Int Urogynecol J DOI 10.1007/s00192-014-2332-y
IUJ VIDEO
Vulvar anatomy and labia minoraplasty Ladin A. Yurteri-Kaplan & Jeannine M. Miranne & Cheryl B. Iglesia
Received: 18 December 2013 / Accepted: 9 January 2014 # The International Urogynecological Association 2014
Abstract Aim of video/Introduction Female genital cosmetic surgery is performed for aesthetic reasons as well as for medical and functional indications, such as congenital labia minora hypertrophy. The purpose of this video is to teach vulvar anatomy and review labia minorplasty techniques. Methods We demonstrate one technique in this video. Conclusions There are a variety of different techniques for labia minorplasty. When deciding the most appropriate technique to use, the patient’s goals must be considered. Keywords Vulvar anatomy . Labia minoraplasty . Labioplasty . Labiaplasty
Description of the vulva The structures that comprise the vulva extend inferiorly from the pubic arch and include the mons pubis, labia majora and minora, clitoris, and vestibule of the vagina. The mons pubis is a triangular area of tissue overlying the anterior aspect of the pubic bone and consists of hair-bearing skin and underlying adipose tissue. The labia majora are lateral folds of hairPresented as an oral video at the 34th Annual Scientific Meeting of the American Urogynecologic Society in Las Vegas, NV, USA, 16–19 October 2013 Electronic supplementary material The online version of this article (doi:10.1007/s00192-014-2332-y) contains supplementary material, which is available to authorized users. This video is also available to watch on http://videos.springer.com/. Please search for the video by the article title. L. A. Yurteri-Kaplan (*) : J. M. Miranne : C. B. Iglesia Section of Female Pelvic Medicine and Reconstructive Surgery, Medstar Washington Hospital Center/Georgetown University School of Medicine, 106 Irving Street NW POB Suite 405 South, Washington, DC 20010, USA e-mail: [email protected]
bearing skin and adipose tissue that extend inferiorly from the mons and meet in the midline at the posterior fourchette. They contain the distal ends of the round ligaments and have a rich supply of sebaceous, apocrine, and eccrine sweat glands. The length of a normal labia majora, from the most superior aspect of the clitoral hood to the posterior fourchette, ranges between 7 and 12 cm [1]. The labia minora are hairless skin folds located medial to the labia majora. Anteriorly, each separates into two folds that run over and under the glans of the clitoris. The superior folds unite in the midline to form the prepuce, or clitoral hood. The inferior folds insert into the underside of the clitoris to form the frenulum. The posterior aspects of both labia minora merge with the labia majora at the posterior fourchette. Hart’s line demarcates the transition between the keratinized epithelium of the labia minora and the nonkeratinized epithelium of the vestibule of the vagina. Normal labia minora length ranges from 2 to 10 cm, measured from the frenulum of the clitoris to the posterior fourchette [1]. The normal width of the labia minora varies from 0.7 to 5 cm, extending laterally from the hymen [1]. The clitoris is an erectile organ. It consists of a midline shaft capped with a rounded tubercle known as the glans and two crura, which are located in the superficial compartment of the perineum. Direct stimulation of the clitoris leads to female orgasm. The average clitoral length is approximately 2 cm with a range of 0.5 to 3.5 cm. The average width of the glans is 5.5 mm with a range of 3 to 10 mm [1]. The vestibule of the vagina includes the area between the hymen and Hart’s line laterally, the frenulum of the clitoris anteriorly, and the posterior fourchette posteriorly. The area between the hymen and posterior fourchette is the fossa navicularis. The external urethral meatus is located within the vestibule of the vagina superior to the vaginal opening. Two paraurethral Skene’s glands are located at the posterior– lateral aspect of the urethral meatus, line the urethra longitudinally, and aid in lubrication.
Int Urogynecol J
There has been speculation regarding the existence of the Gräfenberg G-spot, first described in 1950. This erogenous zone was claimed to be 1–2 cm proximal to the urethra on the anterior vaginal wall. Stimulation of this area was thought to aid female orgasm. However, review of the literature has failed to provide objective evidence of this entity. The greater vestibular glands, commonly known as Bartholin’s glands, open into the posterior–lateral aspect of the vestibule at approximately the 5 and 7 o’clock positions. Multiple minor vestibular glands are located concentrically within the vestibule. The vulva is innervated by the pudendal nerve, which originates from the anterior rami of the second through fourth sacral nerve roots and exits Alcock’s canal just medial to the ischial tuberosity. Branches of the pudendal nerve include the dorsal nerve of the clitoris, the perineal nerve, and the inferior rectal nerve. The posterior femoral cutaneous, ilioinguinal, and genitofemoral nerves also supply the vulva. The bulbocavernosus reflex involves the S2 through S4 nerve roots. Gently tapping the clitoral prepuce stimulates the sensory afferent component of the dorsal nerve of the clitoris, which is transmitted to the motor efferent component of the inferior rectal nerve resulting in an anal wink. The vulva derives its vascular supply primarily from the internal pudendal artery, a branch of the internal iliac. The external pudendal artery originates from the external iliac artery to supply the most superior aspect of the labia majora.
