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What are the labia minora?
What are the labia majora?
Lying just inside the labia majora are the labia minora. These are usually thin pieces of skin that do not contain much fat and hair follicles are absent. The left and right labia minora may extend only part way down the introitus but in some women will extend all the way down to and become part of the perineum or forchette. Superiorly the labia extend up to and around the clitoris forming the frenulum below and the prepuce above. Immediately on either side of the frenulum an extra slip of skin forms the paraclitoral fold.
The labia majora extend from the mons pubis above, on either side of the vaginal introitus, to the perineal area below. The outer sides of the labia are covered with pigmented skin, sebaceous glands, and after puberty, coarse hair. The inner sides are smooth and hairless, with some sweat glands. Beneath the skin layer, there is mostly fatty tissue with some ligaments, smooth muscle fibres, nerves and blood vessels.
The labia minora show a considerable degree of variation between individuals in shape, length, width and pigmentation
The labia majora show a considerable degree of variation between individuals in size, prominence, shape, turgor, width and pigmentation
The only comment that can be made with any certainty regarding the size and shape of the labia is that they are all very different and that the range of what can be considered to be ‘normal’ is very broad indeed. In many cases their appearance would not result in an ability to predict whether any individual woman would have any symptoms or be concerned about how they look.
They can become distorted by an increase in glandular cells resulting in small cyst formation, hypertrophy (thickening of the tissue) resulting from friction as well as hyperpigmentation (becoming darker, usually at the edges) from a combination of frictional and hormonal forces.
Indications for labial reduction
Labia minora reduction is the most commonly requested surgery on the female external genitalia. Although hidden from general view, the impact of surgical correction of thickened, elongated, uncomfortable and unsightly labia on the self confidence of the individual woman cannot be underestimated. Labial reduction surgery is a very individual decision, only one that you can make for yourself.
Some women report that they have had the impression of the labia minora being elongated before or around the time they reached puberty. Others will comment that they had noticed a gradual increase in the size of the labia minora over time. Within this group a significant proportion will have observed that pregnancy appeared to be a trigger factor for acceleration of this growth.
- Sometimes the increase in length and/or thickness will be isolated to one labia minora and this disproportion may reflect a function of normal growth differentials between the labia minora that began prior to puberty.
Clinical assessment prior to surgery
Inspection
Palpation
Traction
Visualising the area of concern is important and requires adequate exposure. Assessing the area of concern taking into account surrounding anatomy is important in planning management. Sometimes it is necessary for examination to take place with the patient standing to get a complete picture of the issue. Use of a mirror helps ensure that both patient and doctor are addressing the same subject.
Physical palpation of the tissues between the index finger and thumb gives an impression of any tenderness, tissue thickness, cyst formation and micro-tears in the tissue.
Traction (placing tension) on the tissues gives a better demonstration of the degree of tissue stretch and redundancy. Using fingers to pull on the tissue is usually done in the office with the patient awake. During surgery, better traction can be obtained using instruments which would be too painful during normal office examinations.
This is a patient being assessed prior to undergoing bilateral labia minora and majora reduction:
Traction of the labia majora reveals marked skin relaxation but no significant loss of fat tissue.
Traction of the labia minora unmasks the extent of elongation and allows for a more detailed examination of the labial tissues with the surrounding structures.
Labiaplasty can be achieved using a variety of instruments. These include the laser, diathermy, knife or scissors. Use of the knife in labial surgery is avoided in my practice. Typically I will use diathermy or laser energy, both of which I believe to be associated with less blood loss, report of less pain after surgery and are both tools that can be used with precision. Occasionally I will use very fine scissors when operating around the paraclitoral folds.
In some surgeons hands a labia minora reducton can be completed within 15 minutes; the surgeon cutting off excess skin with knife or scissors and then closing the wound with interrupted stitches. The technique that I employ to reduce and refashion both labia minora takes an average of 60 minutes. If the prepuce or paraclitoral folds are also addressed the surgical time may increase by an extra 20-30 minutes.
This techique employs a cosmetic approach to achieve a functional result with meticulous attention to tissue handling, dissection and contouring. Commonly used techniques such as ‘Wedge resections,’ are, in my opinion, inferior as they are more likely to be associated with ongoing hyperpigmentation, hypertrophy, scarring, labial distortion and discomfort.
Most procedures involving the labia minora will be performed as day case surgery with the patient discharged home within 6 hours of surgery. Some patients who are undergoing labia majora reduction will be advised to stay in hospital overnight because of the risk of wound haematoma. These decisions are made between Dr and patient on a case by case basis.
