Labia minora hypertrophy: causes, impact on women’s health, and treatment options

Lymphatic Pathways on Indocyanine Green Lymphography in Patients with Labia Minora Hypertrophy

BACKGROUND

Labia minora hypertrophy (LH) is a growing aesthetic concern, yet its etiology and local lymphatic anatomy remain unclear. This study aimed to use indocyanine green (ICG) lymphography to investigate evidence of lymphedema in LH and clarify the anatomy of lymph vessels from the labia minora.

METHODS

Thirty-five patients with LH underwent preoperative ICG lymphography of their bilateral labia minora. The study reviewed demographic, ICG imaging, and measurement data to identify the characteristics of the superficial lymphatic anatomy in the labia minora.

RESULTS

The ICG lymphography findings revealed that 97.1% of the observed patterns were linear, and 2.9% were dermal backflow patterns. Further analysis of the linear patterns revealed the presence of 3 main superficial pathways originating from the labia minora and connecting to the labia majora and clitoral hood. These pathways were identified as the superior, median, and inferior channels. Based on the observed lymphatic mapping in the labia minora, 3 types were classified: type 1 (superior and inferior channels) accounted for 75.0% (51 sides), type 2 (median and inferior channels) accounted for 8.8% (6 sides), and type 3 (superior, median, and inferior channels) accounted for 16.2% (11 sides).

CONCLUSIONS

The study demonstrates that ICG lymphography enables clear visualization of superficial lymph flow from the labia minora. It also suggests that lymphedema is not a common pathologic feature of LH. Understanding the lymphatic anatomy of the labia minora can provide valuable guidance for surgical interventions involving the female external genitalia.

Labia minora hypertrophy: pathologizing diversity?

INTRODUCTION

Labia minora hypertrophy can be characterized by the labial tissue extending beyond the labia majora; however, the exact definition of hypertrophy is a matter of debate. While the prevalence of labia hypertrophy is very common among women, taboo/controversial attitudes and surgical interventions still dominate. The recognition and study of labia minora hypertrophy will increase our knowledge of this underrepresented anatomic diversity.

OBJECTIVES

To provide a report of the current literature on labia hypertrophy and discuss the definition, etiology, attitudes, management, and medicalization surrounding labia minora hypertrophy and the implications.

METHODS

Comprehensive review of literature pertaining to labia minora hypertrophy.

RESULTS

Labia minora appearance and measurements vary extensively, and hypertrophy is extremely prevalent in the population and largely nonpathologic. There remains a lack of standardized criteria to define labia hypertrophy. Attitudes surrounding labia hypertrophy differ globally, but in Western nations the overwhelming sentiment toward labia hypertrophy has largely been medicalized.

CONCLUSION

Negative attitudes and unnecessary medicalization of nonpathologic instances of labia hypertrophy is unjustifiable and comes with potential risks. There remains an impending need to demedicalize nonpathologic elongated labia, educate the public on diverse genital appearance, and improve understanding of the long-term outcomes and risks of genital cosmetic surgery.

Reconstructive and Aesthetic Surgeries on the Female Genitalia. Guideline of the DGGG, DGPRÄC, OEGGG and SGGG (S2k-Level, AWMF Registry No. 009/019, May 2022)

Aim This official guideline was coordinated and published by the German Society for Gynaecology and Obstetrics (DGGG), the German Society for Plastic, Reconstructive and Aesthetic Surgery (DGPRÄC), the Austrian Society for Gynaecology and Obstetrics (OEGGG), and the Swiss Society for Gynaecology and Obstetrics (SGGG). The guideline aims to provide a consensus-based overview of reconstructive and aesthetic surgeries on female genitalia based on an evaluation of the relevant literature. Methods This S2k-guideline was developed by representative members from different medical professions on behalf of the guidelines commission of the DGGG, DGPRÄC, OEGGG and SGGG using a structured consensus process. Recommendations Statements and recommendations on the epidemiology, aetiology, classification, symptoms, diagnosis, and treatment of acquired changes of the external genitalia are presented and special situations are discussed.

Women's aesthetic perceptions of the genitalia and their association with anatomical measurements

BACKGROUND

The purpose of this study is to determine women's perceptions of the vulva with the criteria defined in the literature for the ideal vulva and determine their relationship with anatomical measurements to determine the extent to which women's perceptions of normal align with our aesthetic standards of normality.

