Body Contouring Continuing Medical Education Article Aesthetic Surgery of Female External Genitalia Aesthetic Surgery Journal 2015, Vol 35(2) 165 177 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com DOI: 10.1093/asj/sju020 www.aestheticsurgeryjournal.com Lina Triana, MD; and Ana Maria Robledo, MD Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. Abstract Aesthetic surgery of the external genitalia in women encompasses many procedures and may address the labia minora, clitoral hood, labia majora, mons pubis, or vaginal opening. During the initial evaluation, the surgeon should consider all aspects of the external genitalia to develop an appropriate surgical plan. It may be necessary to perform 2 or more procedures during the same surgical session to achieve the desired aesthetic result. In this continuing medical education (CME) article, we review the literature and summarize the available cosmetic techniques for female external genitalia. Resection of the labia minora has been described in several peer-reviewed reports. We also discuss the procedures and modifications to direct resection, wedge resection, and deepithelialization of the labia minora. Aesthetic surgery of the clitoral hood may involve straight-line resection, extended wedge resection, or inverted V hoodoplasty. The mons pubis may be treated with mons pubis pexy, wedge resection, or lipomodeling. The labia majora can be managed with direct resection or lipomodeling, and hymenoplasty may be performed to correct a wide vaginal opening. Accepted for publication May 28, 2014. Learning Objectives The reader is presumed to have understanding of aesthetic surgical procedures. After studying this article, the participant should be able to: (1) Identify the 5 components of the external genitalia in women that are suitable for surgical modification. (2) Classify the patient s complaint. (3) Describe the most common techniques to address the external vagina appropriately. Physicians may earn 1 hour of AMA PRA Category 1 Credit by successfully completing the examination based on this article. American Society for Aesthetic Plastic Surgery (ASAPS) members and Aesthetic Surgery Journal (ASJ) subscribers can complete this CME examination online by logging on to the CME portion of ASJ s website (http://aes-cme. sagepub.com) and then searching for the examination by subject or publication date. The popularity of plastic surgery of female external genitalia has increased dramatically in recent years 1,2 in far greater proportion to that of cosmetic procedures overall. According to ASAPS, 3 the incidence of cosmetic procedures increased by 3.1% from 2011 to 2012, whereas vaginal rejuvenation procedures increased by >60% in the same period (from 2142 to 3521 procedures). Despite this growing popularity, knowledge about aesthetic surgery of female genitalia is lacking among patients and physicians. 4 The status of vaginal plastic surgery is similar to that of liposuction in the 1990s: many patients are eligible for surgery, but few are aware that the procedures exist. Those who know about vaginal plastic surgery may not be able to find a surgeon or facility, and some patients who desire this surgery often are too embarrassed to discuss it. Plastic surgeons may practice different approaches and techniques for female genital surgery 5 ; others may lack experience or have Dr Triana is a plastic surgeon in private practice in Cali, Colombia. Dr Robledo is a plastic surgeon in the Burned Patient Unit at the Hospital Universidad del Valle in Cali, Colombia. Corresponding Author: Dr Lina Triana, Calle 3 Oeste #34-19, San Fernando, Cali, Colombia. E-mail: linatriana@drlinatriana.com
166 Aesthetic Surgery Journal 35(2) misconceptions about patients who desire this surgery. Without sufficient surgeons skilled in these techniques, the increasing demand for surgery of the female external genitalia will be unmet. A woman usually seeks this type of aesthetic surgery to improve her comfort with her genitalia and her perception of her body, which are directly related to her sexual function. 6 The plastic surgeon who has mastered cosmetic procedures involving the genital area can educate patients on the best alternatives for their sexual well-being. In the present article, we review the existing scientific literature on this subject and emphasize that more research is warranted. ANATOMY The vulva and clitoris are anatomic structures of the female external genitalia (Figure 1). The vulva includes the mons pubis, labia majora, labia minora, vaginal vestibule, and bulb of the vestibule. The mons pubis is anterior to the pubic bone and contains a variable amount of fatty tissue. The labia majora are 2 cutaneous folds that extend posteriorly from the mons pubis, which are wider anteriorly and narrower posteriorly than the labia minora. The labia majora contain a variable and surgically modifiable amount of fatty tissue. The labia majora converge with the labia minora at the posterior commissure or fourchette. The labia minora are cutaneous folds located medial to the base of the labia majora that have much less subcutaneous tissue and are not precisely symmetric. 