Labiaplasty: Motivation, techniques, and ethics

Abstract

Labiaplasty (also known as labia minora reduction) is attracting increasing attention in the media and in online forums. Controversy exists among health-care professionals on how to manage a request for this surgery. Furthermore, the indications for and outcomes of labiaplasty have not yet been systematically assessed, and long-term outcomes have not yet been reported. Labia minora hypertrophy is defined as enlargement of the labia minora; however, the natural variation of labia minora size has scarcely been studied, with only one study suggesting objective criteria. Perception of the 'normal' appearance of labia minora is influenced by culture, exposure to idealized photographs in media, health-care professionals' opinions, and family, friends, and sexual partners (although this influence has not been substantiated by research). The desire for labiaplasty is predominantly based on dissatisfaction with genital appearance and not on functional complaints. Most health-care professionals believe that women seeking labiaplasty should be referred to a psychiatrist or psychologist for consultation before surgery, although whether counselling and education are effective at alleviating dissatisfaction or a low genital self-esteem is not clear. As the nature of patient motivation for this type of surgery is often psychological, counselling and education could be useful in reducing the demand for labiaplasty. However, current studies on surgical technique and outcomes include few patients, therefore, evidence on the results of different labiaplasty techniques and patient satisfaction is inconclusive. Further research is required to assess the value of this treatment and the appropriate indications for it. Improved understanding as to why women seek this treatment is needed and whether conservative treatments (such as counselling) are effective. Furthermore, systematic assessment of the surgical and patient-reported outcomes of labiaplasty is needed to assess whether it is safe and effective. Moreover, understanding the effect of cultural trends, for example, the way in which many women in Western society see any exception to the ideal body as a problem, will be insightful.

Full text

Labiaplasty (or labia minora reduction) refers to the
surgical reduction of the size of the labia minora as a
treatment for labia hypertrophy. Causes of labia hyper‑
trophy are secondary to congenital conditions, such as
disorders of sex development, but it can also develop as a
result of oestrogen or androgen treatment during child‑
hood1,2, tissue expansion by repetitive pulling, or infec‑
tion, or it can occur concomitantly with incontinence3,4.
However, a clear definition of labia hypertrophy is still
lacking, and no consensus exists in the literature with
respect to the varying grades and classification of labial
hypertrophy 5. Only one study has suggested objective
criteria for labia minora hypertrophy (width >50 mm)
or labia minora asymmetry (difference >30 mm) based
on data on natural female genital variation6.
Labiaplasty seems to be a relatively new phenomenon
that has emerged in association with the trend for the
pursuit of perfection in modern, economically devel‑
oped societies7; however, François Mauriceau described
women requesting treatment for discomfort caused by
labia hypertrophy in 16818, and Meissner9 and Treub10
also published such descriptions. Nonetheless, in mod‑
ern society, this subject is increasingly being addressed
among media platforms and medical organizations11.
Growing attention for this subject has been reported
to be associated with an increasing demand for this
procedure12. Articles on labiaplasty invariably intro‑
duce the subject by describing an increase in requests
for labiaplasty; however, the actual numbers of women
requesting labiaplasty, the numbers of women who
1Department of Plastic,
Reconstructive and Hand
Surgery, Vrije Universiteit
Amsterdam Medical Center,
Amsterdam, Netherlands.
2Peninsula College of
Medicine and Dentistry, John
Bull Building, Science Park,
Plymouth, UK.
3Department of Epidemiology
and Biostatistics, Vrije
Universiteit Amsterdam
Medical Center, Amsterdam,
Netherlands.
*e-mail: m.ozer@vumc.nl
doi:10.1038/nrurol.2018.1
Published online 6 Feb 2018
Labiaplasty: motivation,
techniques, and ethics
Müjde Özer1*, Indiana Mortimore2, Elise P.Jansma3, and Margriet G.Mullender1
Abstract | Labiaplasty (also known as labia minora reduction) is attracting increasing attention in
the media and in online forums. Controversy exists among health-care professionals on how to
manage a request for this surgery. Furthermore, the indications for and outcomes of labiaplasty
have not yet been systematically assessed, and long-term outcomes have not yet been reported.
Labia minora hypertrophy is defined as enlargement of the labia minora; however, the natural
variation of labia minora size has scarcely been studied, with only one study suggesting
objective criteria. Perception of the ‘normal’ appearance of labia minora is influenced by culture,
exposure to idealized photographs in media, health-care professionals’ opinions, and family,
friends, and sexual partners (although this influence has not been substantiated by research).
