As part of Female Health Education, Dr. Quimby and I led a health education class at a local girls’ private high school. We wanted the talk to be straight from gynecologists, different than others they had heard. As part of it, we showed real photos of external female genitalia (images previously printed in the medical literature). The point? Let them see what normal vulvas look like! No other person has seen more vulvas than a gynecologist and we are the best equipped to give reassurance that variations on anatomy are normal and expected.   

What happens when something does not look anatomically normal though, or if it is a normal variation but causing symptoms and problems in that person’s body? It depends on what body part we’re talking about of course, and it depends on the issues that are arising. Sometimes the answer is corrective surgery. And when we talk about the vulva, and more specifically the labia, that corrective surgery is called a labiaplasty.

That’s my topic today and here’s what you’ll find:

• A quick anatomy lesson
• Medical reasons for labiaplasty
• Considerations for cosmetic labiaplasty

ANATOMY

The vulva also includes: Clitoral hood and clitoris (the most important organ of female genitalia for sex but not one we will be discussing today; urethral opening; vaginal opening called the introitus; vaginal vestibule – the entry into the vagina, just inside the introitus.

Other components like Bartholins glands and Skenes glands that are less obvious (this article about Bartholin glands cysts and abscess is my most read article).

~ A quick word about slang terms for the vulva ~

The overused “slang” of saying vagina instead of vulva is truly problematic. Example: “My vagina hurts after that wax.” You definitely mean the vulva. If your cosmetologist is waxing your vagina please run far far away.

I don’t have an issue with slang for genitals in and of itself– as long as it’s used with good humor and by adults for adults (kids should be learning the proper terms before starting to use nicknames or slang).

There are plenty of slang terms and nicknames for male genitalia : balls / nuts / cojones / sack / family jewels for testicles; cock / dick / rod / weenie / peter / prick / johnson / schlong for penis. I have no problem with these (besides some being gross) because each of these slang terms is for a specific and anatomically distinct body part. No one is using a slang “testicles” to describe a penis. No one says “penis” when they mean testicles. “Penis” and “testicles” are not used interchangeably as part of slang vernacular.

Why is it different with female anatomy? Why do we say “vagina” instead of vulva and so often refuse to say the term “vulva” altogether? Because of lack of knowledge? See above for anatomy lesson. Because our genitals are more complex? Pathetic excuse. Because the vulva is treated as an enigma or some “secret” that should not be spoken out loud? Those days are past. Let’s use accurate language. Let’s learn proper female anatomy. Let’s empower ourselves by not being embarrassed by the names of our organs. Let’s teach our kids (our daughters) their crucial and important body parts.

Take this as a plea from me – use the correct term. My daughter is growing up using the term vulva to describe her vulva. Unfortunately sometimes she also refers to my Volvo as a vulva too – but that’s a different post (but btw – she’s not embarrassed when she accidentally says that).

Moving on to the main topic: Labiaplasty

Labiaplasty is surgical repair of the labia. There are 2 sets of labia, as described above: labia majora and labia minora. Labiaplasty almost always refers to labia minora and the “surgical repair” is to reduce its size.

Why is labiaplasty done?

The primary medical diagnosis for labiaplasty is “labia minora hypertrophy” which means enlargement of the labia minora. The problem is the lack of a standardized definition of “enlargement”, so it turns into a judgment, an opinion that the labia are enlarged, not an actual fact. It often means that one or both of the labia minora extend past the labia majora, but there is no specific measurement, size, or criteria to say how far beyond the labia majora the labia minora needs to extend to consider it hypertrophied.  In one study looking at anatomy in females, more than 50% of females had “labia minora hypertrophy”. This statistic alone tells us extension of the labia minora past the majora is not an abnormal enlargement but a common, expected, normal anatomic variation of the vulva. I can tell you from the gazillion pelvic exams I’ve done in my career, there is vast variation in appearance and size of the labia majora and minora.

The follow up question is then: If it’s normal, why would there be a medical indication for surgical repair?

When labia minora “hypertrophy” exists, extending past the protective labia majora, there’s the possibility of irritation, pain, even infection of that delicate tissue. The pain and irritation are typically with exercise, when the friction of the labia against underwear and clothing is excessive.

A few of my patients have had these concerns too:

• Complaining that their labia minora is long enough to sneak outside or get caught on their underwear. You can see how this would be really uncomfortable and distracting.
• Interfering with sex is another one –the longer labia minora gets pulled or tethered.
• I once had a patient with a very thin skin tag hanging from her labia minora, about 1 centimeter long. It had grown over the course of a few months, likely an inflammatory response to injury of the tissue. It was getting caught when she wiped after peeing, during sex, and sometimes just putting on underwear, causing pain and even more inflammation and irritation. I removed it with a quick office procedure. The pathology? Labia minora hypertrophy.

Considerations for Cosmetic Requests for Labiaplasty

Cosmetic procedures is a layered topic in general. The goal with procedures solely on the focus of cosmetics – what something looks like – is to make the individual person undergoing the procedure feel better about their appearance. Sometimes fixing the one feature that is causing someone distress – be it their nose, boobs, labia, or whatever – really, truly fixes the problem. Sometimes, however, that feature was a temporary focus of that person’s dissatisfaction with themselves and when it’s cosmetically altered, the fixation turns to some other body part. Over and over again. The root of the problem is their view of their body as whole, not just that one specific body part. They need to work on their brain to improve their body image. In this population, cosmetic surgery is working on the wrong body part.

In a culture with a heavy emphasis on appearance AND where porn is widely available, the appearance of a hairless, small vulva and labia is often thought of as the ideal appearance, especially for heterosexual men. Females are then pressured, either overtly or discretely, to obtain this “ideal”. This is where cosmetic requests for labiaplasty come in.

Cosmetic labiaplasty is then fraught with this question – will the surgery actually be helpful? What if it still doesn’t look like their ideal? For these complicated reasons, many cosmetic surgeons require patients to have a psychologic evaluation and be older than 18 years old prior to a cosmetic labiaplasty.

Don’t get me wrong – I think there is a role for cosmetic labiaplasty. I also think cosmetic labiaplastys are sometimes done for a bad reason. Any cosmetic procedure may turn out to be the most important surgery of someone’s life and help restore their confidence … or it can be a useless surgery with the potential for complication and lifelong regret. That’s a lot to consider.

Having a Labiaplasty – details about the procedure itself

The surgeon will explain the procedure, reviewing potential risks and expectations for recovery. This is typical of any surgical procedure. While the point of surgery is to fix whatever problem is occurring with the labia, there is no guarantee that the patient will be 100% happy with the results. While that’s the ultimate hope, improvement in symptoms is the goal.

The labiaplasty procedure itself is done in a procedure or operating room with anesthesia. The part of the labia minora that extends beyond the labia majora is removed with a scalpel and then sutures placed. Anatomy is assessed throughout. After care usually involves modified activity for up to 2 weeks:  avoiding irritation to the area by wearing loose clothing and avoiding certain exercises or activity that can put friction on the sutures. Topical anesthesia like lidocaine spray or gel is often recommended too. As the sutures dissolve it is common to have itching or burning and is important to not rub or scratch the healing area as well.

And that’s the end of your lesson!

I’d be happy for you to share your experience if you feel comfortable!