7 The anterior portion of the labium consists of the clitoral hood and frenulum. 8 The external opening of the urethra is located in the vaginal vestibule, 2.5 cm behind the glans clitoris and anterior to the vaginal opening. The bulb of the vestibule is a mass of erectile tissue positioned along the vaginal and urethral openings and in contact with the urogenital diaphragm through the bulbospongiosus. The clitoris is a sexual organ present only in females. The visible rounded portion of the clitoris is located near the anterior junction of the labia minora, above the openings of the urethra and the vagina. 9 The female clitoris is homologous to the male penis but does not contain the distal urethra. The clitoral body is approximately 2.5 cm long and is attached to the pubic bone by a suspensory ligament. The clitoral glans is a round mass covered by the clitoral hood, which corresponds to the convergence of the labia minora. Figure 1. Illustration of the female genitalia, with anatomic areas indicated: 1, labia majora; 2, labia minora; 3, mons pubis; 4, clitoral hood; 5, glans clitoris; 6, urethra; 7, vaginal opening.
Triana and Robledo 167 Table 1. Classification of Labial Hypertrophy Type The vasculature of the female external genitalia includes the anterior labial arteries, branches of the external pudendal arteries, the posterior labial arteries, and branches of the internal pudendal artery. The labial veins drain to the pudendal and femoral veins. The external genitalia are innervated anteriorly by the anterior labial nerves, which extend from the ilioinguinal nerve, and by the genital nerve, which extends from the genitofemoral nerve. The posterior pudendal branches innervate the external genitalia posteriorly. The bulb of the vestibule is innervated by perineal nerves, and the clitoris is innervated by the pelvic plexus, pudendal nerve, and dorsal clitoral nerve. EVALUATION The surgical consultation should begin with a patient-surgeon discussion of the patient s concerns and desired outcomes; this conversation should precede the examination. The patient s complaints could involve the pubis, labia majora, labia minora, clitoral hood, perineum, vaginal opening, or any combination of these. The surgeon also must determine whether the patient s concern is aesthetic or functional in nature, or both. Discomfort during intercourse, lack of sexual pleasure, issues with exercise or wearing certain clothing, or hygienic concerns could cause a patient to consider surgery of the external genitalia. 8,10 For instance, a patient with hypertrophy of the labia minora may experience poor hygiene, discomfort when wearing tight-fitting pants, and pain during intercourse due to friction and folding of the labia. 11 A patient with insufficient subcutaneous fat underlying the mons pubis may experience pain during intercourse along the pubic bone. CLASSIFICATION Length of Labium (cm) I <2 II 2-4 III 4-6 IV >6 Values represent the maximum length of each labium. Classification system developed by Felicio. 13 Initial findings during physical examination of the genital area should be applied toward an anatomic classification. No classification exists for deformities of the pubis and labia majora, but most authors categorize cases as hypertrophy owing to fat excess or as atrophy owing to weight loss or aging. 12 The labia minora may be classified according to the maximum length of each labium, as reported by Felicio (Table 1), 13 or by the amount of tissue protruding beyond the posterior fourchette or the labia majora, as described by Chang et al (Table 2). 14 The clitoral hood may be classified by the extent and thickness of its tissue, as proposed by Ostrzenski 15 (Table 3). Accurate Table 2. Classification of Labia Minora by Protrusion Beyond Labia Majora Class classification of the patient s concern enables the surgeon to select the most appropriate surgical procedures. SURGICAL TECHNIQUES Protrusion Characteristics 1 <2 cm protrusion beyond the fourchette, without extension beyond the labia majora 2 >2 cm protrusion beyond the fourchette, with extension beyond the labia majora 3 Protrusion as in class 2, and beyond the clitoris anteriorly 4 Protrusion as in class 3, and beyond the vagina to the perineum or anus Classification system developed by Chang et al. 14 Table 3. Classification of Clitoral Hood Abnormalities Description Type 1: occluded Type 2: hypertrophic-gaping Type 3: hypertrophic with subdermal asymmetry Classification system developed by Ostrzenski. 