The desire for labiaplasty is predominantly based on dissatisfaction with genital appearance and
not on functional complaints. Most health-care professionals believe that women seeking
labiaplasty should be referred to a psychiatrist or psychologist for consultation before surgery,
although whether counselling and education are effective at alleviating dissatisfaction or a low
genital self-esteem is not clear. As the nature of patient motivation for this type of surgery is
often psychological, counselling and education could be useful in reducing the demand for
labiaplasty. However, current studies on surgical technique and outcomes include few patients,
therefore, evidence on the results of different labiaplasty techniques and patient satisfaction is
inconclusive. Further research is required to assess the value of this treatment and the
appropriate indications for it. Improved understanding as to why women seek this treatment is
needed and whether conservative treatments (such as counselling) are effective. Furthermore,
systematic assessment of the surgical and patient-reported outcomes of labiaplasty is needed
to assess whether it is safe and effective. Moreover, understanding the effect of cultural trends,
for example, the way in which many women in Western society see any exception to the ideal
body as a problem, will be insightful.
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undergo labiaplasty, and the numbers of medical doc‑
tors performing the procedure are unknown. This dis‑
crepancy could exist because labiaplasty is offered in a
wide range of centres, including hospitals, clinics, and
private practices. Furthermore, many women who are
recorded as receiving the procedure are lost to follow‑up
monitoring for several reasons (such as distance, lack
of compliance, and lack of scientific interest from the
health‑care provider), making data collection difficult13.
Thus, the need for reliable and representative data on
this topic is increasingly pressing. Specialists in sexual
health care are divided with regard to their opinions on
labiaplasty, with 64% reporting that they would never
perform a labiaplasty14. Reasons for this statement dif‑
fered with some not feeling capable of performing it
to because of working in a different field, others not
believing that a labiaplasty affects sexual function,
and some and being opposed to it. Thus, identifying and
understanding the scientific argument for this opinion
are important when considering the place of labiaplasty
in health care14. The remaining 36% of sexual health‑
care specialists who would potentially or do already
perform the procedure must be equipped with the most
recent data concerning patient outcomes and surgical
techniques so that they can make informed decisions
on the management of their patients.
This Review provides an overview of the current data
on labiaplasty and explores current opinions regarding
how to define labial hypertrophy and the indications for
surgery, including the motivations of patients and sur‑
geons and ethical considerations. Surgical procedures
and their outcomes are also discussed. We describe the
challenges presented to physicians by patients request‑
ing genital cosmetic surgery and provide information to
aid physicians and patients in shared decision making
and thereby in making a well‑informed decision when
deciding on the best treatment options.
Defining ‘normal’ labia minora
Definition of labia minora hypertrophy. A definition of
labia minora hypertrophy is required to select patients
for surgery owing to this condition. Currently, no crite‑
ria exist to provide a definition of labia minora hyper‑
trophy, and only one published study has suggested an
evidence‑based cut‑off point for the size of labia con‑
sidered as ‘normal’, which could be seen as an implicit
definition. In this study, 33 women applying for labia
minora reduction were screened for labia size at an out‑
patient clinic. According to the women’s own criteria, a
labia minora width >50 mm or an asymmetry >30 mm
were indications for surgery, as was being >18years
old, based on other research by this same group6. Only
three women in this study were offered surgery owing
to asymmetry of the labia minora >30 mm; the other
30 women were refused the procedure on the basis of
age (<18years) or size of the labia (width <50 mm or an
asymmetry <30 mm). Furthermore, 1 of the 30 women
who were refused surgery was referred to psychiatric
care owing to a danger of self‑mutilation, 12 chose a
second opinion, and 11 accepted a referral to a psy‑
chologist. No information is available concerning 6 of
the 30 women who were refused surgery6. Most women
applying for labiaplasty have labia minora that would
be considered a natural size by a medical professional,
emphasizing the importance of having a validated defi‑
nition of the natural variation in labia size. Ellsworth
and co‑workers15 developed an algorithm for selection
of surgical technique on the basis of the Franco classi‑
fication for labia minora size. The Franco classification
divides labia minora width into four groups: <2 cm;
2–4 cm; 4–6 cm; and >6 cm16 and the algorithm devel‑
oped by Ellsworth and colleagues15 assigns a specific
type of reduction technique to each group. (FIG.1). The
Gonzalez classification, proposed in 2015, resembles the
Franco classification5. These three classifications give
an insight in to labia size and shape, but labia minora
hypertrophy is not explicitly defined. Thus, a clear
definition of labia hypertrophy is still lacking, and no
consensus exists in the literature with respect to the
varying grades and classification of labial hypertrophy.
