Anatomy and Aesthetics of the Labia Minora: The Ideal Vulva?

Labiaplasty in Minors: Medicalizing Mutilation?

Labial hypertrophy, which lacks an accepted definition, is generally understood to refer to morphological and aesthetic characteristics of the labia believed to deviate from a perceived norm. Such ostensive deviation has the potential to affect many domains of a person's well-being, as does its surgical treatment, labiaplasty. Nearly 24,000 labiaplasty procedures were performed in the United States in 2022, representing a greater than three-fold increase since numbers were first reported in 2013. Nearly 20% of these procedures were performed on minors, and cases have been reported in children well before complete pubertal development or the age of personal consent. In this article, we explore the indications that are used to designate labiaplasty as "medically necessary" in minors, a status that, we argue, is required for such procedures to avoid fitting the definition of "medicalized FGM" (i.e., "female genital mutilation") according to the World Health Organization. As a part of this, we consider the particular ways in which outcomes are measured in this population. We shed light on persistent methodological shortcomings in the research on labiaplasty, discuss ethical and legal implications, and make recommendations to improve the relevance, reliability, and generalizability of future investigations into this increasingly common, controversial surgical procedure.

Full labia minora reconstruction with labia sharing flap: a case report

Full labia minora reconstruction can be necessary due to congenital malformation or genetic syndromes, but more often is required following oncologic excisions, or debridements after vulvar or perineal infections. It is important to note that full labia reconstruction can be needed after genital mutilation, or iatrogenic deformity after previous labia reduction procedure. A 37-year-old female patient, with vulvar necrotizing fasciitis after a marsupialization of the right Bartholin's gland, was referred to the Gynecology and Obstetrics unit. Three surgical debridements were performed, associated with prolonged antibiotic therapy, leading to a total loss of the right labia minora and the clitoris glans, in addition to minimal loss of labia majora. With a two-stage approach on the labia minora, the first procedure allowed to pull the left labia minora as a labia sharing flap, in order to join the remnant scar tissue on the right side, respecting the anterior and posterior leaflets. The second part was performed five weeks later, after autonomization of the new labia minora flap. Once the flap was divided, a perfectly vascularized right neo-labia minora was obtained. The flap healed uneventfully. The patient was asked to complete a questionnaire at six months, which confirmed an excellent aesthetic result with a like with like reconstruction. Eight months later, a final correction was performed to enhance the definitive aesthetic aspect with lipofilling of the right labia majora. Two techniques have been previously published with a two-stage cross-labial transposition flap, one using a top cut leading to a bottom pedicle and another using a bottom cut with an upper pedicle. We proceeded with a one-time edge resection, respecting the full vascular pedicle and transposed the full height of the labia minora. This technique revealed to be extremely effective, guaranteeing a reliable vascularization and decreasing the risk of tearing on the pedicle.

Examining the Morphology of External Genitalia in Iranian Women: A Labiagram-based Study in Iran and its Influence on Patients' Self-Satisfaction

BACKGROUND

This study aims to document a woman's external genitalia data in the form of a labiogram and investigate whether variations in the size of specific components of a woman's external genitalia can influence her overall satisfaction with the esthetic appearance of her genitalia.

METHODS

A cross-sectional observational study was carried out on a sample of 500 Iranian women. Socio-demographic information was collected for all participants, and they completed the Female Genital Self-Image Scale (FGSIS) questionnaire. Measurements of different external genitalia components were obtained for all participants.

RESULTS

The findings revealed that there was no significant association between the measurements of the external genitalia and age or BMI. However, a significant negative correlation was observed between the total score on the FGSIS and specific parameters related to the width of different sections of the labia minora. The correlations were as follows: left lower third (r = - 0.305), lower right third (r = - 0.302), left middle third (r = - 0.365), right middle third (r = - 0.435), left upper third (r = - 0.397), and right upper third (r = - 0.407) (P value< 0.001). Moreover, cutoff points of 1.95 cm on the left side and 1.90 cm on the right side were identified through analysis as thresholds for predicting dissatisfaction among women.

CONCLUSION

This study suggests that the width of the labia minora might influence certain women's motivation to undergo labiaplasty, a surgical procedure designed to modify the labia minora. To help women make informed decisions, it is crucial for those considering the procedure to have a comprehensive understanding of different labia minora types, potential benefits, and associated risks. By being well-informed, individuals can make choices that align with their personal preferences and priorities.

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 .

Simultaneous Surgery of the Clitoral Hood-Labia Minora Complex with the Central Neurovascular Pedicle Retained

BACKGROUND

Hypertrophy of the labia minora with clitoral hood redundancy always occurs simultaneously and should be considered in its entirety. This study investigated a new simultaneous procedure for the clitoral hood-labia minora complex (CLC) that retains the central neurovascular pedicle.

