent clitoral hoods in addition to labia minora excess (Figure 6) Clitoral hood redundancy is best detected preoperatively in the standing position (Figure 7) Bulky clitoral hoods have multiple drape-like folds and tend to separate the anterior vulvar commissure when viewed standing It is only postopera-tively after edge trim labiaplasty that the patient sees the hood as redundant It is my opinion that aggressive labial trim or near-amputation may cause this imbalance to be more pronounced even in the patient with a normal-sized clitoral hood
There exists a great deal of anatomical variation in clitoral hood anatomy and since the hood is contiguous
with the labia minora procedures to reduce the labia usu-ally must address the clitoral hood as well Excess submu-cosal tissue or extra folds of the mucosa overlying the clitoris may create a thick hood that protrudes anteriorly If these anatomical variations are not taken into consid-eration preoperatively excess clitoral hood projection is worsened by trimming the labia minora alone The loca-tion of the frenulum of the clitoris is important to note at the time of labia minora reduction as well inadvertent release of this structurersquos attachments may further contrib-ute to iatrogenic clitoral hood prominence12
In patients with prominence of the clitoral hood preop-eratively the wedge labiaplasty with a lateral extension may be a better option Two cases of wedge labiaplasty
Figure 6 This 36-year-old woman has clitoral hood and labia minora redundancy
Figure 7 This 24-year-old woman has clitoral hood redundancy
Hamori 1035
with lateral extension are shown in Figures 8 and 9 The photographs show redundancy of the clitoral hood preop-eratively which was ameliorated by performing the extended central wedge resection as described by Alter8 Free-edge resection or mucosal deepitheliazation6 tech-niques only address labia minora redundancy hence in this subset of patients the clitoral hood would have been made to appear even more prominent The posterior trac-tion placed on the clitoral hood with removal of the wedge helps reduce the anterior redundancy of the clitoral hood and the removal of the dog ear superolaterally with the extension narrows the width of the hood (Figure 8B)
In patients who present with clitoral hood prominence after labiaplasty it is important to restore balance between the clitoral hood and labia minora Treatment of iatrogenic labial deformities includes small wedge resections along the labia minora for areas of persistent redundancy reat-tachment of the frenulum of the clitoris and lateral or central reduction of the clitoral hood Care must be taken in dorsal clitoral hood reduction as this may cause
exposure of the glans clitoris (Figure 5A) If the patient complains of discomfort from an exposed clitoris the clitoral hood may be advanced forward as a V-to-Y flap Finally redundant clitoral hood tissue may be used for reconstruction of amputated labia minora by means of rotational flaps as described by Alter12
ConClusions
Surgery of the female perineummdashspecifically labia minora reduction or labiaplastymdashis on the rise Labia minora edge trim techniques have been popular among surgeons for years and provide good results in most cases but varia-tions in the size and shape of the clitoral hood should be taken into account when choosing the appropriate labial minora reduction technique Anatomy should be dis-cussed with the patient preoperatively with specific atten-tion paid to the clitoral hood size and appearance of the area in the standing position It is my opinion that
Figure 8 (A) This 29-year-old woman complained of an enlarged clitoral hood (B) Two months after wedge labiaplasty with lateral reduction of clitoral hood
Figure 9 (A) This 47-year-old woman complained of excess labia minora and clitoral hood (B) Two months after wedge labiaplasty with lateral clitoral hood reduction
1036 Aesthetic Surgery Journal 33(7)
modified wedge resections may be a better choice for patients with a prominent clitoral hood and surgeons should exercise caution when performing edge trim tech-niques in these patients
Disclosures
The author declared no potential conflicts of interest with respect to the research authorship and publication of this article
Funding
The author received no financial support for the research authorship and publication of this article