15 Aesthetic surgery of the female external genitalia encompasses numerous surgical procedures. In this CME article, each procedure is described in terms of the anatomic structures they manage. Vaginoplasty, perineoplasty, and vaginal tightening address the internal genitalia and are beyond the scope of this article. Reduction of the Labia Minora Anatomic Presentation The clitoris is buried under a partially or completely closed clitoral hood opening The clitoral hood skin is elongated or thick The thickness of the clitoral hood skin is uneven Women frequently give nonaesthetic reasons for seeking surgery to correct hypertrophy of the labia minora. This condition is associated with pain during intercourse, discomfort when exercising or wearing tight clothing, and concerns about hygiene. In a multicenter study by Goodman et al 16 of plastic surgery among women, functional issues were the most common reason for considering labiaplasty (75% of 258 patients), followed by aesthetic concerns and low self-esteem. Reduction of the labia minora has increased in popularity and is the most frequently performed vaginal procedure. In the United Kingdom, the number of procedures to reduce the labia minora increased from <400 in 1998/1999 to 1200 in 2007/2008. 8 Several techniques exist to reduce the labia minora. Direct excision (Figure 2) is performed most frequently; 17-19 it involves amputation of the labial tissue protruding through the labia majora and reapproximation of the edges. This technique creates a straight scar positioned along the labial edge and
168 Aesthetic Surgery Journal 35(2) Figure 2. (A) This 19-year-old woman presented with hypertrophy of the labia minora and clitoral hood. She underwent direct excision of the labia minora and longitudinal reduction of the clitoral hood. (B) Two years postoperatively. removes the labial border, which can darken with age and become aesthetically unpleasant. 20 However, direct excision may distort the labial edge and is not indicated for patients who wish to retain the labial border. Moreover, the linear scar may contract and cause tight introitus or tension in the posterior fourchette (Figure 3). The first modification to direct excision was developed by Maas and Hage 21 and involved a zigzag incision. With this approach, each labium is divided into 2 flaps, and excess tissue in each flap is resected in a W-plasty that mirrors that of the other flap. The creation of complementary incisions enables closure with 1 layer of absorbable sutures (Figure 4). Like the zigzag incision, the lazy S incision 7 is made to avoid potential contraction of a straight scar. With this technique, 1 labium is left slightly larger than the other to improve closure of the introitus. A wedge or V-shaped resection can be centered over the protuberant region of the labia minora (Figure 5) 22 to reduce the size of the labia while preserving the labial border. However, this resection pattern can create an abrupt color change in the labial border, and leaves a linear scar that can contract and distort the natural contour of the labium. To manage excess tissue at the clitoral hood, the wedge can be extended anteriorly, and a hockey stick shaped resection can be made (Figure 6). 18 Two modifications have been described to avoid linear contraction of the scar made by wedge resection. One modification adds 90 Z-plasties to each arm of the wedge, 23 and the other adds a horizontal wedge to each arm of the vertical wedge that can be angled according to the location of the excess tissue (ie, star modification; Figure 7). 8 Resection of the inferior wedge and reconstruction of the superior pedicle flap are indicated for patients with moderate to severe hypertrophy of the labia minora. To mark the tissue for resection, the middle portion of each labium is stretched inferiorly toward the posterior vaginal introitus. The resulting wedge of pinched tissue is resected. This technique, known as the pinch test, and can be applied to resections of several structures of the female genitalia. When the borders are reapproximated, the superior flap reconstructs the defect (Figure 8). 