METHODS

This retrospective observational study, conducted between January 2021 and August 2022, included 29 patients with labia minora hypertrophy and clitoral hood redundancy who underwent a surgery wherein procedures on the CLC were performed simultaneously. A divisional design to separate the medial and lateral labia minora and to remove the skin and subcutaneous tissue asymmetrically, while retaining the central neurovascular pedicle and the natural margin of labia minora, was employed. Postoperatively, all patients were followed up via the Internet or at the outpatient clinic. The follow-up included observing postoperative outcomes and any complications and completing the satisfaction questionnaires.

RESULTS

All the patients who underwent surgery showed good wound healing without discomfort of thread friction. Postoperatively, the labia minora had a natural appearance and retained sexual sensitivity. The scarring on the surgical incision was not evident. Hematoma and evident bilateral asymmetry occurred in one patient each. The satisfaction rate within 14 days and after 3 months of surgery was 96.6% and 92.6%, respectively.

CONCLUSIONS

This method uses a hidden incision, to remove the hypertrophic tissue and retain the natural edge and shape of the labia minora. Qualitatively, the patients were highly satisfied. This method was safe, effective, and easy to implement.

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 .

[Psychiatric, socio-legal and perioperative aspects of vaginoplasty]

The number of scientific papers on gender-confirming surgeries as well as the surgeries themselves have increased by leaps and bounds in recent years. This leads to sometimes considerable waiting times for people seeking treatment. Social media and the internet do not always provide reliable and high-quality information. Therefore, it is necessary that both surgically and conservatively active urologists are familiar with topics regarding transgender persons. The establishment of structured training, the guarantee of minimum quality standards in the treatment of transgender persons and the further education and training of medical staff pose particular challenges. The German Society for Urology (DGU) and the German Society for Plastic, Reconstructive and Aesthetic Surgery (DGPRÄC) have already founded their own working groups on the surgical side, which coordinate their work. Under the auspices of the professional societies DGU and DGPRÄC, a guideline on surgical procedures for gender incongruence was developed under the umbrella of the AWMF ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften") which is currently being finalised. For a long time, the health care of transgender people has been moving in a field of tension between the right of self-determination of those seeking treatment, on the one hand, and the fear of making the wrong medical decisions, on the other. In contrast to most other conditions in urology, the goal of treatment is largely determined by the person seeking treatment and does not necessarily follow predetermined schedules or content. The treatment should primarily aim at reducing the individual's suffering and promoting quality of life.

"Normal vulva" based on the first national Labiagram design in adult Iranian women not seeking female genital cosmetic surgery: a pilot study

Background

Several studies have been published to present normal values of female genitalia in different age and racial groups.

Aim

The primary objective of our study was to measure the parameters of the external genitalia in adult Iranian women, record the data using the Labiagram system (the first national Labiagram design in Iran), and establish a preliminary database.

Methods

A descriptive study was conducted from March 2022 to December 2022, involving 220 nonpregnant adult women who presented to the gynecology clinic. Women who met the inclusion criteria for the study underwent a comprehensive examination of the external genitalia. The data collected during the examinations were recorded in electronic files and the Labiagram system.

Outcomes

The data showed the diversity of external genital parameters of nonpregnant adult Iranian women.

Results

In this descriptive study, the mean ± SD age of the participants was 51.5 ± 13.44 years, ranging from 15 to 84 years. A total of 192 women (87.3%) had a history of vaginal delivery. There was no statistically significant difference observed in the average measurements of the vulva among the 4 age groups (P < .05). The Pearson correlation coefficient test indicated a statistically weak correlation between body mass index and perineum length (r = 0.174, P = .010). Additionally, a weak correlation was found between body mass index and the width of the labia minora at the left-lower point (r = 0.143, P = .030) and the right-middle point (r = 0.146, P = .031). Furthermore, the results demonstrated that women with a history of vaginal delivery had a significantly longer introitus (49.3 vs 44.3 mm, P = .037), longer labia majora (91.3 vs 87.3 mm, P = .046), and longer labia minora (56.8 vs 50.9 mm, P = .008) when compared with women without prior labor experience.

Clinical Implications

The data will be used as a basis for future studies.

Strengths and Limitations

The use of simple tools for the measuring, data recording, and digital drawing of female external genital anatomy, along with privacy protection, is one of the strengths of this research. The weakness is the small sample size, which is the reason for piloting the Labiagram chart for more extensive studies.

Conclusion

Increasing age and the number of births had no statistically significant effect on the size of external genital parameters among Iranian women. Despite the considerable diversity in these parameters, it has not resulted in a significant demand among Iranian women for female cosmetic surgery.