ReFeRenCes
1 Hogenboom M The rise in women seeking a perfect vagina wwwbbccouknewshealth-18947106 Accessed March 21 2013
2 Koning M Zeijlmans IA Bouman TK van der Lei B Female attitudes regarding labia minora appearance and reduction with consideration of media influence Aes-thetic Surg J 200929(1)65-71
3 Tepper OM Wulkan M Matarasso A Labiaplasty anat-omy etiology and a new surgical approach Aesthetic Surg J 201131(5)511-518
4 Alter GJ A new technique for aesthetic labia minora reduction Ann Plast Surg 199840287
5 Goodman M Placik OJ Gonzalez F et al A large multi-center outcome study of female genital plastic surgery J Sex Med 201071565-1577
6 Choi HY Kim KT A new method for aesthetic reduction of labia minora (the deepithelializaed reduction labio-plasty) Plast Reconstr Surg 2000105419-422
7 Reitsma W Mourits M Koning M Pascal A van der Lei B No (wo)man is an islandmdashthe influence of physiciansrsquo personal predisposition to labia minora appearance on their clinical decision making a cross-sectional survey J Sex Med 201182377-2385
8 Alter GJ Aesthetic labia minora and clitoral hood reduc-tion using extended central wedge resection Plast Recon-str Surg 20081221780-1789
9 Liao L Creighton S Requests for cosmetic genito-plasty how should healthcare providers respond BMJ 20073341090-1094
10 Giraldo F Gonzalez C de Haro F Central wedge nymphec-tomy with a 90-degree z-plasty for aesthetic reduction of the labia minora Plast Reconstr Surg 20041131820-1825
11 Girling R Slaisbury M Ersek R Vaginal labioplasty letters and viewpoints Plast Reconstr Surg 2005116(6)1792-1793
12 Alter G Labia minora reconstruction using clitoral hood flaps wedge excisions and YV advancement flaps Plast Reconstr Surg 20111272356-2363
Hamori 1033
another surgeon (the details of her previous procedure were also unavailable) She complained of an excess clito-ral hood and a flattened appearance of her labia minora The standing view bothered the patient the most as the clitoral hood protruded excessively between her labia majora She stated that it was not that way prior to her
labiaplasty She felt that this problem was ldquoruining [her] sex liferdquo
In the standing position the labia majora were dwarfed by the interposition of a prominent ovoid clitoral hood (Figure 5A) In lithotomy there was an elongated ldquobish-oprsquos hatrdquo clitoral hood that widened inferiorly just above
Figure 5 (A C) This 46-year-old perimenopausal woman complained of excess clitoral hood and flattening of the labia minora 6 months after labiaplasty (via an unknown technique) by a previous surgeon (B D) One year after postlateral reduction of the widened clitoral hood and fat grafting to the labia majora (E) Intraoperative view immediately after the patientrsquos procedure
1034 Aesthetic Surgery Journal 33(7)
the irregular overshortened labia minora (Figure 5C) The labia minora appeared flattened with posterior dog ears present bilaterally
suRgiCAl teChnique
In the first case under local anesthesia the excess clitoral hood skin was addressed in an inverted ldquoVrdquo resection over the dorsum of the clitoral hood With this maneuver atten-tion must be paid to perform a very conservative dorsal hood reduction as exposure of the glans clitoris is possible The incision was conservatively marked and incised down tomdashbut not intomdashthe investing fascia of the clitoris A 2-layer closure was performed with 5-0 Monocryl (poligle-caprone 25 p-1 needle) and 5-0 Vicryl Rapide (polyglactin 910 p-1 needle) both of which are manufactured by Ethicon (Somerville New Jersey) The labia minora edge irregulari-ties were then addressed with a series of small wedge resec-tions perpendicular to the axis of the labia minora The shortening of the minora in the anterior-posterior direction and reattachment of the hanging clitoral frenulum helped retract the clitoral hood posteriorly (Figure 4A-E)
In the second case the problem with the clitoral hood was width rather than dorsal skin excess This was addressed with a lateral triangular resection placing the scar in the groove between the labia majora and the clito-ral hood Once again markings were performed and local anesthetic was injected Two triangles of lateral clitoral hood were resected 1 on either side A 2-layer closure was performed with the sutures described above In addition fat grafting of the mons pubis and labia majora was per-formed on the second patient to further conceal the prominent clitoral hood and restore a more youthful appearance to the area (Figure 5A-E)