Justifying the decision of a health‑care professional to
perform labiaplasty or to refuse to do so is difficult as
a strict and evidence‑based definition of labia minora
hypertrophy has not yet beenformed.
Natural biological variation in labia minora width.
The extent of natural biological variations in the dimen‑
sions of female genitalia has been assessed in two stud‑
ies.17,18 (TABLE1). Lloyd etal.17 performed measurements
of female genitals in 50 premenopausal, anaesthetized
women before they received routine hysterectomy or
diagnostic laparoscopy. No statistically significant asso‑
ciation was reported between labia size and age, parity,
ethnicity, use of hormones, or history of sexual activity.
Labia minora width ranged from 7 mm to 50 mm with
a mean width of 21.8 mm17. Basaran etal.18 recruited 50
premenopausal and 50 postmenopausal women and
conducted labial width measurements in their outpatient
clinic. Mean labia minora width was significantly smaller
in postmenopausal women than in the premenopausal
group (15.4 ± 4.7 mm versus 17.9 ± 4.1 mm; P = 0.01) 18.
Why this difference in size exists is unclear and could be
an artefact of the small samplesize.
The limited available data suggest that the labia
minora width of women who request a labiaplasty
Key points
• No criteria exist to provide a definition of labia minora hypertrophy, and the
perception of normal labia minora size differs among women, health-care
professionals, and cultures
• Media outlets, such as magazines, show mainly altered images of labia, which affects
women’s genital self-image
• Eleven surgical approaches to labiaplasty have been described, meaning no
gold-standard technique exists
• Complication rates are low, and most complications are minor, but severe
complications can occur with considerable consequences
• The limitations of current studies are small sample size, few reporting on satisfaction,
complications, and outcomes, and lack of long-term data
• Patient-reported outcome measures are needed to enable evaluation of patient
satisfaction
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generally falls within the range of natural variations6,19
and is not substantially different from that of women
who do not desire genital surgery17,18. Thus, labiaplasty
is being performed on women who have labia minora
that would be considered normal according to cur‑
rent criteria. Interestingly, women in Zambia attempt
to elongate their labia minora with the use of weights
or pulling. Elongation of the labia is considered an
aspect of becoming a proper Zambian woman (one
who is ready to get married), creates bonds between
girls (by helping each other with pulling their labia),
makes a new labia shape (creating a beauty ideal),
and enhances sexual well‑being because an increased
labia length increases sexual pleasure. This behaviour
arguably puts the trend towards labia minora reduc‑
tion in economically developed societies in a different
perspective20.
Ambiguity concerning what constitutes ‘accept‑
able’ labia minora width was noted within professional
clinical practice, with variation in opinion reported by
surgeons. The labia minora width defined in reports
as the intended aim of labiaplasty ranges between 1 cm
and 4 cm after labiaplasty21–23. Only three studies have
attempted to define objective criteria for labiaplasty. The
algorithm proposed by Ellsworth etal.15 (FIG.1) is based
on the Franco classification16, which divides labial width
into four types: typeI (<2 cm); typeII (2–4 cm); typeIII
(4–6 cm); and typeIV (>6 cm). The algorithm advises a
de‑epithelialization technique for Franco classifications
I and II (for labia with a width <4 cm). For labia with a
width ≥4 cm, the classification indicates a full‑thickness
excision. Depending on the desire to remove or to retain
the naturally darker edge of the labia, an edge resection
technique or a superior pedicle technique is advised.
Gonzalez etal.5 modified the Franco classification in 2015
by adding two further dimensions (location of hypertro‑
phy being anterior (A), central (B), or generalized (C)
and adding symmetric (S) and asymmetric (AS) classifi‑
ers), which give a more complete description than previ‑
ous classification systems. However, best‑fit techniques
are not proposed. This classification system can simplify
communication among clinicians; for example, ‘2BS’ are
labia that are symmetrical and have a central hyper trophy
2–4 cm wide5. All three classifications stipulate typeI
width as hypertrophy of the labia, which is controversial
with regard to Crouch and colleagues’ definition of nat‑
ural labia minora6. The Ellsworth algorithm is especially
controversial in this regard, suggesting that typeI and
typeII should be treated with de‑ epithelialization reduc‑
tion and typeIII and IV with edge reduction or the supe‑
rior pedicle technique15 (FIG.1). However, Crouch etal.6
suggest that labiaplasty should only be offered to women
who have a labia minora width >5 cm or an asymmetry
>3 cm on the basis of their research on labia measure‑
ments and women’s opinions. These investigators con‑
cluded that labia minora within this range are normal
and that surgery is not required.
