The female external genitalia are also collectively termed the “vulva,” which comprises the paired labia (two majora and two minora), the clitoris, the vaginal introitus, and urethral opening. It is in continuity with the mons pubis anteriorly, the perineum and anus posteriorly, and the medial thigh laterally Fig. 125.1. The paired labia minora are separated from the labia majora by the interlabial sulcus. They converge anteriorly on the ventral surface of the clitoral glans as the frenulum of the clitoris. The labia majora converge with the labia minora posterior to the vaginal vestibule to form the posterior fourchette. The clitoris comprises the glans (covered by the clitoral hood), the body, and the paired crura and vestibular bulbs. The suspensory ligament of the clitoris anchors the clitoral body to the pubic symphysis. The vaginal vestibule contains the urethral meatus (~2.5 cm ventral to the clitoral glans), the vaginal introitus (marked by the hymen), and the vestibular glands which provide lubrication of the vaginal vestibule.1,2
2. Triana L, Robledo AM. Aesthetic surgery of female external genitalia. Aesthet Surg J 2015;35(2):165–177 Thorough knowledge of the anatomy of the female external genitalia is key to performing safe and effective surgery to this area. This is illustrated in Fig. 125.1. The urethral meatus is located in the vaginal vestibule along with the vaginal introitus and the vestibular glands which provide secretions to the vaginal vault. The clitoris and the clitoral hood lie ventral to the vaginal vestibule in the midline. The labia majora are located laterally next to the medial thigh and the minora are located medial to the majora at the edge of the vaginal opening, a part of which they form. The main arterial supply to the external female genitals is received from the internal Fig. 125.1 Anatomy genitalia. (From Hamori C, Banwell C, Alinsod R. Female Cosmetic Genital Surgery. Thieme, 2017.) Pupic symphysis Anterior labial commissure Hood of clitoris Glans of clitoris Frenulum of clitoris Urethral orifice Ischium Labium minus Labium majus Vaginal orifice Posterior labial commissure pudendal artery and its branches, which is a branch of the internal iliac artery, but more laterally, the areas are supplied by the external pudendal artery, which is a branch of the femoral artery. The vulva is innervated by the anterior labial branches of the ilioinguinal and genitofemoral nerves as well as branches of the pudendal nerve. The pudendal nerve divides into three divisions near the ischial tuberosity to give the dorsal nerve of clitoris, perineal nerve (supplies the labia majora and perineum), and inferior rectal nerve (supplies the perianal area).1–4
surgery? Female genital cosmetic surgery is a highly sensitive and personal issue for many women and there needs to be a real emphasis on ensuring patients feel supported and safe during the consultation and examination process. It is vital for both the patient and clinician that a female chaperone is always present to ensure high standards of care are met. This approach protects both the patient and clinician and is a key component from a medicolegal perspective. The requirement for bimanual pelvic examination and examination of the perineum and anus will be dependent on the precise focus of the consultation and are not required in every case. The patient must be assessed supine in the frog-leg position, and, in some cases, also standing because this can highlight soft-tissue excesses and their appearance when gravity is acting upon them, for example, when labial or mons excess is a concern. The use of a mirror can be very helpful in a number of aesthetic surgery consultations, not just female genital surgery. However, it will not be required in every case, only those where it will help the dialogue and understanding between patient and physician.1–4
4. Pauls RN. Anatomy of the clitoris and the female sexual response. Clin Anat 2015;28(3):376–384