DisCussion
Surgical procedures to improve the appearance of the female genitalia have increased dramatically over the past several years9 Labia minora protrusion beyond the majora seems to be the dominant complaint of women seeking surgery10 Conceptually labiaplasty seems simple shorten the labia minora by trimming the edge11 This technique works well in most cases but may cause disharmony in select patients who present with prominent clitoral hoods in addition to labia minora excess (Figure 6) Clitoral hood redundancy is best detected preoperatively in the standing position (Figure 7) Bulky clitoral hoods have multiple drape-like folds and tend to separate the anterior vulvar commissure when viewed standing It is only postopera-tively after edge trim labiaplasty that the patient sees the hood as redundant It is my opinion that aggressive labial trim or near-amputation may cause this imbalance to be more pronounced even in the patient with a normal-sized clitoral hood
There exists a great deal of anatomical variation in clitoral hood anatomy and since the hood is contiguous
with the labia minora procedures to reduce the labia usu-ally must address the clitoral hood as well Excess submu-cosal tissue or extra folds of the mucosa overlying the clitoris may create a thick hood that protrudes anteriorly If these anatomical variations are not taken into consid-eration preoperatively excess clitoral hood projection is worsened by trimming the labia minora alone The loca-tion of the frenulum of the clitoris is important to note at the time of labia minora reduction as well inadvertent release of this structurersquos attachments may further contrib-ute to iatrogenic clitoral hood prominence12
In patients with prominence of the clitoral hood preop-eratively the wedge labiaplasty with a lateral extension may be a better option Two cases of wedge labiaplasty
Figure 6 This 36-year-old woman has clitoral hood and labia minora redundancy
Figure 7 This 24-year-old woman has clitoral hood redundancy
Hamori 1035
with lateral extension are shown in Figures 8 and 9 The photographs show redundancy of the clitoral hood preop-eratively which was ameliorated by performing the extended central wedge resection as described by Alter8 Free-edge resection or mucosal deepitheliazation6 tech-niques only address labia minora redundancy hence in this subset of patients the clitoral hood would have been made to appear even more prominent The posterior trac-tion placed on the clitoral hood with removal of the wedge helps reduce the anterior redundancy of the clitoral hood and the removal of the dog ear superolaterally with the extension narrows the width of the hood (Figure 8B)
In patients who present with clitoral hood prominence after labiaplasty it is important to restore balance between the clitoral hood and labia minora Treatment of iatrogenic labial deformities includes small wedge resections along the labia minora for areas of persistent redundancy reat-tachment of the frenulum of the clitoris and lateral or central reduction of the clitoral hood Care must be taken in dorsal clitoral hood reduction as this may cause
exposure of the glans clitoris (Figure 5A) If the patient complains of discomfort from an exposed clitoris the clitoral hood may be advanced forward as a V-to-Y flap Finally redundant clitoral hood tissue may be used for reconstruction of amputated labia minora by means of rotational flaps as described by Alter12
ConClusions
Surgery of the female perineummdashspecifically labia minora reduction or labiaplastymdashis on the rise Labia minora edge trim techniques have been popular among surgeons for years and provide good results in most cases but varia-tions in the size and shape of the clitoral hood should be taken into account when choosing the appropriate labial minora reduction technique Anatomy should be dis-cussed with the patient preoperatively with specific atten-tion paid to the clitoral hood size and appearance of the area in the standing position It is my opinion that
Figure 8 (A) This 29-year-old woman complained of an enlarged clitoral hood (B) Two months after wedge labiaplasty with lateral reduction of clitoral hood