METHODS

First of all, a questionnaire was given to all participants. The items of the data collection form included personal information, obstetric and gynecological information, their perceptions of their external genitalia and any physical, sexual, psychological, and hygiene problems they experience. Then examination and measurements of the external genitalia were performed.

RESULTS

The majority of participants considered their genitalia normal (n = 101, 89.4%), while 12 participants (10.6%) considered them abnormal. Statistical analyses showed that women's perception of their genitalia as normal in appearance and size was associated with labia minora asymmetry (p = 0.023 and p = 0.006, respectively) and hyperpigmentation (p = 0.010 and p = 0.047, respectively) but not with labia minora measurements or protrusion (p > 0.05).

CONCLUSIONS

Although there is a tendency in the field of aesthetic surgery to define ideals and aesthetic standards for all parts of the body, our definitions of normality do not always coincide with those of the individual. The appearance of the genitalia is as personal as the face, and an individual's self-perception is more important than our ideal.

LEVEL IV

Evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Quantitative analysis of the labia minora morphology in 400 Chinese women: A new method for assessing the shape of the labia minora

Purpose

To investigate the shape of labia minora in Chinese adult women.

Methods

Women who visited the Genital Plastic Surgery Center from January 2021 to February 2022 were included and the vulvar regions were photographed. The shape of the labia minora was converted into quantifiable values [left side line segment 1-9 (L1-L9 values) and right side line segment 1-9 (R1-R9 values)]. The 400 enrolled patients were grouped by age, parity, and the types of vulvar surgeries they planned to undergo.

Results

After a graphic-to-digital and digital-to-graphic conversion, the simulated average image of the labia minora in Chinese adult women was constructed based on the mean values of L1-L9 and R1-R9. Comparing the values of Ln and Rn in the four age groups revealed that the mean values of Ln and Rn gradually decreased with age, but only two subgroups showed statistically significant differences (P-value <0.05). When the patients were stratified according to the number of births and whether labiaplasty was planned to perform, there were no significant differences among all groups (P-value >0.05).

Conclusion

To measure and evaluate the labia minora, a new assessing method was used. It is an innovative attempt to transform the simple rough description of the shape of the labia minora into more precise data reflecting the shape features. It allows the comparison of labia minora shape between individuals by comparing quantifiable values. Besides, the average shape of labia minora in Chinese adult women was provided visually. Factors including age, parity, and whether the patient planned to undergo labiaplasty were not significantly associated with the shape of the labia minora.

Trilobal Methods for Composite Reduction Labiaplasty

BACKGROUND

It is difficult to plan a simple and effective surgical strategy for patients with horizontal and vertical redundant tissue of the labia minora and clitoral hood redundancy. A single edge resection or wedge resection labiaplasty with clitoral hood reduction that simultaneously resolves these three issues has yet to be reported. This study investigated the clinical effects and safety of trilobal labiaplasty via a composite incision.

METHODS

The single-center, retrospective, observational study included data from patients with hypertrophy of the labia minora and clitoral hood who underwent trilobal labiaplasty.

RESULTS

Altogether, 136 patients (average age: 31.6 ± 8.82 years; range: 21-53 years; 224 sides) sought surgery for aesthetic (39/136, 28.7%), functional (17/136, 12.5%), or both reasons (80/136, 58.8%). Overall, 134 patients (134/136, 98.5%) were followed up for 3 months. No serious complications or malformations occurred. Three patients (2.2%) underwent secondary repair surgery due to incomplete bilateral symmetry, 122 (91.0%) scored ≥ 21 points on the Female Genital Self-Image Scale, 107 (91.5%) were satisfied with the cosmetic outcomes, and 93 (95.9%) were satisfied with the functional improvement.

CONCLUSIONS

Trilobal labiaplasty performed via a composite incision using edge and wedge labiaplasty to adjust horizontal and vertical hypertrophy of the labia minora and remove lateral folds of the clitoris is a safe and effective method to improve the appearance and rearrange the position of the clitoral hood and clitoral frenulum while preserving the fine structure of the surrounding tissue. This method results in few complications and high functional and aesthetic satisfaction rates.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A preliminary observational study on the vascular, nerve, and lymphatic anatomy and histology of the labia minora from cadaveric and surgical samples

INTRODUCTION AND HYPOTHESIS

To better understand details of the fine anatomy of the labia minora, present images of the vascular anatomy and characterize the nerve and lymphatic distribution of the labia minora.

