D. v. Lukowicz, S. Deichstetter

Recent surveys by the leading international plastic surgery and intimate surgery societies show a strong upward trend in intimate surgery. In most cases, it is not only aesthetic reasons that trigger a visit to an intimate surgeon. About 75% of all female patients complain of functional complaints such as pain during sports or pinching of too long labia when wearing tight clothing or sexual intercourse. Some women feel a psychological burden. About 53% of patients also want the operation for cosmetic reasons (Goodmann 2011, Placik and Arkins 2015). A successfully performed procedure combines the reconstruction of functionality with the restoration of the aesthetic unit.

The external female sexual organs are collectively referred to as the vulva. The vulva includes mons pubis, labia majora, labia minora, clitoris, vaginal vestibule, vestibular erectile tissue and vestibular glands.The pubic mound, mons pubis, is a triangular fat pad located in front of the symphysis and is covered with pubic hair in the mature female.Starting from the mons pubis, paired labia majora extend dorsally and enclose the median pubic cleft. The two skin folds consist of tight fat pads, numerous smooth muscle cells and a venous plexus, which function like erectile tissue.The labia majora cover the labia minora, the clitoral tip, urethral meatus and vaginal Introitus.
The labia minora are paired hairless skin folds, covered on the outside by a stratified keratinized squamous epithelium and on the inside by a nonkeratinized squamous epithelium with numerous sebaceous glands.They consist of many elastic fibers, little fat and numerous veins and meet ventrally in the frenulum of the clitoris. The glans of the clitoris is protected by the clitoral hood. The skin of the clitoral hood joins the labia minora posterior the clitoral tip.The two labia minora folds end, together with the labia major, at the posterior commissure or fourchette (Schiebler 1997).
The anterior genital region receives its blood supply by the Rr. labiales anteriores from the A. pudenda externa of the A. femoralis and the A. epigastrica inferior from the A. iliaca externa. The posterior genital region is supplied by the Rr. labiales posteriores of the A. perinealis from the A. pudenda interna.Venous drainage follows the internal pudendal vein, the venosus vesical plexus, and the external pudendal veins.The pelvic floor is largely innervated by the pudendus nerve. The anterior region of the labia is innervated by the labial anterior nerve from the ilioinguinal nerve, as well as by the R. genitalis of the genitofemoral nerve (Netter 1987).Histological studies revealed a high density of sensitive nerve endings from the anterior labial and posterior labial nerves throughout the labia minora. The sensitivity of the labia minora will persist after reduction (Kelishadi et al. 2016).

The appearance of the Labia minora can vary greatly, Asymmetrie and labia widths ranging form 0,7 to 5,0 cm may be regarded as physiologically normal. Yet functional symptoms and aesthetic issues often occur within this range. Frequently reported functional problems with hypertrophy of the labia minora are pain when riding a bicycle or horse, during sexual intercourse or wearing tight pants. Labiaplasty is also overwhelmingly sought for aesthetic reasons. Psychological reasons should also be considered when deciding on surgery.Most patients demand functional improvement as well as the most aesthetic result possible. The complete closure of the labia majora over the labia minora is considered aesthetically pleasing, as well as a regular image of the labia (Alter G).
Many women present with anatomical challenges that make achieving a good aesthetic result difficult. Vertical and horizontal clitoral hood hypertrophy, excess labial tissue posterior to the introitus, and size, shape, and pigmentation variations are common and should be considered. (Hunter 2013) Hypertrophy of the clitoral hood is spoken of when tissue is seen between the labia majora in the standing position. In our patient population, after over 1000 surgeries experience, this is the case in over 90% of patients (v. Lukowicz 2014).
Simple reduction of the labia minora in patients with complex anatomy often leads to unnatural results. If there is too much volume of the clitoral hood, complete closure of the labia majora over the labia minora cannot be achieved.In fact, the prominent projection of a large clitoral hood is often enhanced by reducing the labia minora alone. This can result in dissatisfaction and an increased feeling of shame on the part of the patient. Existing hypertrophy of the clitoral hood should be operated on with labia reduction to achieve a natural, aesthetic appearance of the intimate region (Hamori 2013).
The findings of the entire anatomical region - labia minora, labia majora, clitoral hood, perineum and mons pubis - should therefore be included in the preoperative planning of labia minora reduction (Gress 2011).

A very good help for planning the surgery is the algorithm of von Lukowicz (v. Lukowicz 2013).During the preoperative examination, attention is paid to hypertrophy of the clitoral hood, mobility of the clitoral tip, and the distance between the clitoral tip and the urethral meatus. The length of the labia is not important for the choice of the surgical method. It can be well adjusted with any method.The decisive factor for selecting the appropriate surgical technique is considering the aesthetic unit. The aesthetic unit consists of the labia minora and the clitoral hood and, by extension, the labia majora.The aim of the surgical intervention is to preserve or restore the aesthetic unit.If the clitoral hood is not treated despite enlargement, a disproportion between the upper and lower parts of the aesthetic unit will result (Gress 2007, 2013; von Lukowicz 2013, 2014).