Figure 9 (A) This 47-year-old woman complained of excess labia minora and clitoral hood (B) Two months after wedge labiaplasty with lateral clitoral hood reduction
1036 Aesthetic Surgery Journal 33(7)
modified wedge resections may be a better choice for patients with a prominent clitoral hood and surgeons should exercise caution when performing edge trim tech-niques in these patients
Disclosures
The author declared no potential conflicts of interest with respect to the research authorship and publication of this article
Funding
The author received no financial support for the research authorship and publication of this article
ReFeRenCes
1 Hogenboom M The rise in women seeking a perfect vagina wwwbbccouknewshealth-18947106 Accessed March 21 2013
2 Koning M Zeijlmans IA Bouman TK van der Lei B Female attitudes regarding labia minora appearance and reduction with consideration of media influence Aes-thetic Surg J 200929(1)65-71
3 Tepper OM Wulkan M Matarasso A Labiaplasty anat-omy etiology and a new surgical approach Aesthetic Surg J 201131(5)511-518
4 Alter GJ A new technique for aesthetic labia minora reduction Ann Plast Surg 199840287
5 Goodman M Placik OJ Gonzalez F et al A large multi-center outcome study of female genital plastic surgery J Sex Med 201071565-1577
6 Choi HY Kim KT A new method for aesthetic reduction of labia minora (the deepithelializaed reduction labio-plasty) Plast Reconstr Surg 2000105419-422
7 Reitsma W Mourits M Koning M Pascal A van der Lei B No (wo)man is an islandmdashthe influence of physiciansrsquo personal predisposition to labia minora appearance on their clinical decision making a cross-sectional survey J Sex Med 201182377-2385
8 Alter GJ Aesthetic labia minora and clitoral hood reduc-tion using extended central wedge resection Plast Recon-str Surg 20081221780-1789
9 Liao L Creighton S Requests for cosmetic genito-plasty how should healthcare providers respond BMJ 20073341090-1094
10 Giraldo F Gonzalez C de Haro F Central wedge nymphec-tomy with a 90-degree z-plasty for aesthetic reduction of the labia minora Plast Reconstr Surg 20041131820-1825
11 Girling R Slaisbury M Ersek R Vaginal labioplasty letters and viewpoints Plast Reconstr Surg 2005116(6)1792-1793
12 Alter G Labia minora reconstruction using clitoral hood flaps wedge excisions and YV advancement flaps Plast Reconstr Surg 20111272356-2363
1034 Aesthetic Surgery Journal 33(7)
the irregular overshortened labia minora (Figure 5C) The labia minora appeared flattened with posterior dog ears present bilaterally
suRgiCAl teChnique
In the first case under local anesthesia the excess clitoral hood skin was addressed in an inverted ldquoVrdquo resection over the dorsum of the clitoral hood With this maneuver atten-tion must be paid to perform a very conservative dorsal hood reduction as exposure of the glans clitoris is possible The incision was conservatively marked and incised down tomdashbut not intomdashthe investing fascia of the clitoris A 2-layer closure was performed with 5-0 Monocryl (poligle-caprone 25 p-1 needle) and 5-0 Vicryl Rapide (polyglactin 910 p-1 needle) both of which are manufactured by Ethicon (Somerville New Jersey) The labia minora edge irregulari-ties were then addressed with a series of small wedge resec-tions perpendicular to the axis of the labia minora The shortening of the minora in the anterior-posterior direction and reattachment of the hanging clitoral frenulum helped retract the clitoral hood posteriorly (Figure 4A-E)
In the second case the problem with the clitoral hood was width rather than dorsal skin excess This was addressed with a lateral triangular resection placing the scar in the groove between the labia majora and the clito-ral hood Once again markings were performed and local anesthetic was injected Two triangles of lateral clitoral hood were resected 1 on either side A 2-layer closure was performed with the sutures described above In addition fat grafting of the mons pubis and labia majora was per-formed on the second patient to further conceal the prominent clitoral hood and restore a more youthful appearance to the area (Figure 5A-E)
DisCussion