My patients receive intravenous antibiotics at the time of surgery. Intravenous painkillers are also given at the time of surgery and these are continued in oral form after the patient leaves hospital.
I also recommend application of Bio-Oil or a skin hydrator such as hyaluronic acid to the wound as this appears to improve and accelerate the healing process. The appropriate time to start using this will be discussed with you.
Prior to surgery, patients will receive advice about wound management including strategies for washing and drying the labia, guidance on appropriate clothing and activities to avoid until the healing process is established or complete.
Most of the healing process takes place within the first 2 weeks (4 weeks for the majora), however complete resolution will take 6-8 weeks (3-4 months for the majora). The majority of women will return to work within 2-4 days (not less than 7 days for the majora) after surgery.
For what can be considered to be a very sensitive area, the overall level of discomfort is low and mostly resolved within the first week of surgery. Typically, my patients report that they have an awareness of having had surgery and an increased sensitivity of the area rather than specific discomfort.
These symptoms are no longer present 6-8 weeks after surgery and one would anticipate any discomfort associated with an enlarged/elongated labia to have resolved.
Some women are concerned that labial reduction may somehow impact adversely on their sensation during intercourse. This is not the case. The labia are filled with pain receptors that are stimulated by stretching, tearing, rubbing and pinching.
They do not contain any receptors that convey pleasurable responses on any kind of manipulation. Labial reduction surgery, when done appropriately, will reduce in-folding, stretching, tears and rubbing.
All labial tissue removed at the time of labiaplasty is sent for histological analysis
Usually, the only findings are those consistent with chronic irritation but rarely, more significant findings are made that influence patient followup
Labiaplasty case histories
1
Folded labia minora still look prominent and irregular
Left labia minora similar to right
Hyperpigmentation Hypertrophy Cystic
Close examination of right labia minora – very elongated
Histology
Low grade spongiotic vulvitis with developing lichen simplex chronicus.
Labial edges chaffed through friction
Infraclitoral bilateral labia minora reduction
Patient 3 months post surgery
2
Right labia minora much longer than the left and the principle cause of irritation
Immediate post surgery result; the patient opted to have a bilateral labia minora reduction because she had noticed that the left side had also begun to elongate as well as for aesthetic considerations
3
Both of these patients have isolated hyperpigmented lesions on the inner aspect of the right labia minora. These lesions are always treated with suspicion as there is a risk that they might represent a melanoma. The lesion on the right looks and feels more suspicious as it is raised and has a rough edge; furthermore the patient noticed that is had been growing rapidly
Histology
Fortunately, both lesions were described as heavily pigmented benign compound melanocytic naevus. This is a benign lesion with no cancerous potential
4
Complex reduction.
- Elongated infraclitoral labia minora
- Prominent paraclitoral folds
- Bifolds on prepuce
- Prominent infraclitoral folds
- Extension into forchette
Immediately after complex reconstruction and reduction of prepuce, paraclitoral folds, labia minora and perineum
3 weeks after complex reconstruction and reduction of prepuce, paraclitoral folds, labia minora and perineum
5
This patient complained of vulval irritation when wearing jeans and tight clothing. During intercourse she suffered from discomfort at the bottom part of the entrance to vagina
Detailed examination reveals hyperpigmentation and hypertrophy. The area of greatest elongation is the continuation of the labia minora around the perineum. It is this area that caused discomfort during intercourse due to infolding
6
Getting a good result in labia majora reduction can be every bit as challenging as labia minora reduction but there are significant differences in anatomy, surgery, blood supply, recovery and tissue response. The surgical skill required for each is quite different and requires a combination of patience, experience and artistry
Intra-operative: right side complete, left side dissection complete and closure about to commence
View from above at the end of surgery confirms adequate tissue reduction and symmetry
Wound at 6 week review. Mild residual swelling is typical
7
Enlargement of the labia majora is commonly associated with prominence of the mons pubis as their connective tissue and fat constituents are similar and anatomically they are confluent. In this patient, there was isolated labia majora with minimal extension into the mons pubis. This finding is much less common
Immediately after reduction of the labia majora
3 months after reduction of the labia majora
8
Complex genital reconstructive surgery
In some, fortunately uncommon, cases, the ideal of restoring function and maintaining normal anatomy poses a challenge even in a multidisciplinary setting
Case background:
- Vaginal births with trauma to vaginal entrance via episiotomy & tears.
