It has been recognised in the media and medical literature that there has been a large increase in the demand for female genital enhancement surgery. However, it remains one of the least common procedures performed by plastic surgeons. Plastic surgery has always advocated dedication to the restoration of appearance and function, and to the author's mind this is also applicable to cosmetic surgery of the female genitalia. However, little progress has been made in this challenging field. In the vast majority of cases, cosmetic enhancement is achieved by reducing the labia minora by total or subtotal amputation in order to achieve better aesthetic outcomes. In the author's opinion, amputation of the labia minora does not achieve this.
Anatomical abnormalities, oncological tumours and post-childbirth reconstruction fall outside the scope of pure cosmetic surgery to the female genitalia. In general cosmetic surgery, amputation of body parts rarely yields the desired aesthetic and/or functional result and is therefore rarely practised. The same should therefore be true of cosmetic surgery to the genitalia.
Anatomy and appearance of the female genitalia can be varied, but all are, in principle, normal. All patients are informed that the size of the labia minora is variable and that protrusion of the labia beyond the vulva is quite normal. It is also emphasised that the indication for cosmetic surgery of the female genitalia is not fundamentally different than any other type of cosmetic surgery, e.g. rhinoplasty or otoplasty. The majority of patients undergoing reduction of the labia minora do so for functional reasons, with minimal outside influences affecting their decision for treatment. It is also presumptuous to state that all women requesting cosmetic genital surgery have psychological problems or lack of self-esteem. In the author's opinion, women requesting cosmetic surgery to this part of the anatomy often possess similar expectations and motivation to women requesting any other cosmetic surgical procedures.
Between 2000 and 2008, the author performed in excess of 500 cosmetic procedures to the female genitalia, most of which included reduction labiaplasty. A modified, simple plastic surgical flap technique has been developed by the author and has been used successfully for the reduction of the labia minora over the last 8 years.1 This technique preserves the normal labial edge and therefore the function of the labia minora. The procedure is carried out as a day case, with an operation time of less than 1
h. This is often performed in combination with a clitoral hood plasty to achieve a better aesthetic result. The skin of the labia minora is a continuation of the skin of the clitoral hood and therefore the labia minora and the skin of the clitoral hood should be addressed as one anatomical entity.
To date, patient satisfaction has been very high, with complication rates remaining very low. The author proposes that simple trimming of the labia should not be the standard operation for women who request improvement of the aesthetic and often functional aspects of their genitalia. The labial trim should not be classified as a labiaplasty. The Greek word plassein means ‘to shape’ and reducing the size of the labia by amputation is not necessarily defined as ‘shaping’.
The function of the labia minora is to protect the vagina from drying out and the labia play a significant role in the process of micturition by funnelling the urine stream. Having seen a considerable amount of women with functional and aesthetic complaints after subtotal or total labiectomy, the author has come to the conclusion that these amputations are potentially dangerous procedures, where the function of the labia minora can be severely impaired (leading to vaginal irritation and dryness). Furthermore, the resulting scar in the introitus, following labial amputation, can result in entry dyspareunia of the vagina either by a tampon or a penis during sexual intercourse.
With women increasingly expressing desire to look less ‘unattractive’ in the genital area, this can only be achieved by applying proper plastic surgical principles, rather than simple amputation. Women ask to look less ‘unattractive’, even on close inspection. The perception of female genital beauty is very much culturally dependent. For example, in Japan the so-called ‘butterfly’ appearance is greatly admired. In Western society, protruding inner labia are considered less attractive, whereas in parts of Africa, the inner labia are deliberately stretched from a young age. There are also fringe groups in Western society, who stretch different parts of the genitalia.
The only real justification of aesthetic surgery is that the repaired and reconstructed part must blend harmoniously with the whole, whatever the surgery done. This cannot be achieved by amputation. The beauty of the vulva cannot be described in words, but can easily be illustrated. Figure 1 is pre-operatively; Figure 2 is immediately post-operatively after labial reduction and clitoral hood plasty.
In medicolegal terms, the Bolam test should be applicable to this type of cosmetic surgery. The ordinary skill of an ordinary, competent man exercising this particular art should be applied, but ‘ordinary’ should mean the application of plastic surgical principles, rather than amputations. Unfortunately, the author has been involved in too many cases where almost irreparable damage has been inflicted. At times, confusion exists about the fine line between female genital mutilation and female genital cosmetic surgery. Both plastic surgeons and gynaecologists performing this type of surgery should be aware of potential damage being caused and which in the future may be classified as ‘mutilation’.
As plastic surgeons with a duty to care for our patients, the author strongly feels that when confronted with women requesting cosmetic surgery to their genitalia, surgeons should be aware of different treatment options. The threshold for referral of patients to more experienced colleagues should be encouraged. In summary, the principle of primam non nocere is very much applicable in the science and art of female genital cosmetic surgery.
FULL TEXT