Labiaplasty for the labia minora are performed in 98% of cases under local anesthesia. Prior lidocaine cream is applied to the intimate area, which significantly reduces the pain from the injection of the local anesthetic. After disinfection and precise marking of the incision, local field anesthesia is performed with lidocaine plus adrenaline (1:100 000) to create a nearly bloodless field. A nerve block is not used. If the planned resection is not marked before injecting the local anesthetic, the results are usually very asymmetrical.The tissue is cut with a radiofrequency device. Reduced labia tend to lose projection postoperatively and tend to melt into the surrounding area. This creates the appearance of overcorrection. To avoid this, the final step is to stabilize the projection with a deep, transmural suture. For this purpose, starting at the level of the tip of the clitoris, a back stitch suture is placed from the inside to the outside at the level of the fold between the inner and outer labia. The suture can be continued dorsally in the sense of a mattress suture. It is important here to leave approx. 3 mm space between the stitches alternately on the inside and outside. In this way, the blood and lymph circulation is not hindered too much. The initial and final nodes must be loose to avoid pressure necrosis. Even with relatively loose knots, pressure necrosis and perforations can occur due to slowly absorbable sutures.

From a multitude of known techniques for the reduction of the labia minora, three main techniques have emerged for the author, with which the desired result can be achieved in almost all patients.

This technique describes the reduction of the labia minora below the clitoris via a semilunar incision (Hodgkinson and Hait 1984).
In our opinion, a satisfactory aesthetic result can only be achieved with the correct indication. This technique is only suitable for patients with naturally small clitoral hood. The tip of the clitoris should also not be too mobile. Otherwise, after shortening of the labia minora, a ventralisation of the clitoral tip may occur, due to the lack of downward traction of the labia minora. Due to the very narrow range of indications, this technique is used in only about 5% of cases.

In addition to technique 1, correction and reduction of the clitoral hood is performed here. This technique involves linear resection of the labia minora as in technique 1. Additionally, the clitoral hood is reduced in the horizontal axis. It is narrowed by removing the lateral parts of the skin (Munhoz et al. 2006, Pardo et al. 2006, Rouzier et al. 2000). The amount of tissue to be resected is determined by a bilateral pinch test with surgical forceps along the longitudinal axis. A longitudinal, spindle-shaped area can be marked, leaving a 4 to 5mm wide prepuce in situ in the midline over the clitoris. In the area of the clitoral hood, resection should initially be limited to the skin. Depending on the findings, more tissue can also be removed. This increases the risk of sensory disturbances and also of postoperative bleeding.Technique 2 is only used in less than 5% of cases.

In the rare case of an additional vertical hypertrophy of the clitoral hood and an immobile clitorial tip, in addition to technique 2 a small vertical reduction should be planned. The reduction is achieved with an inverted V- or U-shaped excision above the clitoral tip. The edges of the resulting wound should close without tension.

This is, with more than 90%, the most frequently performed technique in our patient clientele. In most cases, with enlarged labia and severe excess skin in the area of the clitoral hood, there is also a significant mobility of the clitoris. All problems can be corrected by a combination of horizontal lifting, as in technique 2, and vertical lifting (Gress 2007, 2013). This surgical technique combines reduction of the labia minora with a marginal incision, lateral reduction of the clitoral hood and additionally removal of a strip of tissue between the tip of the clitoris and the urethra.The extent of resection below the clitoral tip depends on the flexibility of the clitoris.the flexibility of the clitoris. A minimum distance between the tip of the clitoris and the urethra of 1.5 cm should be left to avoid distortion of the ostium urethrae.The marking runs parallel to the sulcus of the labia majora with a distance of 1-2 mm from ventral to dorsal on the inner labium or clitoral hood. A slight curve is planned at the level of the clitoral tip, reaching the highest point just below the new clitoral tip position. A height of 1.2-1.5 cm has proven successful. A certain amount of shrinkage is to be expected. In terms of a high wedge excision, the lobules of the labia margins are formed into two flaps. The ventral part of the clitoral hood is resected similar to technique 2 (Gress 2007, 2013). To secure the hold of the flaps dorsally, a "reverse flap" is mobilized, pulled dorsally and fixed there.

If the clitoral hood remains too long even after applying technique 3, an additional horizontal tightening with inverted V- or U-shaped excision above the clitoral tip can be performed. This combination was developed by Gress and referred to as the composite technique.