METHODS

Two fixed and five fresh cadaveric specimens were perfused and dissected, and the vascular network was photographed. Labia minora samples, prepared from cadavers, and tissue resulting from labia reduction surgery underwent hematoxylin and eosin staining and S100 and D2-40 immunohistochemical staining.

RESULTS

Arteries emanated from the base to the edge of the labia minora, where there was a larger feeding artery, and the arteries were anastomosed. The veins formed anastomotic branches in the same direction as the edge of the labia minora. Arteries and veins that accessed the labia minora were successfully perfused at the same time with no obvious association. Sensory nerve endings were abundant, mostly larger with myelinated nerve trunks and Schwann cells in the central area with suggested neurovascular associations and smaller with no obvious aggregation at the edge. The medial area had 23.63 ± 11.82 nerves/view, the lateral area 21.30 ± 11.49 nerves/view (P > 0.05). The thickest nerve bundle was 3.16 ± 1.41 mm from the medial epidermis and 3.13 ± 1.47 mm from the lateral epidermis. Lymphatic vessels showed no obvious regional distribution. Labia minora were 21.77 ± 5.69 mm wide with 252.87 ± 63.01 lymphatic vessels at 3.67 ± 1.61/mm2 density. The shortest inner diameter of dilated lymphatic vessels was 161.09 ± 49.99 μm.

CONCLUSION

A larger feeding artery exists in the labia minora, which should be noticed in the pre-surgery design of labiaplasty. No difference was observed in the nerve distribution between the medial and lateral sides. Lymphedema might not be the cause of labial hypertrophy.

Do variations in labial anatomy have an effect on recurrent urinary tract infection?

INTRODUCTION AND HYPOTHESIS

Variations in labial anatomy may constitute a risk factor for vaginal pH increase and recurrent UTIs. Our objective in this study was to show the effects of variations in labial anatomy on vaginal pH and recurrent UTI.

METHODS

A total of 331 non-menopausal and sexually active patients between the ages of 18 and 50, meeting recurrent urinary infection criteria and not meeting exclusion criteria were included in the study in group 1, the infection group, and 440 patients without recurrent UTI were included in group 2, the control group. Vaginal pH values of the participants were measured. Labia minora were classified as labial anatomy based on the Banwell classification. Predisposing factors and demographic data were also questioned, measured, recorded, and compared.

RESULTS

A significant difference was detected in labial anatomy between groups 1 and 2 based on the Banwell classification. Banwell type 3 in group 1 (76%) and Banwell type 2 in group 2 (55%) were observed to be significantly higher. There was a significant difference in right and left vertical and horizontal dimensions of the labia minora between the two groups. It was also observed that the vaginal pH was significantly more alkaline in group 1 compared with group 2 (6.11 vs 4.48).

CONCLUSION

Although there are many causes of recurrent urinary tract infections, this study showed that vaginal pH imbalance and labia minora anatomy in the lower third prominence based on the Banwell classification (type 3) were among the most important causes. Thus, we think that the vaginal anatomy should be evaluated in recurrent UTI patients.

The First Experience of Using the Pedicled Labia Minora Flap for Urethral Lengthening in Transgender Men Undergoing Anterolateral Thigh and Superficial Circumflex Iliac Artery Perforator Flap Phalloplasty: A Multicenter Study on Clinical Outcomes

OBJECTIVE

To describe the novel surgical technique of urethral lengthening in anterolateral thigh and superficial circumflex iliac artery perforator flap phalloplasty with a pedicled labia minora flap (PLMF) and report on the clinical outcomes.

METHODS

Between March 2014 and August 2018, 16 transgender men underwent phalloplasty with a PLMF for urethral lengthening at the Amsterdam UMC (VU university), the Netherlands and the Belgrade University Hospital, Serbia. Patient demographics, surgical characteristics, neourethra characteristics, intra- and postoperative complications, pre-and postoperative voiding evaluation, and the length of hospital stay were retrospectively identified from chart reviews.