[Vulvoplasty after gender-affirmating genital surgery]

Functional and aesthetic results after vaginoplasty in sexual reassignment surgery have improved in recent years. Improved surgical techniques, well-established expert teams and a growing demand for and interest in this type of surgery are some of the reasons for these results. However, there is a growing demand for genital cosmetic surgery, not only among cis women, but also among trans women. The main shortcomings in results are therefore presented and listed. The aesthetic revision surgery techniques specifically indicated are described. Labiaplasty and clitoridoplasty appear to be the two main requests for secondary surgery following trans vaginoplasty.

The Effect of Female Genital Cosmetic and Reconstructive Procedures on Body and Genital Self-Image: A Systematic Review and Meta-Analysis

Performance of female genital cosmetic and reconstructive procedures (FGCRP) has been increasing over past decades. Appearance and functional concerns are the most common reasons for seeking FGCRP. Poor body and genital self-image may contribute to the increase in demand for surgery. The aim of this systematic review is to explore outcomes of FGCRP in the domains of body and genital self-image. A systematic literature review of PubMed, Web of Science, Scopus, PsycINFO, Embase, and the Cochrane Library was conducted to identify articles that measured body and genital self-image in females after FGCRP. The authors identified 5 articles for a systematic review of body image and 8 studies for a systematic review of genital self-image. The most common procedure performed was labia minora labiaplasty. Instruments for body image evaluation were the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder and the Body Image Quality of Life Inventory. Genital image was assessed with the Female Genital Self-Image Scale and Genital Appearance Satisfaction (GAS) scale. Most of the studies indicated that FGCRP can improve both body image and genital self-image; meta-analysis revealed that FGCRP improved GAS scores by 17.96 (range: 0-33; P < .001). It appears that FGCRP leads to improvements in females' body and genital self-image. Inconsistencies in study design and measures, however, limit this conclusion. Future research should involve more rigorous study designs (for example randomized clinical trials with large sample sizes) for a more accurate assessment of FGCRP's consequences.

LEVEL OF EVIDENCE: 4

A Novel Hyaluronic Acid Filling Technique for Restoring Volume of the Labia Majora

Vulvar rejuvenation, which includes both functional and aesthetic aspects, has received a lot of attention in recent years. Despite the fact that surgical interventions have proven to be effective, the development of minimally invasive techniques for restoring volume and tissue function remains a top priority. This case study describes a novel method for vulvar volumization and collagen stimulation of the labia majora using a hyaluronic acid filling technique. The procedure begins with a meticulous assessment of each patient's anatomical characteristics and specific concerns, followed by hyaluronic acid retroinjections using a microcannula. The current article describes the use of this technique on a single patient and emphasizes its potential benefits in addressing various vulvar concerns, with a focus on minimal downtime and high patient satisfaction. The case report adds to the ongoing search for optimal vulvar rejuvenation strategies by providing valuable insights into the efficacy and utility of this novel approach.

Using Google Trends for Evaluation of Public Interest in Female Genital Aesthetic Procedures

BACKGROUND

Genital aesthetics is a treatment that is increasing in popularity.

OBJECTIVE

To clarify public interest in genital aesthetic procedures among women between 2004 and 2022.

MATERIALS AND METHODS

In total, 12 terms including labiaplasty, vaginoplasty, perineoplasty, laser vaginal rejuvenation, labia cosmetic surgery, vaginal cosmetic surgery, vaginal tightening, genital bleaching, hymenoplasty, clitoroplasty, labiaplasty cost, and vaginal laser were reviewed. To evaluate public attention to female genital aesthetic procedures between January 1, 2004, and January 1, 2022, three 6-year periods were compared about the abovementioned 12 terms.

RESULTS

Public attention to labiaplasty and hymenoplasty was significantly higher in 2010 to 2016 than in 2004 to 2010 and 2016 to 2022. Vaginoplasty, laser vaginal rejuvenation, and labia cosmetic surgery terms were researched significantly less in 2010 to 2016 and 2016 to 2022 than in 2004 to 2010 (p = .001). Public interest in vaginal tightening and labiaplasty cost significantly increased from 2004 to 2022. Finally, the term vaginal laser was researched most between 2016 and 2022 (p = .001).

CONCLUSION

This study found that public attention to labiaplasty cost and vaginal tightening continuously increased between 2004 and 2022. In addition, public interest in the term vaginal laser significantly increased after 2016. By contrast, vaginoplasty, laser vaginal rejuvenation, and labia cosmetic surgery terms were researched significantly less after 2010.

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.

Preliminary Exploration of a New Clitoral Hood Classification System and Treatment Strategy

BACKGROUND

Increasing attention has been given to clitoral hoods in recent years, but few studies have been conducted on the classification and treatment strategies of clitoral hood hypertrophy. The purpose of this article is to introduce a new system of clitoral hood classification based on relevant anatomy and make recommendations for clitoral hood reduction.