Surgical procedures to improve the appearance of the female genitalia have increased dramatically over the past several years9 Labia minora protrusion beyond the majora seems to be the dominant complaint of women seeking surgery10 Conceptually labiaplasty seems simple shorten the labia minora by trimming the edge11 This technique works well in most cases but may cause disharmony in select patients who present with prominent clitoral hoods in addition to labia minora excess (Figure 6) Clitoral hood redundancy is best detected preoperatively in the standing position (Figure 7) Bulky clitoral hoods have multiple drape-like folds and tend to separate the anterior vulvar commissure when viewed standing It is only postopera-tively after edge trim labiaplasty that the patient sees the hood as redundant It is my opinion that aggressive labial trim or near-amputation may cause this imbalance to be more pronounced even in the patient with a normal-sized clitoral hood
There exists a great deal of anatomical variation in clitoral hood anatomy and since the hood is contiguous
with the labia minora procedures to reduce the labia usu-ally must address the clitoral hood as well Excess submu-cosal tissue or extra folds of the mucosa overlying the clitoris may create a thick hood that protrudes anteriorly If these anatomical variations are not taken into consid-eration preoperatively excess clitoral hood projection is worsened by trimming the labia minora alone The loca-tion of the frenulum of the clitoris is important to note at the time of labia minora reduction as well inadvertent release of this structurersquos attachments may further contrib-ute to iatrogenic clitoral hood prominence12
In patients with prominence of the clitoral hood preop-eratively the wedge labiaplasty with a lateral extension may be a better option Two cases of wedge labiaplasty
Figure 6 This 36-year-old woman has clitoral hood and labia minora redundancy
Figure 7 This 24-year-old woman has clitoral hood redundancy
Hamori 1035
with lateral extension are shown in Figures 8 and 9 The photographs show redundancy of the clitoral hood preop-eratively which was ameliorated by performing the extended central wedge resection as described by Alter8 Free-edge resection or mucosal deepitheliazation6 tech-niques only address labia minora redundancy hence in this subset of patients the clitoral hood would have been made to appear even more prominent The posterior trac-tion placed on the clitoral hood with removal of the wedge helps reduce the anterior redundancy of the clitoral hood and the removal of the dog ear superolaterally with the extension narrows the width of the hood (Figure 8B)
In patients who present with clitoral hood prominence after labiaplasty it is important to restore balance between the clitoral hood and labia minora Treatment of iatrogenic labial deformities includes small wedge resections along the labia minora for areas of persistent redundancy reat-tachment of the frenulum of the clitoris and lateral or central reduction of the clitoral hood Care must be taken in dorsal clitoral hood reduction as this may cause
exposure of the glans clitoris (Figure 5A) If the patient complains of discomfort from an exposed clitoris the clitoral hood may be advanced forward as a V-to-Y flap Finally redundant clitoral hood tissue may be used for reconstruction of amputated labia minora by means of rotational flaps as described by Alter12
ConClusions
Surgery of the female perineummdashspecifically labia minora reduction or labiaplastymdashis on the rise Labia minora edge trim techniques have been popular among surgeons for years and provide good results in most cases but varia-tions in the size and shape of the clitoral hood should be taken into account when choosing the appropriate labial minora reduction technique Anatomy should be dis-cussed with the patient preoperatively with specific atten-tion paid to the clitoral hood size and appearance of the area in the standing position It is my opinion that
Figure 8 (A) This 29-year-old woman complained of an enlarged clitoral hood (B) Two months after wedge labiaplasty with lateral reduction of clitoral hood
Figure 9 (A) This 47-year-old woman complained of excess labia minora and clitoral hood (B) Two months after wedge labiaplasty with lateral clitoral hood reduction
1036 Aesthetic Surgery Journal 33(7)
modified wedge resections may be a better choice for patients with a prominent clitoral hood and surgeons should exercise caution when performing edge trim tech-niques in these patients
