The Safe Practice of Female Genital Plastic Surgery

Abstract

The purpose of this article is to guide surgeons in the safe practice of female genital plastic surgery when the number of such cases is steadily increasing. A careful review of salient things to look for in the patient's motivation, medical history, and physical examination can help the surgeon wisely choose best candidates. The anatomy is described, with particular attention given to the variations not generally described in textbooks or articles. Descriptions are included for labiaplasty, including clitoral hood reduction, majoraplasty, monsplasty, and perineoplasty with vaginoplasty. Reduction of anesthetic risks, deep venous thromboses, and pulmonary emboli are discussed, with special consideration for avoidance of nerve injury and compartment syndrome. Postoperative care of a variety of vulvovaginal procedures is discussed. Videos showing anatomic variations and surgical techniques of common female genital procedures with recommendations to reduce the complication rate are included in the article.

Fig. 1.

Systematic assessment of the vulval complex. Dividing the vulval complex into 6 areas allows careful evaluation. B, Careful attention should be paid to each of these areas: labia minora, clitoral complex, labial-clitoral interface (complex), labia majora, pubic area, and perineal area. The quality of the tissues, rugosity, pigmentation and asymmetries should be noted. Reproduced with permission from Hamori CA, Banwell PE, Alinsod R. eds. Female Cosmetic Genital Surgery. Concepts, Classification, and Techniques. New York: Thieme; 2017.

Fig. 2.

Anatomic variations seen in clinical practice. Labia minora vary in pigmentation, texture (rugose or smooth), thickness, symmetry, shape, projection, and symmetry. Above left, This patient has a double clitoral hood, with an upper fold and lower fold. In this case, the lateral fold merges onto the superior aspect of the labia minora. Above right, In this patient, the lateral clitoral hood merges with the medial labia minora. The labia minora merge superiorly with the medial labia majora. The clitoris is recessed, and clitoral hood projects more laterally than centrally. Below left, In this patient, the thick mucosa of the fourchette merges with the raphe over an expansive area. Below right, In this patient, the clitoral hood merges onto the medial labia minora, and the labia minora merge superiorly onto the medial labia majora. Reproduced with permission from Plast Reconstr Surg. 2020;146:451e–463e. 10.1097/PRS.0000000000007349.

Fig. 3.

The Banwell Classification. The labia minora are divided into three morphological types. Top left, center, and right, The most prominent point (width) of the labia may be seen in the upper third (Type I), middle third (Type II), or lower third (Type III). Example of Type I (lower left), Type II (lower center), and Example of Type III (lower, right). Reproduced with permission from Hamori CA, Banwell PE, Alinsod R. eds. Female Cosmetic Genital Surgery. Concepts, Classification, and Techniques. New York: Thieme; 2017.

Fig. 4.

Mapping of the labial arteries. On the y axis, emergence of the arteries found in every subject is noted. An arrow indicates the mean value of emergence for every artery as a distance from the posterior fourchette. The anterior artery is small, the central artery is dominant, and there are two posterior arteries. Reproduced with permission from Plast Reconstr Surg. 2015;136:167–178. doi: 10.1097/PRS.0000000000001394.

Fig. 5.

Vaginal laxity results from the trauma and stretching associated with pregnancy and vaginal delivery. The stretching can attenuate the tissues and separate the levator ani, bulbocavernosus, and superficial transverse perineal muscles, similar to diastasis of the rectus abdominis. Reproduced with permission from Plast Reconstr Surg. 2020;146(4):451e–463e. doi: 10.1097/PRS.0000000000007349.