24 This approach preserves the free edge of the labium and leaves a scar in the posterior, more hidden aspect of the labia minora. However, a mild bulging deformity of the contour may result because the superior flap is wider than the posterior edge of the labium. Posterior wedge resection is a modification to inferior wedge resection and reconstruction of the superior flap. 20 With this procedure, more of the anterior labial border is preserved, and most of the tissue is resected from the middle of the labium. These modifications reduce tension and decrease the risk of a bulging deformity but leave a narrow anterior flap with a potentially reduced vascular supply (Figure 9). Deepithelialized reduction labiaplasty is indicated in cases of mild or moderate labial hypertrophy (types II or III; Table 1) and involves fusiform resection of the epidermis at the inner and outer sides of the labium (Figure 10). This technique reduces the lengths of the labia and preserves the border. Moreover, deepithelialization reduces the number of sebaceous glands, thereby reducing the outflow of vaginal secretions. 25,26 Bidimensional reduction of the labia minora is similar to deepithelialized reduction labiaplasty but includes a full-thickness inferior wedge resection (Figure 11). This modification enables treatment of severe hypertrophy. Reduction of the Clitoral Hood Excess tissue surrounding the clitoris may reduce sensitivity, impair sexual function, and appear aesthetically unpleasant. 27 Excess tissue at the clitoral hood must be identified preoperatively and excised during resection of the labia minora. Resection of the inferior wedge and reconstruction of the superior pedicle
Triana and Robledo 169 Figure 3. Direct excision of the labia minora, with amputation of the labial tissue protruding through the labia majora and reapproximation of the edges. Figure 4. The zigzag incision, a modification of direct excision. Excess tissue is resected in a W-plasty that mirrors the pattern of the other flap. Figure 5. Wedge, or V-shaped, resection positioned over the most protuberant region of the labia minora. Figure 6. Hockey-stick modification to wedge resection. The anterior modification manages clitoral hood excess. Figure 7. Star modification to wedge resection. Figure 8. Inferior wedge resection and superior flap reconstruction.
170 Aesthetic Surgery Journal 35(2) Figure 9. Full-thickness posterior wedge resection. Figure 10. Deepithelialized reduction labiaplasty, with fusiform resection of the epidermis over both sides of each labium. Figure 11. Bidimensional reduction of the labia minora, with full-thickness inferior wedge resection. Figure 12. Longitudinal resection of excess tissue at the clitoral hood, and reapproximation of the edges. flap can reduce the labia minora as well as the clitoral hood. Specifically, when the superior flap is pulled to reconstruct the inferior defect, the traction also pulls excess tissue at the clitoral hood and exposes the clitoris. Similarly, resection of an extended central wedge 18 reduces tissue at the clitoral hood by means of the anterior hockey stick shaped resection. These 2 techniques are applicable to patients with Ostrzenski 15 type 2 hypertrophicgaping deformities of the clitoral hood but cannot be performed in patients whose clitoral hood opening is occluded. Mild to moderate excess of the clitoral hood can be treated by longitudinal resection. 17 This approach involves amputation of the clitoral hood border and positions the scar in the skin-mucosa transition. To perform this procedure, the clitoral hood is lifted, and the excess skin is resected with scissors (Figure 12). Sufficient hood tissue must be retained to cover the clitoris, because permanent exposure of this structure can cause pain and discomfort while walking and sitting. Severely excessive tissue should not be treated by longitudinal resection because the resulting scar would be placed outside the mucosa, increasing its visibility and tendency to contract. Alternatively, excess tissue at the clitoral hood can be resected in a horseshoe design with the incision at the base of the hood (R. Kalra, personal communication, January 2012). This technique can be performed in patients who have severe tissue excess, but care must be taken to avoid overresection and exposure of the clitoris. The horseshoe resection may be extended beyond the limits of the clitoral hood to treat hypertrophy of the labia minora (Figure 13). Clitoral Hoodoplasty Patients with phimosis of the clitoral hood can experience impaired sexual function and sensitivity due to a buried clitoris and often have hygienic complaints such as odor and rash because fluids accumulate around the clitoris. 15 Rather than simple reduction, hoodoplasty is indicated in these patients to