RESULTS

The mean neourethral length was 16.8 ± 2.3 cm, and the pars pendulans 11.7 ± 2.2 cm. The neomeatus was localized on top of the neophallus in 12 (75%) patients. No intraoperative complications occurred. Urethral fistula formation occurred in 4 (25%) patients and strictures in 6 (37.5%) patients. In 3 (18.7%) patients a (temporary) perineostomy had to be performed. Voiding from a standing position was possible in 9 (56.3%) patients.

CONCLUSION

The PLMF for urethral reconstruction, both pars fixa and pars pendulans, in phalloplasty is a feasible surgical technique in transgender men undergoing anterolateral thigh or superficial circumflex iliac artery perforator flap phalloplasty with sufficient labia minora tissue.

A Novel Technique for Mapping the Vascularity of Labia Minora Prior to Labiaplasty: Cold Light Illumination

Objective Aim of the study was to assess the feasibility of a novel technique to determine the vascularity of labia minora prior to labiaplasty.

Methods A cold light source employed in laparoscopic procedures was used to illuminate the outer surface of the labia minora as described in this prospective descriptive study.

Results Of the patients, 46.1% (n = 41) had upper third prominence, 36% (n = 32) had middle third prominence, and 18% (n = 16) had lower third prominence according to the Banwell classification of morphologies. Right labia minora width was 0 – 2 cm in 51.7% (n = 46), 2 – 4 cm in 47.2% (n = 42) and > 4 cm in 1.1% (n = 1) of cases. Left labia minora width was 0 – 2 cm in 52.8% (n = 47), 2 – 4 cm in 41.6% (n = 37) and > 4 cm in 5.6% (n = 5) of cases. The incidence of Anterior 2 and Posterior 1 vessels in the different morphologies were statistically significantly different (p = 0.007, p = 0.018). The Anterior 2 vessel was higher in the lower morphology group whereas the Posterior 1 vessel was higher in the upper morphology group. A central vessel was observed in 93.3% (n = 83) of patients in the left labium minus and the right labium minus. The incidence of the Posterior 1 vessel was significantly higher in the left labium minus than in the right labium minus (p = 0.021).

Discussion This novel technique to assess labial vascularity using a cold light source could be very useful to reduce dehiscence by avoiding excessive resection of highly vascularized tissue. Most units can easily access a cold light source, which can be used to assess labial vascularity prior to labiaplasty.

Labiaplasty: Indications and Predictors of Postoperative Sequelae in 451 Consecutive Cases

BACKGROUND

The increasing demand for labiaplasty is well recognized; however, the procedure remains contentious.

OBJECTIVES

We aim to provide a large-scale, up-to-date analysis of labiaplasty outcomes and factors influencing postoperative sequelae (POS).

METHODS

We analyzed a single-center, prospectively maintained database of females undergoing labiaplasty between 2002 and 2017. Demographic, procedural, and outcomes' data were retrieved. Binary logistic regressions were used to evaluate the odds of developing POS (revisional surgery and complications); presented as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Data for 451 consecutive patients were retrieved, ten of whom were <18 years of age. Overall, 86% were Caucasian, mean age was 32.6 years, and 11.8% were smokers. Concomitant labia majora reduction was performed in 7.3%, and clitoral hood reduction in 5.8%. There were 32 cases of POS (7.1%), while the complication rate was 3.8%. Comparing those with POS to those without, there were no differences in age (32.8 vs 29.9 years, P = 0.210), operative time (78.5 vs 80.6 minutes, P = 0.246), or comorbidities (P > 0.05 for all). On univariable analysis, increased odds of POS occurred with sexual dysfunction as an indication for surgery (OR 3.778, CI 1.682-8.483). On subgroup analysis of those ≥18 years, both smoking (2.576, CI 1.044-6.357) and sexual dysfunction as an indication (OR 4.022, CI 1.772-9.131) increased the odds of POS. On multivariable analysis of the subgroup, sexual dysfunction as an indication persisted in significance (OR 3.850, CI 1.683-8.807).

CONCLUSIONS

Results compare favorably with previously reported complication and revisional surgery rates. Smoking and sexual dysfunction may increase the risk of complications.

LEVEL OF EVIDENCE 2