Perception of normality. The fluidity of the concept of
‘normal labia minora’ and the implications for socie‑
ties are reflected in differing reports on the perception
of labia minora within various populations. A study of
Zambian women and labia minora elongation showed
that, in this population, a labia minora width ranging
from 1.5 to 2 inches (3.81 cm to 5.08 cm) was desira‑
ble to create a “complete and proper woman”20. At the
same time, women in modern economically developed
societies want petite and nonprotruding labia minora19.
The results of one study have demonstrated that the
perceptions of women in Australia regarding the appear‑
ance of vulvas can be influenced by prior exposure to
images of natural or surgically modified vulvas24. In
this study, women participated in a two‑phase study;
in phase1, participants were randomly allocated into
one of three groups. One group was shown 35 images
of non‑modified (natural) vulvas on a computer screen,
one group was shown 35 modified vulvas (which had
undergone labiaplasty), and the final group viewed a
Nature Reviews | Urology
Degree of labia
minora hypertrophy
Retain
Corrugated, naturally
darker edge
Remove
Corrugated, naturally
darker edge
Superior pedicle
technique
Edge resection
technique
Franco type I
(<2 cm) Franco type II
(2–4 cm) Franco type III
(4–6 cm) Franco type IV
(>6 cm)
De-epithelialization
technique Full-thickness
excision
Fig. 1 | The Ellsworth algorithm for selection of technique for labiaplasty11. This
algorithm is based on the Franco classification of labia minora size9, which divides labia
minora width into four groups: <2 cm (typeI); 2–4 cm (typeII); 4–6 cm (typeIII); and >6 cm
(typeIV). The algorithm assigns a specific type of reduction to each group: typeI and typeII
should be treated with de‑epithelialization reduction and typeIII and IV with edge reduction
or superior pedicle technique. Reproduced with permission from REF.15, Springer.
Participants Method Mean age (years) ± SD (range) Mean labial width (mm) ± SD (range) Refs
50 premenopausal women Under anaesthetic 35.6 ± 8.7 (18–50) 21.8 ± 9.4 (7.0–50.0) 17
50 premenopausal women Outpatient clinic 30.2 ± 4.2(22–39) 17.9 ± 4.1 (11.0–30.0) 18
50 postmenopausal women Outpatient clinic 55.1 ± 3.1 (7–60) 15.4 ± 4.7 (8.0–27.0) 18
SD, standard deviation.
Table 1 | Reported labia minora width in women
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blank screen for 1minute. In phase2, all the participants
viewed the same 20 randomly ordered photographs of
10 non‑modified and 10 modified vulvas and were asked
to rate them for normality and the extent to which they
represented society’s ideal. Women exposed to images of
modified vulvas in phase1 were more likely to rate mod‑
ified vulvas as more normal than non‑modified vulvas
than woman who had viewed a blank screen in phase1;
however, the normality ratings given by women who
viewed images of non‑modified vulvas in phase1 were
not significantly different from those given to either of the
other groups. In terms of perception of society’s ideal for
vulva appearance, all three groups rated modified vulvas
as more ideal than non‑modified vulvas. Furthermore,
women who saw modified vulvas in phase1 were more
likely to rate these vulvas as complying with society’s ideal
than those who had viewed non‑modified vulvas, who
in turn were more likely to rate modified vulvas as more
ideal than those who had viewed a blank screen. Thus,
the concept of what is normal can be influenced by expo‑
sure to selected images24. As such, both women seeking
labiaplasty and health‑care professionals can be biased
by altered images, in which modified vulvas become per‑
ceived as natural and, therefore, ideal. This observation
highlights the importance of showing images of natural
vulvas during consultation with women who request a
labiaplasty and also discussing normality.