Labia minoraplasty Female genital cosmetic surgery first appeared in North American journals in 1978 [2]. Labia minoraplasty is one of the most commonly requested cosmetic gynecological procedures. There are a variety of different techniques including linear resection, central V wedge plasty, inferior wedge resection, z-plasty, and de-epithelialization. When deciding the most appropriate technique to use, the patient’s goals must be considered. The patient should be aware that the labia will be smaller, with potential risks of visible scarring, infection, bleeding, wound separation, asymmetry, discoloration, contraction, pain, dyspareunia, and altered sensation [3, 4]. Linear resection involves the removal of excess tissue with reapproximation of the epithelial edges. This can be performed with a scalpel, laser, or monopolar cautery. Benefits include lighter labia minora skin tone [5]. Central V-wedge resection of the central portion of the labia minora is another technique that can be used to preserve the labial edge color [6]. A modification of this is the inferior wedge resection and superior pedicle flap reconstruction where a v-shape wedge is removed between the 3 and 6 o’clock position of the labia minora followed by superior labia advancement to the posterior fourchette [7]. Risks with the modification include
increased bleeding and compromise to the vascular supply, causing distal flap necrosis. Another modification is a central wedge resection and a 90° z-plasty [8]. In this technique the medial incision forms a Z creating three triangular tissue flaps to distribute tension and prevent retraction and dyspareunia. The last technique is de-epithelialization. Steps include removal of the central epithelium on both the medial and lateral aspects of the labia minora using a scalpel or laser. This technique maintains the pigmentation at the edge of the labia minora, while decreasing excess tissue.
Surgical case The patient complained of labial burning and irritation due to rubbing on clothing, invagination of the labia minora during intercourse, and splaying of the urinary stream. Her right labia minora width measured 5 cm while her left labia minora measured 8 cm. We performed a traditional linear resection to achieve her goals of matching the left labium to the right labium. First, we recommend using a plastics instrument to aid fine surgical technique. Measure the area of resection prior to any further manipulation. The resection should not cause tension on the suture line. Over-resection can cause significant scarring and retraction or compromise blood supply. Next, inject the epithelium with local anesthesia. Using a monopolar pinpoint cautery tip, the incision is made along the marked epithelium of the labium. Following incision, the remaining tissue can be cut and hemostasis assured. We recommend using fine 3–0 absorbable vertical mattress sutures to reapproximate the epithelium. An ice pack to the vulva for 24 h can help with edema and an anesthetic ointment for postoperative pain. Suture removal to prevent any scarring within the first week is recommended for optimal healing.
Consent Written informed consent was obtained from the patient for publication of this video article and any accompanying images. This is an Institutional Review Board-exempt (study project # 2013–070) video. Conflicts of interest None. Disclaimer Dr. Cheryl Iglesia is also a federal government employee at the US Food and Drug Administration.
References 1. Lloyd J, Crouch NS, Minto CL et al (2005) Female genital appearance: “normality” unfolds. BJOG 112(5):643–646 2. Honore LH, O’Hara KE (1978) Benign enlargement of labia minora: report of two cases. Eur J Obstet Gynecol Reprod Biol 8(2):61–64 3. Marchitelli CE, Sluga MC, Perrotta M, Testa R (2010) Initial experience in vulvovaginal aesthetic surgery unit within a general gynecology department. J Low Genit Tract Dis 14(4):295–300
Int Urogynecol J 4. Triana L, Robledo AM (2012) Refreshing labioplasty techniques for plastic surgeons. Aesthetic Plast Surg 36(5):1078–1086 5. Miklos JR, Moore RD (2011) Postoperative cosmetic expectations for patients considering labiaplasty surgery: our experience with 550 patients. Surg Technol Int 1:170–174 6. Alter G (1998) A new technique for aesthetic labia minora reduction. Ann Plast Surg 40:287–290
7. Munhoz AM, Filassi JR, Ricci MD, Aldrighi C, Correia LD, Aldrighi JM et al (2006) Aesthetic labia minora reduction with inferior wedge resection and superior pedicle flap reconstruction. Plast Reconstr Surg 118(5):1237–1247 8. Giraldo F, Gonzalez C, de Haro F (2004) Central wedge nymphectomy with a 90-degree Z-plasty for aesthetic reduction of the labia minora. Plast Reconstr Surg 113(6):1820–1825
IUJ VIDEO
Vulvar anatomy and labia minoraplasty Ladin A. Yurteri-Kaplan & Jeannine M. Miranne & Cheryl B. Iglesia
Received: 18 December 2013 / Accepted: 9 January 2014 # The International Urogynecological Association 2014
