Edge Labiaplasty with Clitoral Hood Reduction: Pitfalls and Pearls

INTRODUCTION

Labiaplasty is an increasingly popular procedure for addressing cosmetic and functional issues of the vulva.¹ As the demand for labiaplasty continues to rise, plastic surgeons have an obligation to improve their surgical techniques to enhance patient outcomes.

The edge labiaplasty with clitoral hood reduction (hereafter LCR) has relatively few complications. Clitoral hood reduction frequently accompanies the labiaplasty procedure to bring aesthetic balance to the vulva.² The LCR has a low rate of revision and is relatively straightforward to perform.³ Healing is rapid and results in a low incidence of wound dehiscence. When present, separations are mild and self-limiting. The resulting labia are thin and smooth, with even contours. The scars are inconspicuous. The risk of dorsal clitoral nerve damage is minimal, and loss of sensation has not been encountered. Consequently, the LCR is the corresponding author’s preferred surgical approach for all labiaplasty procedures.³

This article outlines the pitfalls and pearls of the LCR (Table 1).

Table 1.

Clinical and Surgical Pearls and Pitfalls of Edge Labiaplasty with Clitoral Hood Reduction

Clinical and Surgical Pearls	Pitfall/Outcome
Observe and discuss the implications of a large or long clitoris, or a wide gap between the labia majora	A simple cleft outcome for the labia majora is not always possible
Inquire about a patient’s history/frequency of yeast infections	Postoperative antifungal medication should be taken routinely in people with chronic, recurrent yeast infections
Avoid postoperative antibiotics and use baby shampoo to prep the vulva	Antibiotics and antibacterial skin preparations (eg, betadine) can result in yeast infections
Leave a 1-cm bridge over the dorsal clitoral hood	This avoids over-exposure of the clitoral body, which can lead to persistent sensitivity
Carefully incise around the clitoral frenulum	A sharp right-angle resection may cause neuroma formation at the clitoral frenulum. This is more likely when the native frenulum takeoff angle is more acute
Identify and cauterize the posterior labial arteries	Failure to do so will lead to postoperative hematoma formation
Running subcuticular sutures improve postoperative aesthetic outcomes	Simple running sutures will result in track marks, channels, ridges, and sinuses due to swelling and strangulation
The junction between the hood and minora excisions can present technical challenges	Debulk the submucosa at the junction of the hood and labia ellipses and place a key suture at the offset-Y to facilitate alignment and closure
The labia minora must not be pulled when resecting, and should not be cut straight, especially with scissors	A tension or straight cut will result in a scalloped, over-resected, concave central curve, the inverse of the desired ogee curve, or convex S-curve

TECHNIQUE

The patient is placed in lithotomy position, and a mild skin preparation is used. The vast majority of patients (>95%) choose local anesthesia and are met with only slight discomfort. Excessive draping is avoided in favor of sterile towels for this clean-contaminated procedure.

Clitoral Hood Reduction

Two ellipses, one on each side of the clitoral hood, are marked. The proximal points of the ellipses begin at the interlabial sulci cephalad and end distally at the tip of the labia minora. These ellipses will enclose the excess folds of hood tissue. Ensure that a 1-cm bridge of skin across the central clitoral hood is preserved. This protects critical lymphatics and the dorsal nerve of the clitoris.

After marking, local anesthesia is slowly infiltrated, beginning at the most prominent tip of the labia minora and extending gradually up to the apex of the interlabial sulci.

With a 15-blade, a superficial incision should be made to score these markings. Starting inferiorly, dissection should proceed in the submucosal plane with blunt-tipped scissors. This allows entry into the submucosal space and minimizes injury to superficial nerves and vessels. The hood excess can then easily be reflected off of the vulva with a Colorado needle.

A single alignment stitch using a 5-0 Monocryl on a tapered RB-1 needle (Ethicon, N.J.) is placed at the midpoint of the ellipse. An assessment should then be performed to ensure that the glans clitoris is mostly covered. If hood retraction and clitoris exposure seem likely, central tissues should be repositioned caudally. This can be avoided proactively by smaller and more conservative hood ellipses. Conversely, if the glans clitoris is overly covered, the central elements of the prepuce should be advanced cephalad and/or the ellipse may be widened.

Labiaplasty

Sweeping curved “C” markings are made on both labia minora. The apex of the superficial incision should start at the end of the clitoral frenulum, taking care to avoid the glans clitoris and ensure the frenulum is not cut at a right angle. Colorado needle dissection proceeds through the medial labial surface into the submucosal layer. The posterior labial artery and small branches of the perineal artery must be identified and cauterized, as failure to do so will result in a postoperative hematoma. These vessels are easily identified under loupe magnification at the 3- and 9-o’clock portions of the vaginal vestibule.

After hemostasis is achieved, the lateral mucosal surfaces of the labia are evaluated for excision. Greenberg PAR scissors can be used to excise the lateral surface of the labia minora, making sure to align it with the sweep of the medial mucosal surface. A matching sweeping curve of this incision will create a desirable ogee curve of the labia minora. A failure to do so will result in a scalloped and over-resected central portion, especially common if the labia are pulled and cut. A running subcuticular closure can be completed with a 5-0 Monocryl and Olsen-Hegar needle driver for self-sufficiency. A subcuticular closure is preferred over a simple running stitch, as the latter causes strangulation points.

There is a key junction at an offset-Y location where the hood excision meets the labia excision. This can be likened to the T-junction of a breast reduction. An additional suture should be placed here for alignment before subcuticular closure.

Of note, the hood tissue may be especially bulky in this offset-Y location. The only way to smooth out this area is by elevating the medial hood element and excising the underlying submucosal tissue. In patients with very prominent hood tissues, this advanced maneuver may be required. Although this step is not requisite, omitting it can result in a “puffy” appearing central clitoral hood element. [See Video (online), which displays a time-lapse LCR with narration of key points by the corresponding author.]

Video 1. This video displays a time-lapse LCR with narration of key points by corresponding author.

Download video file ^{(95.3MB, mp4)}

POSTOPERATIVE MANAGEMENT AND OUTCOMES

Pain is managed conservatively with ice, Tylenol with Codeine, and bed rest, particularly emphasized for the first 72 hours postoperatively.

Postoperative edema is common and variable. A key distinction must be made between swelling and hematoma. Unilateral and sudden pain with rapid expansion should alert the surgeon to a hematoma. These require evacuation under anesthesia. Upon opening the incision and clearing the clot, the surgeon will invariably and easily locate pulsatile bleeding from the posterior labial artery.

Wound dehiscence, especially at the offset-Y, can rarely occur. Early revisions should not be attempted owing to friability of the tissues. If there are late cosmetic concerns, these can be addressed at the 6-month mark.

Sensation changes have not been encountered, nor have problems with orgasm or dyspareunia. Satisfaction after this procedure is uniformly high. Patients report increased confidence, decreased self-consciousness, elimination of physical discomfort, aesthetic satisfaction (Fig. 1), and improved psychological well-being after the LCR.^4,5

Fig. 1.

Before and after LCR standing (A, B) and in lithotomy (C, D) at 6 weeks postoperatively.

CONCLUSIONS

The LCR is a straightforward, safe, and reproducible option for patients who desire aesthetic and/or functional changes to their vulva. This surgical technique allows patients to achieve a highly satisfactory outcome with relatively few complications.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.