METHODS

The clitoral hood region is divided into the central zone (zone C) and the lateral zone (zone L). According to the anatomical characteristics of each zone, patients can be divided into 5 types: standard form, central hypertrophy, lateral hypertrophy, composite hypertrophy and special type. Central hypertrophy is further divided into wide and long clitoral hoods, and horizontal and vertical redundancy are addressed using bilateral clitoral hood triangular skin resection and inverted horizontal V-shaped skin resection, respectively. Lateral hypertrophy can be treated with vertically oriented excision. Composite hypertrophy is corrected by combining these methods to remove redundant tissue depending on the situation.

RESULTS

1135 patients were classified according to the new classification system and 789 participants were given corresponding treatment measures. Thirty-four patients (4.3%) experienced complications, and 15 (1.9%) underwent revision surgery. Six months after the procedure, clitoral hood images improved significantly without paresthesia, and the overall satisfaction rate of the patients regarding clitoral hood reduction was 95.7%.

CONCLUSIONS

The clitoral prepuce is an important part of the aesthetic unit of female vulva. The new clitoral hood classification strategy systematically summarizes the anatomical characteristics of the clitoral hood and clearly makes recommendations for surgical options.

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 .

Gayzing Women's Bodies: Criticisms of Labia Depend on the Gender and Sexual Orientation of Perceivers

The heterosexual male gaze is often credited with producing bodily anxieties among women, yet empirical and popular cultural evidence suggest gay men have especially negative views toward women's bodies, particularly women's genitalia. Across two studies (N = 6,129; M_age = 27.58; 2,047 women, 4,082 men) we conducted secondary analyses of existing datasets to test the hypotheses that gay men would evaluate labia more negatively than heterosexual men, and that lesbian women would evaluate labia more positively than heterosexual women. We conducted fixed-effects mini meta-analyses to estimate summary effect sizes for perceptions of normalcy and fit with societal ideals; we additionally assessed an outcome of disgust in Study 2. We found support for our hypotheses: For normalcy and societal ideal, we found small summary effects such that gay men evaluated labia more negatively than heterosexual men, and medium summary effects such that lesbian women evaluated labia more positively than heterosexual women. Gay men also rated labia as more disgusting than any other demographic group, and lesbian women rated the stimuli as less disgusting than heterosexual women, supporting our hypotheses. The current findings suggest a pressing need to acknowledge and incorporate gay men's perceptions of women's bodies into literatures on misogyny, objectification, and body image more generally.

Novel Clitoral Reconstruction and Coverage With Sensate Labial Flaps: Potential Remedy for Female Genital Mutilation

BACKGROUND

Complications caused by female genital mutilation (FGM), such as clitoral pain, reduced sensation, and diminished sexual function, can be alleviated by clitoral reconstruction, which can also improve the aesthetics and restore the anatomy of the genitalia.

OBJECTIVES

The aim of this study was to create sensate labial flaps to cover the neoclitoris and assess the outcome of the procedure.

METHODS

Between December 2018 and July 2020, 40 patients with FGM underwent clitoral reconstruction and coverage with sensate labial flaps donated by the remnant of the labia minora and were followed prospectively. Flaps were mapped on the less-mutilated labia minora according to recent descriptions of arterial anatomy and innervation. Before the surgery, the patients' clitoral sensation was assessed on a 6-point scale and they were also given the Female Sexual Functional Index (FSFI) questionnaire to complete. Eight and 24 weeks postoperatively, the same assessment was repeated and the data compared.

RESULTS

The mean Female Sexual Functional Index score increased significantly from 11.64 (range, 2.8-25.6) preoperatively to 29.14 (range, 12.8-35.4) postoperatively. Similarly, clitoral sensation increased significantly from 2.35 (range, 1-4) before the surgery to 4.9 (range, 2-6) after the surgery. In total, 95% of patients benefited from the surgery.

CONCLUSIONS

Clitoral reconstruction with sensate labial flaps after FGM resulted in significant improvements in sexual function, clitoral sensation, genital aesthetics, and self-esteem.

LEVEL OF EVIDENCE: 4

Cosmetic labiaplasty on minors: a review of current trends and evidence

Cosmetic labiaplasty is a form of Female Genital Cosmetic Surgery (FGCS) that is performed with the deliberate intent to alter the appearance and morphology of the external genitalia in the absence of medical concerns. Over the last decade, there is an increasing demand for FGCS and the industry behind it is constantly growing. Adolescents comprise an extremely vulnerable population, with labiaplasties in this particular age group having also increased. However, labiaplasty has been widely contested due to the irrevocable alteration of a psychosexually significant body part on minors too young to consent. Besides, the changes that occur during pubertal development in the genital area can significantly alter pediatric surgical results. Genital anatomy is more diverse than we previously thought and there is evidence to suggest that the labia minora with their rich innervation play an important role in sexual arousal and pleasure. Education regarding the wide range of normal genital appearance suffices in most cases to dissolve concerns regarding body self-image. Mental health issues should always be explored and, if identified, the girl should be referred to an experienced professional for their resolution. Postponing labiaplasty until adulthood is strongly recommended to help adolescents achieve a well-informed decision regarding an irreversible procedure with possible adverse esthetic and functional outcomes.