Triana and Robledo 171 Figure 13. Horseshoe resection of excess tissue at the clitoral hood. (A) Dotted lines indicate the resection pattern. (B) Intraoperative view of the resected clitoral hood prior to reapproximation of the edges. restore the opening of the clitoral hood and separate the glans clitoris from the hood. In hydrodissection with reverse V-plasty, the glans clitoris and hood are separated by hydrodissection, and a V-shaped incision is made in the clitoral hood to resect the contracted part and correct the phimosis. 28 This modified V-plasty also can be applied to patients with excess tissue at the clitoral hood. For patients with asymmetric subdermal hypertrophy, subepithelial reduction 15 is recommended. This technique involves resection of hypertrophied subepithelial tissues to create a clitoral hood with symmetric thickness bilaterally. Augmentation of the Labia Majora The labia majora are the most visible structures of the vulva and account for much of the female genital aesthetic. The size of the labia majora can be surgically reduced or enlarged to achieve the desired aesthetic outcome, but reports of these procedures are limited. Patients who are thin or have undergone massive weight loss may complain of small labia majora that are aesthetically unpleasant and associated with pain during sexual intercourse. The labia may be augmented with fat injections. 7,29 Fat is harvested by liposuction through a 3-mm cannula, preferably from a site where liposuction has not been performed previously. Fat is collected into 5-mL syringes and is injected evenly into the labia majora, with 1.5-mm injection cannulae, until the desired size is achieved (Figure 14). Fat injections are technically less complex than other augmentation procedures and leave smaller scars. However, fat reabsorption may occur and may be variable and unpredictable. Reduction of the Labia Majora Overweight or obese patients may present with enlarged, aesthetically unpleasant labia majora that may be ptotic and resemble a small penis. If the source of the hypertrophy is fat rather than ptotic skin, liposuction may be performed 12,29 by means of 3-mm cannulae. This procedure is simple and involves minimal scarring. However, contour irregularities may arise with time, and existing ptosis may become more severe. If excess skin is the cause of labia majora hypertrophy, resection of skin and fatty tissue is recommended. 30 Longitudinal resection of skin and subcutaneous tissue with scar placement in the vulva-thigh crease 22 reduces the size of the labia without disturbing the labial edge (Figure 15). Markings are made in the crural crease, and the tissue to be resected is determined by the pinch test. Resection is parallel to the crural and vulvar creases. Subcutaneous fatty tissue also is resected, and the final scar is positioned in the crural crease. This method creates a scar in a high-tension area, increasing the likelihood of wound dehiscence and potentially opening the vaginal introitus. This latter complication also is associated with thigh reductions involving only a horizontal incision. 31 Excess skin and subcutaneous tissue also may be reduced by dermolipectomy of the longitudinal aspect of the labia. 32 In this procedure, the resection is marked 1.5 cm from the crural crease, and the amount of tissue to be resected is determined by the pinch test. Skin and fat are removed in the superficial planes. This technique usually positions the scar in the labial border, which may cause contraction and distortion of the labial edge. Alternatively, the final scar can be placed in the skin-mucosa transition, leaving it well concealed (Figure 16). The wedge-like resection 33 is similar to dermolipectomy except that it positions the final scar in the transition between the labia majora and labia minora, thus respecting the labial edge. The pinch test is performed to mark the excess skin to be resected. If the patient presents with deflation of the labia majora, the existing adipose tissue can be retained to supply fullness to the area. When performing wedge resection, the surgeon must be careful to leave enough mucosa so that the introitus is not widened and to place the scar in a location where pigment variations are not noticeable. Treatment of the Pubic Region Obese patients may present with an enlarged and ptotic mons pubis that creates an unpleasant appearance. 34 Liposuction is