This effect has been shown in another study in which
the effect of exposure to pictures of natural vulvas on
a woman’s genital self‑image was analysed using the
Female Genital Self‑Image Scale (FGSIS)25. Participants
in this study were healthy Dutch women who had not
requested any genital alterations. Before seeing the pic‑
tures, a majority (60.5%) of women scored highly on
the FGSIS (selecting agree or strongly agree with each
statement, meaning they were generally happy with the
appearance of their genitals)26. The women were then split
into two groups: one group was shown images of natural
vulvas; and the other group was shown images of neu‑
tral objects. After viewing the images, the women’s views
were reassessed using the FGSIS, and then they completed
the survey again 2weeks later. The group of women who
viewed the pictures showed a significant increase in pos‑
itive appraisal of their own genital appearance. (post‑test
P < 0.001; follow‑up point P < 0.005)26. Observing vulvar
variation increases women’s appreciation of their own
genital appearance, which suggests that the concept of
what is normal can easily be influenced by exposure
to selectedimages. The investigators concluded that
observing vulvar variation positively affects a woman’s
perception of the appearance of her own genitals26.
In our experience, most women are not aware of what
their vulva looks like or are not able to assess their own
vulvas in relation to factors such as sexual sensation and
function, which was made clear in a study by Schober
and colleagues27. Thus, the questions are whether women
have the ability to assess whether the appearance of
their vulva is different from perceived normal appear‑
ance, whether something is wrong with it, and whether
there is an anatomical abnormality that needs correct‑
ing when they are not familiar with vulvar variation.
Thus, counselling, looking at pictures of vulva variation,
and educating women are important, as many are reas‑
sured and change their mind about labiaplasty. In private
practice, the outcome of such interventions might be dif‑
ferent, as many women who attend these clinics seem to
be determined to have a labiaplasty and are willing to
pay for it. Thus, these women can be familiar with vul‑
var variation but want to change the appearance of their
vulvaanyway.
Selective exposure. Women in the Western world are
increasingly being exposed to images of perceived per‑
fection through all types of media19,28. An analysis of cen‑
trefold images in Playboy magazine showed that only
2.7% of images displayed in editions published in 2007
and 2008 depicted the labia minora protruding beyond
the labia majora. Moreover, only the labia majora were
visible in 82.2% of images of the genitals of centre‑
fold models, whereas 15.1% of pictures displayed the
labia minora contained within the labia majora28. This
over‑representation of idealized images of female geni‑
tals generates a substantial risk that the concept of nor‑
mal labia minora does not match reality. Furthermore,
shaving of pubic hair is increasingly prevalent, enabling
women to make comparisons between the appearance
of their genitals and that of others19,28. In one study, 95%
of women were reported to frequently examine their
labia minora29, and adolescents presented with con‑
cerns about abnormal labial appearance after comparing
their genitals with those of other women (for example
siblings, Internet images, and anatomical images)19.
Results of one study showed that girls request‑
ing assessment of their genitals or surgery to their
labia minora had an asymmetry of their labia minora
width ranging from 6 mm to 35 mm or a labia
minora width ranging from 22 mm to 55 mm19. These
values are not substantially different from the natural
range of labia minora width of 7–50 mm suggested by
Crouch and colleagues6. Both of these results are from
women in England6,19, suggesting that natural biological
variation in a population does not necessarily correlate
with that population’s cultural beliefs.
Together, these studies indicate that women in
Western societies are being exposed to a single rep‑
resentation of the appearance of labia minora and are
potentially misjudging the reality of vulva appearance,
in which vulva size is diverse. Women are apparently
negatively influenced by images that they see. However,
men are exposed to the same images but do not experi‑
ence the same effect. For example, a 2007 article in the
girls magazine Yes revealed that girls do not give their
vulva a name, whereas men often have a name for their
penis. Furthermore, men rate the vulva of their girlfriend
with an A grade and girls give themselves a C grade30. An
experiment was conducted on the social media platform
Facebook in which pictures of vulvas were taken and both
the woman and her male partner were asked to say what
they saw looking at the picture. This reaction was filmed
and subsequently shown to the other partner. Women
were fairly negative, and men were loving, proud, and
moved when looking at the vulva of their partner. The
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reaction of the men surprised and moved the women31.
However, men could be negative about their own geni‑
tals, so perhaps all people are critical of themselves.
Counselling. One study has been conducted on effects
of counselling on reducing the desire for labiaplasty32.
Patients requesting the procedure attended counselling
in three separate 1‑hour sessions. Initially, a structured
interview was conducted, focusing on the reasons for
their request and obtaining their medical, psycho‑
social, and sexual history. Afterwards, patients were
informed of the function of the vulva, vagina, and pel‑
vic floor. In parallel, genital normality (supported with
images of natural vulvas), surgical techniques, possible
results, and the risk of complications were discussed.