The anatomical measurements of vulva in Indian women: A cross-sectional prospective study

OBJECTIVE

To measure the anatomical dimensions of the vulva in adult Indian women. To analyze their correlations with age, body mass index (BMI), parity, and mode of delivery.

METHODS

This cross-sectional study was conducted in a tertiary care university hospital in India, among 400 women aged 18 years and above. Various vulval measurements were taken, and Pearson's correction was applied to variables like age, BMI, parity, and mode of delivery.

RESULTS

Mean length of glans of clitoris was 5.2 ± 1.43 mm, the labia minora width was 2.6 ± 0.74 cm, length of introitus was 1.3 ± 0.59 cm, and perineal body length was 2.3 ± 0.60 cm. The range of some measurements was extensive, for example labia minora width ranged from 0.7 to 4.9 cm. Normal centile curves were constructed for vulval measurements according to age groups. Statistically significant positive correlations of age, BMI, and obstetrical history were seen with labia minora width (r = 0.165, P = 0.001; r = 0.284, P < 0.001; r = 0.246, P < 0.001, respectively).

CONCLUSION

The centile curves can be used as a reference for the Indian population of different ages. These can be used when counseling women coming for female genital cosmetic surgery.

Perceptions of Female Genitalia Following Labiaplasty

Labiaplasty - a common form of female genital cosmetic surgery involving the removal of portions of the labia minora - is becoming increasingly popular, yet little research has examined perceptions of postoperative labia relative to perceptions of unaltered labia. The purpose of this study was therefore to examine perceptions of preoperative and postoperative labia. A sample of 4513 participants - 42% women, 56% men, and 3% non-binary (M_age 27.01, SD_age = 9.97) - was shown a randomized series of "before-and-after" images of labiaplasty procedures. Participants rated each image on how well it matched societal ideals, their personal ideal, and perceived normalcy in appearance. Our hypothesis that postoperative labia would be evaluated more favorably than preoperative labia on these constructs was supported. Individuals who specified their gender outside of the binary rated labia more positively overall; women rated labia more negatively than participants of other genders. Ratings were consistently low overall for both pre- and postoperative labia, suggesting critically negative perceptions of female genitalia. Our findings highlight a need for interventions and education to encourage more positive and accurate views of women's bodies.

The cosmetic surgery paradox: Toward a contemporary understanding of cosmetic surgery popularisation and attitudes

Modern women feel compelled to meet near-impossible standards of beauty. For many, this pursuit ultimately culminates in cosmetic surgery - a radical form of beautification that is rapidly becoming popular worldwide. Paradoxically, while prevalent, artificial beauty remains widely unaccepted in contemporary society. This narrative review synthesizes feminist dialogue, recent research, and real-world case studies to argue that female beauty standards account for both the growing popularity of cosmetic surgery and its lack of mainstream acceptance. First, we implicate unrealistic beauty standards and the medicalization of appearance in popularizing cosmetic surgery. Second, we analyze how negative attitudes toward cosmetic surgery are also motivated by unrealistic beauty standards. Finally, we generate a synthesized model of the processes outlined in this review and provide testable predictions for future studies based on this model. Our review is the first to integrate theoretical and empirical evidence into a cohesive narrative that explains the cosmetic surgery paradox; that is, how cosmetic surgery remains secretive, stigmatized, and moralized despite its surging popularity.

Scrotal Labia - An Uncommon Presentation of Vulvar Lichen Simplex Chronicus

Lichen simplex chronicus (LSC) of the vulva is an acquired, persistent, severely itchy dermatosis usually located in easily reachable areas of the body like the extremities, nape of the neck, and genitalia. It also has a strong association with atopy and is said to be initiated and perpetuated by the itch–scratch–itch cycle. Two cases of rugose labia as the sole presentation of LSC of vulva are being presented.

A New Modified Labiaplasty Combined with Wedge De-Epithelialization on the Medial Side and Edge Resection

BACKGROUND

Labiaplasty (labia minora reduction) has been increasingly requested in recent years. The surgical procedures previously reported in the literature may have some complications that affect patient satisfaction.

METHODS

Patients who underwent a new bilateral labiaplasty procedure that combined wedge de-epithelialization on the medial side with edge resection on the lateral side were retrospectively reviewed. Satisfaction rates were assessed, and questionnaires, namely the Female Sexual Function Index (FSFI) and Genital Appearance Satisfaction (GAS) scale, were distributed and analyzed. The data from the study group were compared with data from cases who underwent traditional labiaplasty with wedge resection (control group).