Disclosures
The author declared no potential conflicts of interest with respect to the research authorship and publication of this article
Funding
The author received no financial support for the research authorship and publication of this article
ReFeRenCes
1 Hogenboom M The rise in women seeking a perfect vagina wwwbbccouknewshealth-18947106 Accessed March 21 2013
2 Koning M Zeijlmans IA Bouman TK van der Lei B Female attitudes regarding labia minora appearance and reduction with consideration of media influence Aes-thetic Surg J 200929(1)65-71
3 Tepper OM Wulkan M Matarasso A Labiaplasty anat-omy etiology and a new surgical approach Aesthetic Surg J 201131(5)511-518
4 Alter GJ A new technique for aesthetic labia minora reduction Ann Plast Surg 199840287
5 Goodman M Placik OJ Gonzalez F et al A large multi-center outcome study of female genital plastic surgery J Sex Med 201071565-1577
6 Choi HY Kim KT A new method for aesthetic reduction of labia minora (the deepithelializaed reduction labio-plasty) Plast Reconstr Surg 2000105419-422
7 Reitsma W Mourits M Koning M Pascal A van der Lei B No (wo)man is an islandmdashthe influence of physiciansrsquo personal predisposition to labia minora appearance on their clinical decision making a cross-sectional survey J Sex Med 201182377-2385
8 Alter GJ Aesthetic labia minora and clitoral hood reduc-tion using extended central wedge resection Plast Recon-str Surg 20081221780-1789
9 Liao L Creighton S Requests for cosmetic genito-plasty how should healthcare providers respond BMJ 20073341090-1094
10 Giraldo F Gonzalez C de Haro F Central wedge nymphec-tomy with a 90-degree z-plasty for aesthetic reduction of the labia minora Plast Reconstr Surg 20041131820-1825
11 Girling R Slaisbury M Ersek R Vaginal labioplasty letters and viewpoints Plast Reconstr Surg 2005116(6)1792-1793
12 Alter G Labia minora reconstruction using clitoral hood flaps wedge excisions and YV advancement flaps Plast Reconstr Surg 20111272356-2363
Hamori 1035
with lateral extension are shown in Figures 8 and 9 The photographs show redundancy of the clitoral hood preop-eratively which was ameliorated by performing the extended central wedge resection as described by Alter8 Free-edge resection or mucosal deepitheliazation6 tech-niques only address labia minora redundancy hence in this subset of patients the clitoral hood would have been made to appear even more prominent The posterior trac-tion placed on the clitoral hood with removal of the wedge helps reduce the anterior redundancy of the clitoral hood and the removal of the dog ear superolaterally with the extension narrows the width of the hood (Figure 8B)
In patients who present with clitoral hood prominence after labiaplasty it is important to restore balance between the clitoral hood and labia minora Treatment of iatrogenic labial deformities includes small wedge resections along the labia minora for areas of persistent redundancy reat-tachment of the frenulum of the clitoris and lateral or central reduction of the clitoral hood Care must be taken in dorsal clitoral hood reduction as this may cause
exposure of the glans clitoris (Figure 5A) If the patient complains of discomfort from an exposed clitoris the clitoral hood may be advanced forward as a V-to-Y flap Finally redundant clitoral hood tissue may be used for reconstruction of amputated labia minora by means of rotational flaps as described by Alter12
ConClusions
Surgery of the female perineummdashspecifically labia minora reduction or labiaplastymdashis on the rise Labia minora edge trim techniques have been popular among surgeons for years and provide good results in most cases but varia-tions in the size and shape of the clitoral hood should be taken into account when choosing the appropriate labial minora reduction technique Anatomy should be dis-cussed with the patient preoperatively with specific atten-tion paid to the clitoral hood size and appearance of the area in the standing position It is my opinion that
Figure 8 (A) This 29-year-old woman complained of an enlarged clitoral hood (B) Two months after wedge labiaplasty with lateral reduction of clitoral hood
Figure 9 (A) This 47-year-old woman complained of excess labia minora and clitoral hood (B) Two months after wedge labiaplasty with lateral clitoral hood reduction
1036 Aesthetic Surgery Journal 33(7)