Labiaplasty involves reduction of the labia minora size and/or projection. This is usually performed for both functional and aesthetic reasons. For example, patients experience issues with discomfort, chafing, chronic irritation, and problems during sexual activity. They may also have issues with their appearance in and out of clothing. There are essentially four main techniques that can be utilized: wedge excision, free edge excision, central de-epithelialization, and W-plasty. There are no specific techniques based on Z-plasty. In this case, a wedge excision would suit her requirements best. This involves taking offset wedges from the inner and outer aspects of the minora. Usually, the skin/mucosal surface can be removed plus/minus some of the deeper tissues. Following resection, the wedge is closed so that scarring is well hidden medially in the introitus and laterally within the interlabial sulcus. The other advantage is that the wound edge scar between the upper and lower flaps is very small and the leading edge of the minora is preserved. This technique allows for symmetrization and large reductions as would be required in this case. With a free edge excision, the procedure is quicker to perform, but there will be scarring along the full leading edge of the minora. This technique does allow for fairly large reductions but may be less well suited to do so as a wedge and does risk over-resection, resulting in abnormal looking labia. The W-plasty is a variant of a wedge excision but is more complex and time consuming without a significant advantage. It may also be less well suited to large excisions and more challenging to achieve good symmetry. The central de-epithelialization approach is a technique that is useful to deproject the labia by de-epithelializing skin/mucosa from the medial and lateral labial surfaces with primary reapproximation of the edges. It is typically performed using a triangular or elliptical incision design. It also preserves the free border of the labia and preserves vascularity well but can be a little bulky due to the telescoping effect of deprojection.1–5
Excess tissue of the clitoral hood can be quite bothersome, and women may complain of decreased sensitivity during sexual intercourse, and an inability to reach orgasm. They may also dislike the appearance, especially if it is perceived to look like a “small penis.” Incisions for clitoral hood reduction must be performed in a superficial plane to avoid injury to the clitoral glans and body. Furthermore, scars should not be placed on the clitoral hood itself to minimize the risk of scar hypersensitivity. Clitoral hood reduction is often performed at the same time as labiaplasty, as reduction of the labia minora can make the clitoral hood appear more prominent. However, it is not part of a standard labiaplasty approach. Clitoral hood excess may be present in the horizontal (more common) and/or vertical planes. Horizontal excess is typically managed with a superficial skin excision placed in the sulcus between the labia majora and the clitoral hood. Vertical excess is typically managed with a superficial inverted-“V”–shape excision placed superior to the free-border of the clitoral hood. Clitoral hood reduction should be performed conservatively, and care must be taken to avoid permanent exposure of the clitoris, which can cause significant pain and hypersensitivity.1–4
Youthful appearing labia majora have a full, smooth contour and nearly approximate in the midline. Aesthetic concerns of the labia majora are typically related to either excessive fullness or deflation and ptosis. Excessive fullness can cause the labia majora to touch in the midline, creating a “closed clamshell” appearance in the standing position. Deflation/ptosis can cause the labia majora to appear or have redundant folds. When assessing the labia majora, it is important to examine the degree of skin excess and the amount of subcutaneous tissue present. Labia majora augmentation is appropriate for patients with mild skin excess and mild to moderate subcutaneous tissue atrophy. This would be achieved with either subcutaneous hyaluronic acid filler injection or autologous fat grafting, though soft-tissue flaps and dermal grafts have also been described.1 Labia majora reduction is appropriate for patients with either subcutaneous tissue excess alone, or moderate to severe skin excess. Mild subcutaneous tissue excess without skin excess can be treated with liposuction of the labia majora.2 Moderate to severe skin or subcutaneous tissue excess can be treated with wedge resection of the labia majora. The incision for excisional labia majora reduction can be placed in the vulva-thigh crease, within the labia majora itself, or hidden in the interlabial sulcus (most common). Care must be taken to avoid over-resection of the labia majora, as this may result in opening of the vaginal vestibule with abduction of the thighs as has occurred in this case.