RESULTS

From October 2015 to February 2020, fifty-one women underwent modified labiaplasty, while 26 women underwent traditional labiaplasty. A total of 94.1% (48/51) of patients in the modified group were satisfied with the genital appearance. Compared with the 96.2% (25/26) satisfaction rate in the control group, the difference was not statistically significant. A total of 43/55 valid questionnaires were returned, including 29 in the modified labiaplasty group and 14 in the control group. There was a significant improvement in the postoperative GAS scale compared to the preoperative scale in both groups (P<0.05). The new modified method had a significant FSFI improvement after the operation compared with preoperative scores (P<0.05), while the FSFI improvement was not significant in the control group (P>0.05). There was no significant difference in the FSFI score improvement, postoperative GAS score or postoperative FSFI between the two groups (P>0.05).

CONCLUSION

This new modified labiaplasty is a satisfying and safe method with low risks, and it may result in better sexual sensitivity for the patients 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

The perceptions of female genital self-image and its associations with female sexual distress

OBJECTIVE

To evaluate the perception of women living in Puerto Rico regarding their genitalia and explore the associations of those perceptions with female sexual distress.

METHODS

Women from Puerto Rico willing to complete a self-administered online survey from June 2018 through July 2020 were included in this cross-sectional study. Inclusion criteria included being between 21 and 65 years of age, living in Puerto Rico, having identified as heterosexual, bisexual, or lesbian, and having been sexually active. Descriptive statistics were calculated. The Mann-Whitney test, Pearson's correlation, and robust linear regression were used to associate female genital self-image and sexual distress.

RESULTS

The most common negative thought and perception within women was dissatisfaction with the size of their genitalia (21.9%), and 21.3% of women contemplated undergoing cosmetic surgery, mainly to increase and improve sensation. For each 1-unit increase in the Female Genital Self-Image Scale score, the Female Sexual Distress Scale-Revised score decreased by 1.24 units (95% confidence interval -1.67 to -0.82).

CONCLUSION

A better genital self-image perception might lower levels of sexual distress. Screening instruments could help to identify poor genital perception and sexual distress.

Influence of Self-Perceived Vulvar Appearance on Female Sexual Function

BACKGROUND

Female sexual function is a complex model of biological and nonbiological factors. The impact of self-perceived vulvar appearance on female sexual function is not well understood.

OBJECTIVES

The aim of this study was to determine the influence of vulvar appearance on sexual function in adult women. The primary aim was to assess the relation between self-perceived vulvar appearance and sexual function. The secondary aim was to assess the influence of prior genital procedures on vulvar appearance and sexual function.

METHODS

An observational study of adult women was conducted utilizing Amazon Mechanical Turk, an online crowdsourcing platform. The survey instrument included demographic information, subjective vulvar appearance measures, and the Female Sexual Function Index (FSFI) questionnaire.

RESULTS

Out of 398 respondents, 148 (37.2%) reported concern about their vulvar appearance and 134 (33.7%) reported a history of genital cosmetic procedures. Women who were uncomfortable with their vulvar appearance had lower FSFI scores than those comfortable with their vulvar appearance, 24.6 vs 27.0 (P = 0.01), respectively. Among women uncomfortable with their vulvar appearance, 70.9% of subjects met the criteria for sexual dysfunction. Women who were uncomfortable with their vulvar appearance were significantly more at risk of sexual dysfunction (adjusted odds ratio: 2.43; 95% CI: 1.46-4.10; P < 0.001). Women with a history of cosmetic genital procedures were significantly more at risk of sexual dysfunction (adjusted odds ratio: 2.46; 95% CI: 1.43-4.23).

CONCLUSIONS

Women who are uncomfortable with their vulvar appearance had higher rates of sexual dysfunction. Women seeking cosmetic genital procedures should be screened for sexual dysfunction to facilitate realistic expectations and optimal care.

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.

Vaginal Rejuvenation: A Retrospective Review of Lasers and Radiofrequency Devices

BACKGROUND

Vaginal rejuvenation is a topic of interest to multiple specialties, including dermatologists, plastic and reconstructive surgeons, urologists, and gynecologists. Evidence suggests that minimally invasive, energy-based devices-radiofrequency and laser therapy-are effective at vaginal tightening and decreasing symptoms of genitourinary syndrome of menopause (GSM) and/or vulvovaginal atrophy (VVA).

MATERIALS AND METHODS

A systematic review was completed using PubMed in November 2018 with search terms "vaginal" or "vagina" and "rejuvenation" or "tightening" or "laxity" or "radiofrequency" or "laser," as well as "genitourinary syndrome of menopause," "pelvic prolapse," "atrophic vaginitis," "vulvovaginal atrophy," "sexual function," "urinary incontinence," and "radiofrequency" or "laser." Inclusion criteria were articles written in English and clinical trials or case reports/series dealing with human subjects.