172 Aesthetic Surgery Journal 35(2) Figure 14. (A) Atrophy of the labia majora. (B) Fat injection to improve labial contour. Figure 15. Resection of labia majora skin and subcutaneous tissue, with placement of scar in the vulva-thigh crease. Illustration indicates the amount of tissue that can be removed with this procedure. most commonly performed to decrease the size of the mons pubis. The surgeon should utilize 3-mm cannulae and proceed conservatively to avoid contour irregularities. Compared with traditional liposuction, ultrasound-assisted liposuction shrinks the skin more evenly and leaves a smoother contour. 34 Abdominoplasties pull the mons pubis upward because the skin is streched. 35,36 However, the effects of abdominoplasty on the mons pubis are temporary in obese patients and those who have undergone massive weight loss because the tissues are not attached to a fixed structure. To treat the pubic region effectively, it is important to predetermine whether the excess tissue is vertical, horizontal, or both. Vertically oriented excess tissue is more common and is resected as a horizontal wedge. This lifts the pubic area,
Triana and Robledo 173 Figure 16. (A, C) This 37-year-old woman presented with hypertrophy of the labia majora and underwent wedge resection. (B, D). Two years postoperatively. Note placement of the scar at the skin-mucosa transition. shortening the distance between the mons pubis and the umbilicus to the ideal 10 to 12 cm. When the patient also presents with horizontally oriented excess tissue, both horizontal and vertical wedges are resected to achieve a narrow and youthful appearance. 37 Mons pubis pexy usually is performed with abdominoplasty but may be performed alone in patients without tissue laxity. For this procedure, an ellipse-shaped resection is made above the pubic crease. The fascia of the rectus abdominis can be accessed through this incision (Figure 17). When the resection is complete, the pubic tissues are fixed at 2 or 3 points to the fascia of the rectus abdominis to prevent them from descending. 38,39 This surgical maneuver is essential to the success of the procedure. The wound is closed by standard methods. Hymenoplasty Hymenoplasty is performed to narrow the vaginal opening. 40 During the first vaginal penetration, the hymen usually is torn into several small fragments or hymenal caruncles. Hymenoplasty may be requested by individuals in societies where virginity is culturally expected or by those who are not sexually active but have experienced genital trauma. 41 Hymenoplasty generally is performed under local anesthesia with sedation. The patient is placed in the lithotomy position, and caruncles are identified under a magnifying lens. The margins of each caruncle are freshened, and the caruncles are sutured together with 2 layers of absorbable 5-0 single stitches (Figure 18). 42 The surgeon must preserve an appropriate vaginal opening to allow for passage of vaginal and menstrual fluids. 33 NONSURGICAL TREATMENTS Hyaluronic Acid Patients with irregularities of the mons pubis, labia minora, or labia majora may be treated by injections of hyaluronic acid. This filler is available as prefilled syringes and must be injected into the deep dermis or immediately below the dermis. Hyaluronic acid injections must be repeated every 6 to 12 months to maintain the aesthetic effects. 43
174 Aesthetic Surgery Journal 35(2) Figure 17. (A) Mons pubis pexy. Dotted lines indicate the resection pattern, and purple areas indicate the extent of dissection. (B) The pubis tissue is suspended to the fascia of the rectus abdominis. Figure 18. (A) Vaginal opening depicting hymenal caruncles. (B) Caruncles sutured together. OUTCOMES AND COMPLICATIONS Reduction of the Labia Minora Complications associated with techniques to reduce the labia minora include suture dehiscence, infection, and hematoma. 44 Some surgeons recommend administering prophylactic antibiotics to patients in warm climates to reduce the risk of infection. 45 The incidence of complications with labia minora reduction is <10%, 44 and most complications are minor. Hematomas often drain spontaneously, and mild wound dehiscence heals by secondary intention. 46 In rare cases, a major hematoma may develop that requires surgery. Hematoma is the primary reason for early reoperation, and late reoperations are due to asymmetry, aesthetic complaints, and a postoperatively disproportionate clitoris or labia. 47-49 Patient satisfaction, albeit subjective, ranges from 90% to 100%. 7,17,18 Patient satisfaction rates for the specific procedures reviewed in this CME article are similar. Deepithelialized reduction labiaplasty has the associated benefit of reducing vaginal secretions, which can be a source of hygienic concerns in some patients. The surgeon should choose wedge resection and deepithelialization 25,26 for patients who wish to preserve