Following pregnancy and vaginal childbirth, patients may experience vaginal laxity and pelvic floor weakness due to stretching of the tissues of the vagina and perineum with separation of the pelvic floor muscles. Patients subsequently experience problems with postpartum laxity leading to gaping of the perineum, difficulty maintaining tampon placement, decreased sexual satisfaction, and the potential for excessive vaginal secretions. Vaginoplasty is a term that most commonly refers to a vaginal-tightening procedure. However, it is alternatively used more broadly to describe procedures on the vagina and could therefore be used less correctly to describe reconstruction or refinement of the vagina for a number of reasons. In the setting of vaginal tightening, the operation attempts to restore the damaged postpartum tissues of the vagina and perineum to their nulliparous 1124 Part VII ■ Aesthetic Surgery state. While nonsurgical modalities have demonstrated some success in vaginal tightening, they tend to have more conservative improvements than a surgical procedure. At present, the long-term results of nonsurgical treatments such as radiofrequency stimulation or ablative laser are lacking. Vaginoplasty and perineoplasty share some common concepts but are distinctly different. Vaginoplasty refers to tightening of the vaginal canal above the level of the hymenal ring, where perineoplasty refers to tightening of the vaginal vestibule and perineum below the level of the hymenal ring. A perineoplasty is intended to restore perineal body length, correct gaping of the vaginal vestibule, and strengthen the pelvic floor by reapproximation of the superficial transverse perineal muscles. There are a number of different techniques used for vaginoplasty and the anterior, lateral, or posterior walls may be tightened. Particular care should be taken when performing posterior wall surgery, as this risks injury to the rectum where the levator ani muscles are repaired. Likewise, when performing anterior wall surgery, the bladder is at risk. If there are any concerns, this should ideally be performed with involvement of the gynecologist. Overall, vaginal tightening procedures have been associated with high patient and partner satisfaction outcome measures.1,2
The hymen is a thin, avascular membrane at the level of the vaginal introitus that separates the vaginal vestibule from the vaginal canal. There is significant variation in the native configuration of the hymen, with most common variants being “annular” and “crescentic” shapes. The hymen may be disrupted (“broken”) for a number of reasons. These include trauma, vaginal tampon use, penetrative sexual intercourse, sexual assault, and medical interventions. Some cultures feel that an intact hymen confirms a girl’s virginity. A hymenoplasty is a surgical procedure to restore the hymen back to its undisrupted form and is most commonly requested for ethnic/religious reasons in cultures where premarital virginity is highly valued. Bleeding during consummation of marriage is viewed as a sign of premarital chastity. Furthermore, premarital gynecological examination is required in some cultures to certify virginity. Because disruption of the hymen typically leaves remnants, known as carunculae myrtiformes (“caruncles”), these edges can be excised and repaired back together using absorbable sutures to restore integrity of the hymenal ring. Patients undergoing hymenoplasty should be warned that surgical restoration of the hymen cannot guarantee bleeding during first coitus. An adequate vaginal opening must be preserved (~1 cm) to allow for passage of vaginal secretions and menstrual fluids. The other procedures are requested based on functional and aesthetic grounds rather than religious beliefs.1–3
Deformities of the mons pubis are typically related to massive weight gain and/or loss. They can also become apparent following abdominoplasty where the mons has not been adequately treated. In this situation, the patient has put on weight since her original surgery which will compound the situation. In general terms, weight gain results in fat deposition in the mons and can lead to ptosis. Where significant weight loss occurs, the mons volume decreases leaving skin excess and further ptosis. Add into this an abdominoplasty, which treats the soft-tissue excess above the mons and creates a transverse scar that may tether to the underlying fascia. The result of this can, at the very least, make mons soft-tissue excess appear worse. A full monsplasty targets the three components which are problematic: fat excess, skin excess, and lack of internal support/ptosis. It involves removal of excess skin, liposuction or direct excision of excess fat, and resuspension of the mons to the rectus fascia with long-acting or permanent sutures. Mild to moderate lipodystrophy without skin ptosis may be treated with liposuction alone. Skin excess alone may be treated with skin resection via the abdominoplasty scar. Internal suspension alone would be unsuccessful given the soft-tissue excesses. A revision abdominoplasty would only be indicated if there was residual soft-tissue excess above the scar or if there was a problem with contour or symmetry.1,2
condition? Vaginismus is a genitopelvic pain/penetration disorder characterized by involuntary spasm of the perineal muscles in addition to anxiety/fear with attempted vaginal penetration (e.g., sexual intercourse, tampon insertion, gynecologic examination, and childbirth). It has an incidence of 1 to 7% among women worldwide and unlike other pelvic pain disorders (e.g., vulvodynia, vestibulodynia), treatment for vaginismus is associated with a high success rate. One of the main treatment options is injection of neurotoxin into the muscles responsible for spasm. Other modalities include vaginal dilators, physical therapy with biofeedback, and psychological input with counseling. There is no surgical solution for vaginismus. Vaginismus is classified by the Lamont classification, which is based on the patient history and response to gynecologic examination: Grade I: Tight vaginal muscles, can relax with coaxing to tolerate pelvic examination. Grade II: Tight vaginal muscles, unable to relax but pelvic examination still possible. Grade III: Patient elevates her buttocks to avoid examination. Grade IV: Patient elevates buttocks, retracts, and adducts thighs to avoid examination.1