An Algorithm for Labia Minora Reduction Based on a Review of Anatomical, Configurational, and Individual Considerations

Abstract

A variety of reduction labiaplasty techniques have been introduced to date, but no single technique will offer the optimal solution for every patient. Rather, the technique should be chosen based on anatomical, configurational, and technical considerations, as well as on patients' personal preferences regarded maintenance of the labial rim, maintenance of labial sensitivity, and prevention of iatrogenic thickening of the labium. We reviewed, defined, and assessed labial configurational variety, neurovascular supply, reduction techniques, and patient's preferences as the considerations relevant to the choice of labiaplasty technique. Based on this review, an algorithm was constructed that leads to a choice of reduction technique through five decisions to be made regarding (1) resection or (partial) retention of the labial free rim, (2) the measure of required labial width reduction, (3) labial vascular status, (4) prevention of iatrogenic labial thickening, and (5) preservation of labial sensibility. The choice of techniques includes edge trimming, central spindle form de-epithelialization or full-thickness resection, and three modifications of the wedge resection or de-epithelialization technique. These three modifications comprised a modified anterior resection or de-epithelialization combined with posterior flap transposition, a custom flask resection or de-epithelialization, and a modified posterior wedge resection or de-epithelialization combined with anterior flap transposition. Use of the five decisional steps and the inclusion of modifications of all three conventional reduction techniques offer an improved algorithm for the choice of labioplasty technique.

Keywords: algorithm; cosmetic surgery; female; review; vulva.

Fig. 1

The clinically relevant length for labiaplasty was defined as the measurement along the free rim of the minor labium from the frenulum division anteriorly (green arrows) to the point where the fourchette leaves the medial aspect of the major labium posteriorly (red arrows).

Fig. 2

A relative surplus of preputium (red arrow) is not to be confused with paralabial folds (both green arrows).

Fig. 3

In 1936, Michel Salmon recorded the anterior one-third of the minor labia to be perfused by a branch deriving from the external pudendal artery and the posterior two-thirds by small internal pudendal branches that run perpendicular to the labial long axis. The two systems anastomose to form an arcade along the labial free rim. Note that central arteries may bilaterally be observed running to the most protruding part of the labial free rim. (Reproduced by kind permission from G.I. Taylor and M.N. Tempest, editors. Michel Salmon's Arteries of the Skin. London, UK: Churchill Livingstone; 1988).

Fig. 4

Edge resection, wedge excision, and central de-epithelialization are the three principal techniques for minor labial reduction. (A) Edge resection or trimming involves the straightforward amputation of protuberant tissues. Note that it additionally reduces the labial free rim length. (B) Straight amputation has been modified to a running W-resection to ensure a more robust and natural appearing rim after reduction. (C) Wedge excision involves the resection of a triangular part of skin at both the lateral and medial aspect of the labium minus. Note that it may correct a surplus of labial free rim length but only partly corrects labial width. (D) The initially central wedge excision has been modified to the dorsal wedge excision and anterior flap technique. Note that this modification also lowers the labial width and that the resulting scar runs less conspicuously along the base of the labium minus. (E) Central de-epithelialization involves the partial skinning of the medial and lateral aspects of the labium from its introital base, respectively, the interlabial sulcus outward. It may also be executed as a full-thickness resection or fenestration . Note that this will not reduce the labium free rim length.

Fig. 5

Flowchart of the proposed algorithm for the choice of reduction labiaplasty technique.

Fig. 6

Artist impression of preoperative markings (left) and postoperative outcome (right) of each of the techniques included in the algorithm. The shaded area on the left side represents the part of the labia to be de-epithelialized or resected prior to: (A) Running W-resection of the labial rim; (B) Central de-epithelialization or fenestration. Note that this will not reduce the labium free rim length; (C) Modified anterior wedge de-epithelialization or resection combined with posterior flap transposition; (D) Posterior wedge de-epithelialization or resection combined with anterior flap transposition; (E) Custom flask de-epithelialization or full-thickness resection.