The outer labia enclose the labia minora and can cover them completely. Of course, this depends on the size of the labia minora, but at the same time on the depth of the interlabial sulcus. If the sulcus is relatively shallow, the labia minora will always be visible in the gap between the labia majora. The appearance of the labia majora is critical to the overall appearance of the vulva.

With advancing age, the subcutaneous adipose tissue of the labia majora atrophies, leaving empty, ptotic skin.Lifting of the labia majora is performed by spindle-shaped skin resection. The resection borders are marked medially with 1-2 mm distance to the hairline from ventral to dorsal. The lateral resection margin is measured in the standing position. The maximum width of the skin spindles that can still be closed without tension is determined. Excessive flattening of the outer labia must be avoided. The medial and lateral lines are brought together ventrally and dorsally to form a spindle. If there is a large excess of skin, a Burow's triangle can be planned dorsally. The resection can be extended into the corpus cavernosum (Di Saia 2008).

Minor atrophies or asymmetries of the labia majora can be treated satisfactorily by lifting. If atrophy is more pronounced, the volume loss should be compensated with autologous fat or hyaluronic acid. Lifting and volume building can also be combined.The fatty tissue is removed from a suitable donor area by liposuction using the tumescent technique (Coleman 1995, 2005). In order to achieve the highest possible healing rate, the cells should be distributed well in the tissue in a low layer thickness. Attention should be paid to the corpus cavernosum of the labia majora.The operation can be repeated several times until the desired volume is achieved.

Candida infections are the most common postoperative side effect and can be successfully prevented by administering vaginal suppositories containing lactic acid bacteria immediately after surgery. Following labia surgery, the patient should rest for 24 hours and lie down to reduce the risk of possible post-operative bleeding. Cooling is not necessary and is even counter-productive due to increased tendency to swelling. The suture material is absorbable and usually does not need to be removed. As oral postoperative pain medication, a combination of ibuprofen or paracetamol, novamine sulfone and, if appropriate, oxycodone with naloxone is appropriate. Cleaning of the intimate area under the shower with clear water is possible from the first postoperative day.Stress and friction in this area should be avoided for 6 weeks. This includes sports and activities such as riding or cycling and also sexual intercourse.To prevent an unpleasant feeling of dryness, the application of panthenol ointment to the wounds is recommended. In women over 45 years of age, an ointment containing estrogen can improve wound healing.Since the delicate balance of vaginal flora should not be affected, systemic and topical administration of antibiotics should not be used. To avoid fungal infections, vaginal suppositories with lactic acid bacteria can be administered prophylactically directly postoperatively. In patients who already suffer from recurrent Candida infections preoperatively, a build-up of the site flora is recommended before surgery. The capsules should also be continued postoperatively for at least 14 days.

Complications are rare after a correctly performed surgery. Without preventive measures, the most common complication is Candida infection (approx. 8%), which usually occurs on the second postoperative day (see above for prevention). In case of infection, commercially available antifungal medication should be used.The post-operative bleeding rate is only 0.5% due to careful hemostasis during the operation. Suture loosening rarely occurs. Small dehiscences, usually 2-3 mm wide and 1-2 cm long, heal on their own within a few days. Complications such as postoperative bleeding or loosening of sutures can also be avoided by adhering to the postoperative behavioral measures.Despite all caution, hematomas and severe swelling can occur, which can lead to significant pain. In the event of major hemorrhage, prompt action should be taken. It is advisable to use lidocaine plus epinephrine during revision to better locate the source of bleeding.Wound healing disorders mostly occur on the surface and can be treated well conservatively. Rarely, sebaceous gland hyperplasia occurs due to occlusion of the sebaceous gland opening. This can be prevented by removing the sebaceous glands at the wound edge.
The scars are usually hardly visible after a few weeks. If the preoperative marking is correct, remaining asymmetries of the labia are not to be expected.Sensitivity disorders are not to be expected with correct surgical technique. The reduction of the clitoral sheath and the shortening of the distance between the clitoris and the urethra results in increased sexual excitability in many patients (Placik and Arkins 2015).Overall, a need for correction after reduction of the labia minora is present in only 1% of patients (von Lukowicz 2013, 2014). The combination of labia minora and labia majora reduction is possible if the incision of the labia majora reduction is performed at a significant distance (outside the hair-free zone) from the interlabial sulcus as recommended above.

From our point of view, surgery is indicated when women feel uncomfortable with their intimate area. Often the patients' level of suffering is very high. The impulse for surgery comes from the patient and should be taken seriously.In the hands of an experienced intimate surgeon, labia reduction can be performed at low risk. Overall satisfaction and self-confidence improves significantly with the surgical procedure (Sharp et al. 2016). In our opinion, the indication for a surgical reduction of the labia should therefore be generous.