Aesthetic surgery of women’s genitals: reduction of large labia minora

Sir:

I appreciate the opportunity to reply to Dr. Alter’s thoughtful letter regarding our article on aesthetic labia minora reduction.(1) This allows me to clarify some points of confusion as to the “drawbacks” he suggests for an inferior wedge resection procedure. Dr. Alter is highly recognized as an authority in genital surgery, especially modern aesthetic labia minora reduction, of which he was one of the pioneers (central wedge technique, 1998 (2)). Dr. Alter’s letter makes many good points, and I would not presume to argue with him. I think he actually seems to agree with much of what my coauthors and I said, but he differs with regard to my interpretation of the inferior wedge technique concept. I thank him for his comments.

My experience with the aesthetic labia minora reduction began 8 years ago, with Dr. José Roberto Filassi, a gynecologist, who first introduced me to this technique in an effort to find a simple and reproducible procedure with low rates of complications and fewer trade-offs.(3) As mentioned in the article, at that time (1998), the main technical options available were based on the simple protuberant tissue resection. Despite the reproducibility of this old concept, this procedure removed the natural contour of the labia minora and replaced it with an irregular suture line and an unsatisfactory aesthetic result. In addition, one might surmise that wide and simple resection of the protuberant tissue can occasionally extend to the clitoris and put sexuality at risk. To avoid these undesirable aesthetic and functional outcomes, since the end of 1990s my coworkers and I have used a simple and reliable technique based on the inferior wedge labia minora resection and superior pedicle flap reconstruction.(1,3) Contrary to what Dr. Alter wrote (and I believe that I was just misinterpreted), the main point of our article was not to demonstrate or dispute the superiority of our technique; this was beyond the reach and scope of our article. Rather, the purpose was only to review a series of labia minora reductions using this technique with regard to the main indications, operative planning, advantages, and limitations. We believe that significant conclusions related to aesthetic results following each technique (Dr. Alter X inferior edge resection) should only be evaluated with controlled prospective studies. In addition, the methodology of determining aesthetic outcome should be scientific and performed by a patient, a surgeon, and an independent observer (a physician, nurse, or layperson). In our study, cosmetic evaluation was performed subjectively after a minimal period of 3 months postoperatively. At that time, 85.7 percent of patients presented good or very good aesthetic results and 95.2 percent of patients were either very satisfied or satisfied with their result. All patients mentioned smaller and finer labia minora with a more youthful appearance. Despite this fact, I believe that comparative studies between the two techniques utilizing scientific methodology are necessary for significant conclusions. Up to now, a scientifically valid comparison required that the authors identify and quantify variables in each group. The methodology of our study and Dr. Alter’s does not establish comparable cohorts (comparable groups with quantified tissue and surgical variables). Therefore, Dr. Alter’s data and conclusions (2) do not prove that his technique has better results compared with inferior edge resection. It is just a personal opinion.

As mentioned in the Discussion, the inferior wedge technique is a variation of the innovative technique described by Dr. Alter in 1998 (2) and adapted by Rouzier et al. in 2000.(4) In Dr. Alter’s article, he mentions a wedge-shaped resection in the inferior part of the labia minora and superior flap reconstruction in cases where the labia minora are more protuberant throughout their extension. Correspondingly, the Rouzier group described a V-shaped redundant labial tissue resection located in the inferior region of the labia minora. The surgical planning was performed through rigid marking whereby the authors utilized two Kocher clamps. The first clamp was placed on the posterior part of the labia minora close to their base, and the second was placed across the labia minora. Together they formed an angle of approximately 90 degrees. Unlike Rouzier et al., my coauthors and I avoided rigid marking, because the tissue redundancy varies a lot. For moderate hypertrophy, we prefer a small reduction with an angle between the two lines equal to or less than 90 degrees. In the presence of severe hypertrophy, and if the patient desires a more aggressive reduction, the angle can be greater than 120 degrees.

With regard to the statement “[w]omen seeking this operation desire removal of the most bulky and protruding tissue,” my coauthors and I totally agree with Dr. Alter. However, his statements that “[r]emoval of an inferior wedge leaves the bulky superior tissue as the labial edge” and “is counterproductive” are partially true and do not appear to be supported by published data. This has certainly not been my experience.

In my practice, once the skin laxity also contributes to labia enlargement, simple removal of an inferior wedge can be productive. For this purpose, a simple preoperative evaluation can determine the amount of tissue to be resected and simulate the final result. With a small forceps, the medium portion of the labia minora is stretched inferiorly until the posterior part of the vagina introits (pinching test). If skin tension is observed, the forceps is moved upward; if skin laxity is noted, the forceps is moved downward to resect more tissue. Using this maneuver, it is possible to simulate the final aesthetic result and estimate the amount of tissue that needs to be resected and the extension of the superior flap. Thus, I do not believe that the technique is “counterproductive.” In addition, care must be taken to make certain that the tissue enlargement is not overresected to prevent a tight introitus. When planning the wedge-shaped resection area through the pinch test, the surgeon should place two or three fingers inside the introitus and stretch the labia minora, to estimate a safe amount of tissue resection. The same concept can be used to avoid underresection and tissue enlargement relapse.

Since submission of the article, I have continued to use the technique on patients and have yet to observe a good aesthetic outcome. The study demonstrates that the inferior wedge is a simple and consistent technique. The complications observed were expected and did not extend patients’ hospital stay or interfere with the normal postoperative period. As is frequently observed in any aesthetic surgical procedure, success depends on patient selection, careful preoperative planning, and adequate intraoperative management.
Although I do not doubt that Dr. Alter achieves better results using his approach, the word “better” can be influenced by personal bias, especially when it is applied to aesthetic appearance. Up to now, there has been no consensus concerning the best procedure for labia minora reduction. The main advantages of the technique used should include reproducibility, low interference with physiological function, and long-term results. It is almost certain that these objectives are not attained by any single procedure. Each technique has its advantages and limitations, depending on the excess cutaneous-mucosal tissue, skin laxity, and the patient’s sexual and athletic activities. A single surgical technique, in my opinion, never has been and never will be the optimal solution for every patient.

I thank Dr. Alter for providing us with practical clinical information, and I encourage him to publish his long-term experience with a central wedge excision combined with a lateral hockey stick V excision. No technique is perfect, and each surely has its own compromises.

Alexandre Mendonca Munhoz, M.D.
Department of Plastic Surgery
University of Sáo Paulo, Brazil
Rua Oscar Freire 1702 ap. 78
Sáo Paulo SP 05409-011, Brazil
Munhozalex [@] uol.com.br

REFERENCES

1. Munhoz, A., Filassi, J., Ricci, M., et al. Aesthetic labia minora reduction with inferior wedge resection and superior pedicle flap reconstruction. Plast. Reconstr. Surg. 118: 1237, 2006.

2. Alter, G. J. A new technique for aesthetic labia minora reduction. Ann. Plast. Surg. 40: 287, 1998.

3. Filassi, J. R., Munhoz, A. M., Ricci, M. D., and Melo, N. R. Aplicacao do retalho labial superior para correcao cirúgica da hipertrofia de pequenos lábios. Rev. Bras. Ginecol. Obstet. 26: 37, 2004.

4. Rouzier, R., Sylvestre, C., Paniel, B., and Haddad, B. Hypertrophy of labia minora: Experience with 163 reductions. Am. J. Obstet. Gynecol. 182: 35, 2000.