Abstract Aim of video/Introduction Female genital cosmetic surgery is performed for aesthetic reasons as well as for medical and functional indications, such as congenital labia minora hypertrophy. The purpose of this video is to teach vulvar anatomy and review labia minorplasty techniques. Methods We demonstrate one technique in this video. Conclusions There are a variety of different techniques for labia minorplasty. When deciding the most appropriate technique to use, the patient’s goals must be considered. Keywords Vulvar anatomy . Labia minoraplasty . Labioplasty . Labiaplasty
Description of the vulva The structures that comprise the vulva extend inferiorly from the pubic arch and include the mons pubis, labia majora and minora, clitoris, and vestibule of the vagina. The mons pubis is a triangular area of tissue overlying the anterior aspect of the pubic bone and consists of hair-bearing skin and underlying adipose tissue. The labia majora are lateral folds of hairPresented as an oral video at the 34th Annual Scientific Meeting of the American Urogynecologic Society in Las Vegas, NV, USA, 16–19 October 2013 Electronic supplementary material The online version of this article (doi:10.1007/s00192-014-2332-y) contains supplementary material, which is available to authorized users. This video is also available to watch on http://videos.springer.com/. Please search for the video by the article title. L. A. Yurteri-Kaplan (*) : J. M. Miranne : C. B. Iglesia Section of Female Pelvic Medicine and Reconstructive Surgery, Medstar Washington Hospital Center/Georgetown University School of Medicine, 106 Irving Street NW POB Suite 405 South, Washington, DC 20010, USA e-mail: [email protected]
bearing skin and adipose tissue that extend inferiorly from the mons and meet in the midline at the posterior fourchette. They contain the distal ends of the round ligaments and have a rich supply of sebaceous, apocrine, and eccrine sweat glands. The length of a normal labia majora, from the most superior aspect of the clitoral hood to the posterior fourchette, ranges between 7 and 12 cm [1]. The labia minora are hairless skin folds located medial to the labia majora. Anteriorly, each separates into two folds that run over and under the glans of the clitoris. The superior folds unite in the midline to form the prepuce, or clitoral hood. The inferior folds insert into the underside of the clitoris to form the frenulum. The posterior aspects of both labia minora merge with the labia majora at the posterior fourchette. Hart’s line demarcates the transition between the keratinized epithelium of the labia minora and the nonkeratinized epithelium of the vestibule of the vagina. Normal labia minora length ranges from 2 to 10 cm, measured from the frenulum of the clitoris to the posterior fourchette [1]. The normal width of the labia minora varies from 0.7 to 5 cm, extending laterally from the hymen [1]. The clitoris is an erectile organ. It consists of a midline shaft capped with a rounded tubercle known as the glans and two crura, which are located in the superficial compartment of the perineum. Direct stimulation of the clitoris leads to female orgasm. The average clitoral length is approximately 2 cm with a range of 0.5 to 3.5 cm. The average width of the glans is 5.5 mm with a range of 3 to 10 mm [1]. The vestibule of the vagina includes the area between the hymen and Hart’s line laterally, the frenulum of the clitoris anteriorly, and the posterior fourchette posteriorly. The area between the hymen and posterior fourchette is the fossa navicularis. The external urethral meatus is located within the vestibule of the vagina superior to the vaginal opening. Two paraurethral Skene’s glands are located at the posterior– lateral aspect of the urethral meatus, line the urethra longitudinally, and aid in lubrication.
Int Urogynecol J
There has been speculation regarding the existence of the Gräfenberg G-spot, first described in 1950. This erogenous zone was claimed to be 1–2 cm proximal to the urethra on the anterior vaginal wall. Stimulation of this area was thought to aid female orgasm. However, review of the literature has failed to provide objective evidence of this entity. The greater vestibular glands, commonly known as Bartholin’s glands, open into the posterior–lateral aspect of the vestibule at approximately the 5 and 7 o’clock positions. Multiple minor vestibular glands are located concentrically within the vestibule. The vulva is innervated by the pudendal nerve, which originates from the anterior rami of the second through fourth sacral nerve roots and exits Alcock’s canal just medial to the ischial tuberosity. Branches of the pudendal nerve include the dorsal nerve of the clitoris, the perineal nerve, and the inferior rectal nerve. The posterior femoral cutaneous, ilioinguinal, and genitofemoral nerves also supply the vulva. The bulbocavernosus reflex involves the S2 through S4 nerve roots. Gently tapping the clitoral prepuce stimulates the sensory afferent component of the dorsal nerve of the clitoris, which is transmitted to the motor efferent component of the inferior rectal nerve resulting in an anal wink. The vulva derives its vascular supply primarily from the internal pudendal artery, a branch of the internal iliac. The external pudendal artery originates from the external iliac artery to supply the most superior aspect of the labia majora.