modified wedge resections may be a better choice for patients with a prominent clitoral hood and surgeons should exercise caution when performing edge trim tech-niques in these patients
Disclosures
The author declared no potential conflicts of interest with respect to the research authorship and publication of this article
Funding
The author received no financial support for the research authorship and publication of this article
ReFeRenCes
1 Hogenboom M The rise in women seeking a perfect vagina wwwbbccouknewshealth-18947106 Accessed March 21 2013
2 Koning M Zeijlmans IA Bouman TK van der Lei B Female attitudes regarding labia minora appearance and reduction with consideration of media influence Aes-thetic Surg J 200929(1)65-71
3 Tepper OM Wulkan M Matarasso A Labiaplasty anat-omy etiology and a new surgical approach Aesthetic Surg J 201131(5)511-518
4 Alter GJ A new technique for aesthetic labia minora reduction Ann Plast Surg 199840287
5 Goodman M Placik OJ Gonzalez F et al A large multi-center outcome study of female genital plastic surgery J Sex Med 201071565-1577
6 Choi HY Kim KT A new method for aesthetic reduction of labia minora (the deepithelializaed reduction labio-plasty) Plast Reconstr Surg 2000105419-422
7 Reitsma W Mourits M Koning M Pascal A van der Lei B No (wo)man is an islandmdashthe influence of physiciansrsquo personal predisposition to labia minora appearance on their clinical decision making a cross-sectional survey J Sex Med 201182377-2385
8 Alter GJ Aesthetic labia minora and clitoral hood reduc-tion using extended central wedge resection Plast Recon-str Surg 20081221780-1789
9 Liao L Creighton S Requests for cosmetic genito-plasty how should healthcare providers respond BMJ 20073341090-1094
10 Giraldo F Gonzalez C de Haro F Central wedge nymphec-tomy with a 90-degree z-plasty for aesthetic reduction of the labia minora Plast Reconstr Surg 20041131820-1825
11 Girling R Slaisbury M Ersek R Vaginal labioplasty letters and viewpoints Plast Reconstr Surg 2005116(6)1792-1793
12 Alter G Labia minora reconstruction using clitoral hood flaps wedge excisions and YV advancement flaps Plast Reconstr Surg 20111272356-2363
1036 Aesthetic Surgery Journal 33(7)
modified wedge resections may be a better choice for patients with a prominent clitoral hood and surgeons should exercise caution when performing edge trim tech-niques in these patients
Disclosures
The author declared no potential conflicts of interest with respect to the research authorship and publication of this article
Funding
The author received no financial support for the research authorship and publication of this article
ReFeRenCes
1 Hogenboom M The rise in women seeking a perfect vagina wwwbbccouknewshealth-18947106 Accessed March 21 2013
2 Koning M Zeijlmans IA Bouman TK van der Lei B Female attitudes regarding labia minora appearance and reduction with consideration of media influence Aes-thetic Surg J 200929(1)65-71
3 Tepper OM Wulkan M Matarasso A Labiaplasty anat-omy etiology and a new surgical approach Aesthetic Surg J 201131(5)511-518
4 Alter GJ A new technique for aesthetic labia minora reduction Ann Plast Surg 199840287
5 Goodman M Placik OJ Gonzalez F et al A large multi-center outcome study of female genital plastic surgery J Sex Med 201071565-1577
6 Choi HY Kim KT A new method for aesthetic reduction of labia minora (the deepithelializaed reduction labio-plasty) Plast Reconstr Surg 2000105419-422
7 Reitsma W Mourits M Koning M Pascal A van der Lei B No (wo)man is an islandmdashthe influence of physiciansrsquo personal predisposition to labia minora appearance on their clinical decision making a cross-sectional survey J Sex Med 201182377-2385
8 Alter GJ Aesthetic labia minora and clitoral hood reduc-tion using extended central wedge resection Plast Recon-str Surg 20081221780-1789
9 Liao L Creighton S Requests for cosmetic genito-plasty how should healthcare providers respond BMJ 20073341090-1094
10 Giraldo F Gonzalez C de Haro F Central wedge nymphec-tomy with a 90-degree z-plasty for aesthetic reduction of the labia minora Plast Reconstr Surg 20041131820-1825
11 Girling R Slaisbury M Ersek R Vaginal labioplasty letters and viewpoints Plast Reconstr Surg 2005116(6)1792-1793
12 Alter G Labia minora reconstruction using clitoral hood flaps wedge excisions and YV advancement flaps Plast Reconstr Surg 20111272356-2363