RESULTS

We identified 59 studies (3,609 women) treated for vaginal rejuvenation using either radiofrequency or fractional ablative laser therapy. Studies report improvement in symptoms of GSM/VVA and sexual function, high patient satisfaction, and minor adverse events, including treatment-associated pain, swelling, or vaginal discharge.

CONCLUSION

This review demonstrates radiofrequency and laser are efficacious for the treatment of vaginal laxity and/or atrophy. Further research needs to be completed to determine which specific pathologies can be treated, if maintenance treatment is necessary, and long-term safety concerns.

Knowledge of Vulvar Anatomy and Self-examination in a Sample of Italian Women

OBJECTIVE

The aim of the study was to investigate the knowledge of vulvar anatomy and vulvar self-examination (VSE) in a sample of Italian women attending a gynecology clinic.

METHODS

For this original research from May to July 2019, 512 women attending the Lower Genital Tract Clinic at the Department of Surgical Sciences of the University of Torino were invited to participate in a 29-question survey about vulvar anatomy, VSE, and sociodemographic details. Data were analyzed using descriptive statistics.

RESULTS

Of 512 patients, 500 completed the questionnaire (98% response rate). The mean age of respondents was 41 years (range = 17-77 years). Education level was evenly distributed between elementary, high school, and university graduates. Only 15% of interviewed women were able correctly sketching vulvar anatomy. Seventy-six percent of the women had not heard about VSE, and 61% of the women approach their genitalia with feelings of shame and embarrassment. Only 23% of the women would seek medical advice after identification of possible abnormalities during VSE. A majority (69%) of the women would like to have more information about VSE and vulvar health through educational videos and social media.

CONCLUSIONS

Education about VSE may lead to earlier diagnosis of vulvar cancers and other pathologies. Further efforts are needed to disperse information about normal external female genital anatomy and VSE to achieve self-confidence among women.

What is the anatomical basis of labiaplasty? A review of normative datasets for female genital anatomy

BACKGROUND

Despite increasing numbers of labiaplasties being performed, there is little quantitative information on normal labial diversity to guide medical education, patient education and surgical treatment.

AIM

This scoping review will determine what is known in the published literature about the anatomical basis of normal for labia and female genital cosmetic surgery (FCGS).

MATERIALS AND METHODS

The scoping review identified ten population-based studies that recorded labial dimensions by searching three electronic databases utilising a Preferred Reporting Items for Systematic Reviews and Meta-Analyses search strategy. Strict inclusion and exclusion criteria were applied and then reference lists were scrutinised until no further articles that met the criteria were located.

RESULTS

These studies showed significant variation in labial length (range 5-100 mm) and width (range 1-60 mm). Labia minora were wider in pre-menopausal women than in post-menopausal women, protruding labia minora were more common than not, and asymmetry between right and left labia was common. Variation in recruitment, inclusion and exclusion criteria, and measurement did not allow for summation of the data sets.

CONCLUSION

This information could usefully be added to medical textbooks and teaching to ensure that medical graduates are sufficiently informed about normal variation in female genital anatomy to assess and advise women seeking FGCS.

Re-thinking the Zero Tolerance Approach to FGM/C: the Debate Around Female Genital Cosmetic Surgery

Purpose of Review

To examine the ‘zero tolerance’ policy for female genital cutting (FGM/C) in the international health community in light of the growing popularity of FGCS (female genital cosmetic surgery) worldwide.

Recent Findings

‘Traditional’ FGM/C performed in Egypt and Sudan and cosmetic labiaplasty performed in Europe, the Americas, and Antipodes by medically trained gynaecologists and plastic surgeons are based on similar aesthetic logics: labia minora that protrude beyond the labia majora are deemed ugly, masculine, and ‘abnormal’. Drawing on the burgeoning medical, social science, and humanities literature surrounding labiaplasty, the paper documents the narrowing of aesthetic standards governing ‘normal’ genital appearance and finds that, in addition to adult women, thousands of (mainly Caucasian) adolescents have undergone these operations whose long-term health consequences are unknown.

Summary

Western heteronormativity, gender binarism, ageism, and the colonial association of protruding labia minora with animality contribute to body image insecurities and fuel the labiaplasty phenomenon, despite the ethical challenge that the procedures are clearly defined by the WHO as type II (a–c) female genital mutilations.

Anterior and Posterior Commissuroplasty: Taking Labiaplasty to the Next Level

As the popularity of female cosmetic genital surgery has grown, so has the number of publications detailing surgical techniques, particularly regarding labiaplasty. As a nascent surgical field, much room remains for finesse and exploration of new techniques to optimize outcomes and patient satisfaction. We present the techniques for anterior and posterior commissuroplasty the senior author (O.J.P.) has developed. Anterior commissuroplasty is efficacious in addressing a number of anatomic variations to achieve the appearance of a single midline cleft, which is commonly requested by patients. Posterior commissuroplasty was developed to address skin excess at the posterior fourchette that may develop as a result of labiaplasty. Either technique may be used in combination with labiaplasty or as a stand-alone procedure. These tools may be a useful addition to the repertoire of a surgeon practicing female genital surgery.