Labia minoraplasty Female genital cosmetic surgery first appeared in North American journals in 1978 [2]. Labia minoraplasty is one of the most commonly requested cosmetic gynecological procedures. There are a variety of different techniques including linear resection, central V wedge plasty, inferior wedge resection, z-plasty, and de-epithelialization. When deciding the most appropriate technique to use, the patient’s goals must be considered. The patient should be aware that the labia will be smaller, with potential risks of visible scarring, infection, bleeding, wound separation, asymmetry, discoloration, contraction, pain, dyspareunia, and altered sensation [3, 4]. Linear resection involves the removal of excess tissue with reapproximation of the epithelial edges. This can be performed with a scalpel, laser, or monopolar cautery. Benefits include lighter labia minora skin tone [5]. Central V-wedge resection of the central portion of the labia minora is another technique that can be used to preserve the labial edge color [6]. A modification of this is the inferior wedge resection and superior pedicle flap reconstruction where a v-shape wedge is removed between the 3 and 6 o’clock position of the labia minora followed by superior labia advancement to the posterior fourchette [7]. Risks with the modification include
increased bleeding and compromise to the vascular supply, causing distal flap necrosis. Another modification is a central wedge resection and a 90° z-plasty [8]. In this technique the medial incision forms a Z creating three triangular tissue flaps to distribute tension and prevent retraction and dyspareunia. The last technique is de-epithelialization. Steps include removal of the central epithelium on both the medial and lateral aspects of the labia minora using a scalpel or laser. This technique maintains the pigmentation at the edge of the labia minora, while decreasing excess tissue.
Surgical case The patient complained of labial burning and irritation due to rubbing on clothing, invagination of the labia minora during intercourse, and splaying of the urinary stream. Her right labia minora width measured 5 cm while her left labia minora measured 8 cm. We performed a traditional linear resection to achieve her goals of matching the left labium to the right labium. First, we recommend using a plastics instrument to aid fine surgical technique. Measure the area of resection prior to any further manipulation. The resection should not cause tension on the suture line. Over-resection can cause significant scarring and retraction or compromise blood supply. Next, inject the epithelium with local anesthesia. Using a monopolar pinpoint cautery tip, the incision is made along the marked epithelium of the labium. Following incision, the remaining tissue can be cut and hemostasis assured. We recommend using fine 3–0 absorbable vertical mattress sutures to reapproximate the epithelium. An ice pack to the vulva for 24 h can help with edema and an anesthetic ointment for postoperative pain. Suture removal to prevent any scarring within the first week is recommended for optimal healing.
Consent Written informed consent was obtained from the patient for publication of this video article and any accompanying images. This is an Institutional Review Board-exempt (study project # 2013–070) video. Conflicts of interest None. Disclaimer Dr. Cheryl Iglesia is also a federal government employee at the US Food and Drug Administration.
References 1. Lloyd J, Crouch NS, Minto CL et al (2005) Female genital appearance: “normality” unfolds. BJOG 112(5):643–646 2. Honore LH, O’Hara KE (1978) Benign enlargement of labia minora: report of two cases. Eur J Obstet Gynecol Reprod Biol 8(2):61–64 3. Marchitelli CE, Sluga MC, Perrotta M, Testa R (2010) Initial experience in vulvovaginal aesthetic surgery unit within a general gynecology department. J Low Genit Tract Dis 14(4):295–300
Int Urogynecol J 4. Triana L, Robledo AM (2012) Refreshing labioplasty techniques for plastic surgeons. Aesthetic Plast Surg 36(5):1078–1086 5. Miklos JR, Moore RD (2011) Postoperative cosmetic expectations for patients considering labiaplasty surgery: our experience with 550 patients. Surg Technol Int 1:170–174 6. Alter G (1998) A new technique for aesthetic labia minora reduction. Ann Plast Surg 40:287–290
7. Munhoz AM, Filassi JR, Ricci MD, Aldrighi C, Correia LD, Aldrighi JM et al (2006) Aesthetic labia minora reduction with inferior wedge resection and superior pedicle flap reconstruction. Plast Reconstr Surg 118(5):1237–1247 8. Giraldo F, Gonzalez C, de Haro F (2004) Central wedge nymphectomy with a 90-degree Z-plasty for aesthetic reduction of the labia minora. Plast Reconstr Surg 113(6):1820–1825
