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Plastic surgery to change the shape and size of the labia minora is one form of labiaplasty. Labial reduction is requested by women who feel that their labia are too large.
Several techniques of labial reduction have been practiced over the past two decades. They began with edge resection which then evolved into wedge resection. This itself may be of several types. The most commonly practiced today is the central wedge resection which was popularized by Gary Alter in 1998.
The central wedge resection is aimed at removing a V-shaped piece of tissue with the apex pointing towards the labial edge, from the most prominent part of the labium which is being excised. This is done on both sides. The technique has been refined over time to allow a more cosmetically pleasing closure with minimal scarring or wound contracture, as well as to shape the clitoral hood and reduce the recovery period and risk of complications.
One disadvantage of the central wedge resection is that it requires more technical skill and is more time-consuming than the other older techniques, such as trimming of the edges of the labia. It also fails to completely eliminate the dark pigmentation seen at the labial edges in many women as a normal variant. The amount of skin that can be removed in this way is limited compared to edge resection.
This is more than counterbalanced by the improved morbidity and post-operative appearance. It preserves the natural transition zone between the labia and the clitoral hood. The scars are also better, being aligned towards the vertical labial edge, and less likely to be visible or to interfere with the anatomy of the vulva. It avoids the appearance of a large overhanging clitoral hood over a pair of barely visible labia and results in the edges of the labia as neater and not scalloped. Chronic post-operative pain is also less, and dyspareunia is unlikely.
The procedure is usually done under general anesthesia to avoid physical as well as psychological distress to the patient during the surgery. It could also, however, be performed under local anesthesia. The lines of the wedge are different on the outer and inner surfaces of the labia. After the marking of the wedge is done, it is resected and the required portion of the lateral clitoral hood is also removed through the same vertical external incision. For a very long hood a horizontal incision may be made across the clitoral skin. Various modifications of this procedure exist to allow clitoral repositioning if it is necessary. The rationale for combining excision of these two areas is that they belong to the same unit.
The marked skin is removed but only as much subcutaneous tissue as will ensure the labia are the desired size after healing. The presence of adequate tissue in this area is important to promote proper circulation and healing to a firmly closed scar. It is important to preserve peripheral vaginal sensation by not being too aggressive in the removal of tissue in the labial area.
After removing the wedge closure is done under magnification in several layers. If necessary in the surgeon’s judgment, the posterior vaginal lip is also released if it is too high to allow painless intercourse.
All steps are designed to minimize the risks of wound dehiscence, fistula formation and postoperative pain.
A more recent modification is the 90 degree Z-plasty which further improves the cosmetic appearance of the final result, leading to high patient satisfaction with the labial form after surgery.