Triana and Robledo 175 the labial border and should select amputation procedures for patients who desire replacement of the labial edge. 50 Hoodoplasty and Reduction of the Clitoral Hood Aesthetic procedures for the clitoral hood involve reduction in clitoral hood size and improvements to aesthetics and functionality, without creating permanent overexposure of the glans clitoris. 51 Clitoral hoodoplasty enables fluid drainage from the vagina and reduces hygienic issues related to phimosis, such as odor. However, these procedures have been described by few authors. In a cross-sectional study, Minto et al 52 noted diminished sexual pleasure and lack of clitoral sensitivity in patients with ambiguous genitalia who underwent clitoral reduction or clitorectomy during early childhood as part of the sexual assignment process. Surgeons who have performed clitoral hoodoplasty and clitoral hood reduction reported no surgical complications and indicated that the desired surgical outcomes were achieved. 42 However, long-term follow-up is lacking among the literature. Augmentation of the Labia Majora Augmentation of the labia majora is often requested to achieve fuller labia that appear more youthful and to avoid pain or discomfort during sexual intercourse. Fat injections produce the desired outcomes (R. Kalra, personal communication, January 2012), but integration of the fat graft is variable and may necessitate a second procedure. 29 Thighlifts involving a deepithelialized flap are associated with partial necrosis and retraction, which may require subsequent fat grafting. 53 Reduction of the Labia Majora Resections of the labia majora are made to rejuvenate the appearance of the vulva. Surgeons must exercise caution when performing techniques that leave a scar in the crural crease because the vaginal opening may be affected. Surgical procedures to address the labial border may cause distortion of the border and leave visible scars. Reported complications are similar to those of labia minora reduction. Treatment of the Pubic Region The 2 aesthetic considerations for the pubic region are fat and skin. Although liposuction reduces fat volume, it may create contour irregularities and loosen the skin if performed aggressively. 53 Skin resections rejuvenate the mons pubis, but unless the tissues are fixed to the rectus fascia, they are likely to descend with time. 54 Complications from these procedures are rare and include infection, hematoma, and suture dehiscence that could necessitate reintervention in severe cases. Hymenoplasty Hymenoplasty returns the vaginal introitus to a virgin-like state, and has been designated revirgination. The primary complication associated with hymenoplasty is hematoma 55 because the caruncles are highly vascularized structures. However, reports of this procedure are scarce. 56 Maximizing Successful Outcomes Individuals may regard numerous conditions of the female external genitalia 18 as deformities necessitating surgery. 57 Virtually all these conditions involve hypertrophy or atrophy of 1 or more genital structures. Several techniques have been described to address each structure specifically; 58,59 however, our experience suggests that the surgeon must address several genital structures simultaneously to achieve the most favorable outcomes. The surgeon should be aware of all available procedures for female genital surgery, regardless of which techniques he or she prefers. This knowledge is essential for surgical planning because patients may desire very different aesthetic outcomes. However, the choice of surgical approach is of secondary importance compared with the surgeon s initial evaluation, during which he or she must listen to the patient and ascertain her reason for considering genital surgery. The patient s concerns, in conjunction with the anatomic abnormality, must guide selection of the surgical procedures. This process is vital to ensuring patient satisfaction. CONCLUSIONS The demand for external genitalia surgery is increasing. Aesthetic plastic surgeons should master the bevy of techniques that enhance female genital structures in the effort to design the most appropriate surgical plan and achieve the patient s aesthetic goals. The external genitalia should be considered as a whole, rather than as isolated structures, and surgeons should reject the notion that vaginal plastic surgery is limited to excision of the labia minora. Because published reports on many of these techniques are scant, substantially more research is warranted. REFERENCES 1. 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