- Scarring and tightness of vaginal entrance resulted in pain and subsequent inability to have intercourse.
- Corrective surgery on 2 separate occasions by her obstetrician using a Fenton’s procedure technique.
- Ongoing tightness, scarring and pain.
- Referred by her obstetrician to a plastic surgeon.
- Plastic surgeon carried out a Wee procedure. This is a neurovascular pudendal thigh flap.
- Patient subsequently able to engage in intercourse.
- Patient became concerned that because the entrance was wider, she had reduced sensation during intercourse.
- She was also bothered that her genitalia looked abnormal.
- The plastic surgeon referred the patient to Dr Onuma.
- Dr Onuma carried out a complex genital reconstruction involving bilateral minora & majora reduction/refashioning, perineal body reconstruction and a modified plastic repair of the forchette.
- The patient was able to resume intercourse without discomfort, with improved sensation and was much happier that the external genital did not look grossly abnormal.
Patient prior to surgery with Dr Onuma
Surgical wounds immediate post surgery
Progress as at 6 weeks post surgery
9
Prepuce and paraclitoral fold reduction
The upper parts of the labia minora represent the greatest technical challenge with regards to surgery, and when one examines the anatomy, the reasons become clear. The clitoris is bounded laterally by the paraclitoral folds, above by the prepuce and below by the frenulum. These can be prominent and any attempt to refashion them must be tempered by caution and guided by experience.
The structures most at risk of injury are the body of the clitoris and the clitoral nerves and vessels. The distance between the body of the clitoris and the excess skin of the prepuce and frenulum can be measured in milimetres and, as such, a careless or ill considered movement with the surgical cutting tool could potentially result in amputation or injury of the clitoris, its’ nerve or blood supply.
The junctional anatomy of the prepuce, frenulum and paraclitoral folds is complex. Refashioning to provide a smooth, aesthetic, scar free result following surgical reduction is an intricate, complex exercise. A three-way junctional repair is at increased risk of wound breakdown and may require re-enforcing sutures to reduce this risk.
This patient had undergone a previous bilateral labiaplasty at another clinic. She had been bothered by the prominence of the prepuce but felt disappointed that this had not been addressed at the time of surgery. Once the inferior clitoral aspects of her labia minora had been corrected she reported becoming increasingly aware of and bothered by the prominence of the prepuce
To achieve the desired outcome, the prepuce has had to be reduced and simultaneously elevated. 6 weeks after surgery, the patient no longer suffers from discomfort and is pleased with the absence of bulge above the clitoris. The midline scar is about 90% healed and will fade even further over the next 3 months
Reduction of the prepuce is a specifically acquired skill and many surgeons who perform labia minora reduction will avoid operating on this area. Hoodectomy is a variation of prepuce reduction. The aim of this procedure is to remove some of the epithelial tissue covering the clitoris.
The terms can and are often used interchangeably. I prefer to use the term ‘hoodectomy‘ for circumstances in which the intent is to reduce the cover of the clitoris in order to make it more accessible for manipulation.
Although technically challenging, the option of prepuce and paraclitoral surgery needs to be considered very carefully. Why? Because reduction of the labia minora can, in some cases, be achieved successfully only to result in the prepuce and paraclitoral areas appearing more prominent.
Risks associated with labiaplasty
General
Specific
Dissatisfaction with the outcome of surgery can be very distressing for all concerned. It is important that you have clear and realistic expectations and your doctor will help you formulate this.
The most serious risk of labial minora reduction is clitoral injury. This is a very rare event and has never happened to a patient under the care of Dr Onuma.
- Bruising (common).
- Haematoma (less common).
- Wound dehiscence.
- Prolonged healing process.
The most common risks of surgery (<1%) are those seen with any type of surgical intervention:
- Anaesthetic complications.
- Bleeding.
- Haematoma.
- Infection.
- Scar tissue.
For some women, the labia minora mask the spraying of urine as it comes out of the urethra. This is because they physically obstruct the natural trajectory of the urine flow. Thus, if the labia are reduced in these women, they may well report the ‘new’ symptom of urine spraying. This situation is not a result of surgery to the labia and any attempt to correct it would require surgery to the paraurethral area. **If in doubt, check what happens when you empty your bladder by parting the labia as you urinate. Do this prior to surgery and if in doubt discuss with your surgeon. If you do spray, and you think that exposure of this through labial reduction may be bothersome to you, then you may need to reconsider your request for labia minora reduction surgery.
