Dr Oseka Onuma
Labioplasty
Labia Minora Reduction (Labioplasty)
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, incomfortable 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.
Dr Onuma has internationally recognised expertise in labial reduction surgery. Patients travel to him from all areas of Australia, New Zealand and Asia for surgery with excellent outcomes and high levels of satisfaction.
Things That You Might Want to Know!
- Shape and Size
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The labia minora can be a variety of shapes and sizes (much like the breasts). Nevertheless there would appear to be a pervading impression amongst women that they should be very small and of equal length.
Since it would be fair to say that women rarely compare their external genitalia, one has to wonder how this impression has arisen. Women infrequently inspect their own genitalia and often have a poor understanding of the anatomical relationships of the various components. Does this impression arise from viewing 'soft' pornographic photograhps or videos? Possibly for some, but certainly not for all.
Generally, women who report that their externall genitalia look different to others have come to this conclusion because they have had the opportunity to make a direct comparision. Typically this may be in the shower or change room area as early as the school days and for some this may not occur until they begin to attend the gym as younger or older adults.
The only comment that can be made with any certainty regarding the size and shape of the labia minora is that they are all very different and that the range of what can be considered to be 'normal' is very broad indeed. A very long or very short labia minora would, thus, be considered to be a variant of normal and 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.
When examined carefully, it is clear that the labia minora are rarely of equal length (even though they may appear to be so on brief inspection), shape or diameter. Their relationship to the clitoris, particularly with the formation of the paraclitoral folds often differs with one side being more prominent than the other.
The labia minora have an abundant blood supply but little in the way of fat cells. 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.
- Hypertrophy after labial reduction surgery.
The process of labial hypertrophy can, and usually does, continue, even after labial reduction surgery. In most cases the rate of growth of cells is barely noticeable and as such most women who have surgery do not represent requesting further reduction. The majority of women who have further reduction surgery fall into one of 2 categories; those who have chosen to have a limited reduction so as to preserve greater than 5mm length of labia and those who have not had the paraclitoral folds or prepuce reduced during primary surgery. There is an even smaller group of women who have had primary paraclitoral fold reduction but due to ongoing frictional forces find that the paraclitoral area becomes bulky and uncomfortable again.
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Some women report that they have had the impression of the labia minora being elongated before they reached puberty, although most in this group would report that it was around the time of puberty that they became more aware of this. 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.
- Surgery to the Prepuce, Paraclitoral folds and Frenulum
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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 milimeteres 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 reduced this risk.
Reduction of the prepuce is a specifically acquired skill and many surgeons who perform labia mimora 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 challengiing, 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.
- Motivation for Labia Minora Reduction Surgery
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The motive for women requesting reduction of the labia minora falls into two categories; functional and cosmetic. In may cases the two will co-exist. Common complaints of functional disturbance of the labia minora include pain and discomfort associated with wearing tight fitting underwear and trousers, discomfort during activities such as cycling, horse riding and gym work and in-folding of the labia minora during intercourse or when attempting to insert a tampon.
Although many women would be hard pressed to identify various parts of their external genitalia, for a small group of women the request for labia minora reduction is purely for cosmetic reasons. They simply do not like the way their labia looks and can be quite apprehensive about this area being viewed by an otherwise intimate partner. Within this group there is a very small subset that appear to spend an extraordinary amount of time on self-inspection and may have multiple procedures on their labia and prepuce in an attempt to achieve a certain result. This result might be interpreted as a desire for an appearance that some would describe as pubescent with little in the way of a prepuce, clitoral fold, minimal labia minora and small labia majora. Surgery on this very small subset of women can sometimes be unsatisfactory in outcome for both patient and doctor due to unrealistic expectations.
A significant proportion of women seeking to undergo labia minora reduction have a functional issue and their interest in the aesthetics tends to be more apparent after surgery rather than before.
- Instruments used for Labioplasty
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Labioplasty can be achieved using a variety of instruments. These include the laser, diathermy, knife or scissors. Use of the knife in labial surgery is avoid 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 techiques employs a cosmetic approach to achieve a functonal 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.
- Practical Advice and Information
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Most labial surgical procedures will be performed as day case surgery, with the patient able to be discharged home within 6 hours of surgery. Post surgical management is as important as surgical technique. I provide my patients with 5-10 days of oral antibiotics to use following their discharge from hospital. This compliments the intraveous antibiotics given at the time of surgery. Intravenous painkillers given at the time of surgery are continued in oral form after the patient leaves hospital.
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, however complete resolution will take 6-8 weeks. The majority of women will return to work within 2-4 days 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.
- A Common Myth
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- 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.
- Risks of Surgery
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- The most common risks of surgery (<1%) are those seen with any type of surgical intervention; bleeding, infection and scarring. 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. It is pertinent to note that, 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 urinary tract and cannot be reversed. If in doubt, check what happens when you empty your bladder by parting the labia as you void (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.