LEVEL OF EVIDENCE: 4

Individualized Surgical Treatment of Different Types of Labia Minora Hypertrophy

Objective To explore an optimal surgical approach for different types of labia minora hypertrophy and to design a better personalized surgical treatment plan for patients. Methods Forty-five patients with labia minora treated in our department from January 2014 to January 2019 were the study participants. Depending upon the appearance of the labia minora, they were divided into length labia minora hypertrophy, width labia minora hypertrophy, overall labia minora hypertrophy, and labia hypertrophy combined with clitoris foreskin. By combining the characteristics of the patient's labia minora hypertrophy and the aesthetic requirements for postoperative appearance, we designed a personalized treatment plan for each group of patients. The surgical approaches include upper pedicle flap wedge resection, upper and lower pedicle flap similar to wedge resection, lower pedicle flap pedicle wedge resection, and labia minora combined with clitoris foreskin surgery. We followed up the postoperative results, recovery, and complication rates for a period of 3 months. Results All patients who underwent surgery had good wound healing. The labia minora had good bilateral symmetry, moderate size, and desired appearance. The scar of the surgical incision was also not obvious. The postoperative labia minora felt normal without any serious complications. Overall, the treatment effect was satisfactory. Conclusion There are many surgical methods for the reduction in the labia minora. Our findings suggest that in order to achieve better results, a personalized surgical plan should be designed considering the patient's unique type of hypertrophy and the individual aesthetic requirements. 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.

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.

Microneedling on the external female genitalia's flaccidity in patients with Ehlers-Danlos: Case report

INTRODUCTION

The Ehlers-Danlos Syndrome (EDS) can presentis a reduction in fibroblast proliferation and collagen production. Microneedling a minimally invasive technique that through mechanical stimulus there is incentive to the production of collagen and elastin.

OBJECTIVE

Present a case study in a patient with EDS complaining of flaccidity on large genital labia, using microneedling as a therapeutic proposal.

METHODOLOGY

A 36-year-old female with EDS type III. The external genitalia showed tissue flaccidity associated with hyperchromia. Microneedling was performed with 0.5 mm needles and the cosmetology was used soon after the application. The level of pain was questioned to the patient through a Likert scale. The clinical response to treatment was evaluated through self-report, visual analogue scale and analysis of photographic images. Five other people evaluated the results through before and after images.

RESULTS

Microneedle was shown to be bearable in relation to pain and associated with cosmetology for tissue flaccidity due to EDS in the genital region proved to be very satisfactory for the patient, as well individuals who evaluated the comparative image.

CONCLUSION

Microneedle associated with cosmetology may be a new option for studies on skin flaccidity treatments on individuals with EDS and for treatments of genital hyperchromias.

Metoidioplasty

Gender affirmation surgery for transmale patients is still challenging, as creation of the neophallus is one of the most demanding steps in surgical treatment. Metoidioplasty, as a one-stage procedure, can be considered in patients who desire gender affirmation surgery without undergoing a complex, multistage procedure with creation of an adult-sized neophallus. Metoidioplasty presents one of the variants of phalloplasty for patients in whom the clitoris is large enough under testosterone treatment. Advanced urethral reconstruction provides low complication rates with satisfying results of standing micturition.

[Labiaplasty: Motivations and post-surgery satisfaction]

OBJECTIVES

In France, the number of labiaplasty increased by 57% between 2008 and 2016. To date, only one prospective study with low-power evaluated postoperative satisfaction has been performed. This observational prospective study aims to evaluate the motives and post-surgery satisfaction of patients who had a labiaplasty.

METHODS

This observational prospective study include all patients over 18 years old operate at the hospital of Angers during an 18-month period. The exclusion criterion was a positive screening test to the Body Dysmorphic Disorder Questionnaire. Patients were interviewed by a written questionnaire on the day of the surgery and by phone 3 and 6 months after the surgery.

RESULTS

A total of thirty patients were included in the study, with an average age of 31.5 (± 10.58). Twenty-three patients answered 3 months after and 19 answered 6 months after. Eighteen patients (95%) expressed satisfaction at 6 months and 16 (84%) "extremely" satisfied. Functional discomfort improved in 18 patients (94%) at 6 months. Eighty-four percent have felt an improvement regarding esthetical discomfort. All patients would recommend the surgery. The main motive was the discomfort when getting dressed for 27 patients (90%).

CONCLUSION

The patients expressed a real functional discomfort and are mostly very satisfied with their surgery at 3 and 6 months after.

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.