Psychosexual education was also given in conjunc‑
tion with an educational physical examination. At the
end of the last consultation, patients were asked once
more about their considerations and decision whether
to undergo a labiaplasty, and 35% of patients chose to
refrain from undergoing surgery32. The persistence of
the 65% of the women still desiring a labiaplasty could
be caused by the fact that they had made up their mind
before attending the outpatient clinic. These women
are willing to risk possible complications and realize
their right of autonomy to change something about
their own body. At a plastic surgery meeting of the
Nederlandse Vereniging voor Plastische Chirurgie
(Dutch Association for Plastic Surgery, NVPC) held
in 2009, discussion occurred about whether all plas‑
tic surgery patients desiring alterations that were not
medically indicated should be referred for counselling
or whether people have the right to alter their body
by piercing, tattoo, or surgery. A potential reason why
labiaplasty is discussed in this context is because of the
comparison that is made with female genital mutilation
(FGM), which is a sensitive subject.
Experience suggests that a large number of women
seeking labiaplasty want to be assured that they are nor‑
mal; they want to hear that nothing is wrong with their
genitals. Counselling and education could make a dif‑
ference in these circumstances and prevent this group
of women from undergoing medically unnecessary
surgery. Educating women about the natural biological
variations in vulva appearance, providing them with
images of natural vulvas, providing correct information
about surgery, and suggesting alternative methods of
reducing genital discomfort can help women to make
well‑ considered choices regarding genital appearance.
Genital self-image
Understanding the implications of a negative or
positive genital self‑image on the lives of individual
women is important when presented with the difficult
question of whether to perform genital cosmetic sur‑
gery. Evidence has suggested that as humans, we have
an unconscious obsession with sexual organs33. Thus,
the implications of having a negative genital self‑image
might be considerable.
Having a negative genital self‑image was shown
to have negative effects on sexual self‑esteem and an
individual’s perception of their own attractiveness34.
Genital self‑image has been shown to correlate with desire
for, participation in, and enjoyment of sexual activity35,36.
Specifically, increased positive perceptions and reduced
negative perceptions were associated with participation
in and enjoyment of sexual (especially oral–genital) activ‑
ity35, and positive genital self‑image has been shown to
negatively correlate with the incidence of sexual distress
and depression36. Conversely, women who are dissatis‑
fied with the appearance of their genitals have increased
self‑consciousness during physical intimacy, which is
associated with reduced levels of sexual self‑ esteem,
sexual satisfaction, and motivation to avoid risky sexual
behaviours owing to a lack of sexual confidence37. Risky
sexual behaviours could result in an increased incidence
of sexually transmitted infections (STIs), which in turn
can cause genital discomfort or more shame about their
genitals and increase their dissatisfaction with their gen‑
itals. Thus, arguably, if genital cosmetic surgery improves
genital self‑image in these women, such surgery could
also improve their sexual health and safety37. However,
more conservative methods than surgery are available for,
and effective in, improving genital self‑image. Data show
that if young women with a positive genital self‑image are
exposed to images of natural vulvas, personal satisfac‑
tion with genital appearance improves for up to 2weeks
after image exposure25. Thus, women who have a negative
genital self‑image could possibly benefit from looking at
naturalvulvas.
Genital self‑image is positively associated with
enjoyment of sexual activity but not necessarily
with frequency of orgasm25. Data from two studies show
that women report the labia minora, the clitoris, and the
skin above the clitoris as the most sexually sensitive areas for
the achievement of orgasm27,38. This sensual function
of the labia minora provides an argument against sur‑
gical excision of the labia minora or the clitoral hood.
However, the results of one study involving women
undergoing labia minora and clitoral hood reduction sur‑
gery showed an increase in orgasm frequency in 35.3%
of patients (P = 0.013) and an increase in orgasm strength
in 35.3% of patients (P = 0.006). Furthermore, 44.1% of
women reported an increase in the number of sexual
relations experienced at the 6‑month follow‑up point
(P = 0.011). Whether the change in the frequency and
strength of orgasm was caused by the clitoral hood reduc‑
tion, the labia minora reduction, or both is unclear39. No
data are currently available on the effects of labiaplasty
procedures alone on the sexual sensitivity of the genital
area. Having quantitative measures of the sensitivity of
the labia minora before and after labiaplasty would be
useful to assess the effects of surgery. However, collecting
quantitative data on the sensitivity of the labia minora
and changes during arousal is difficult.
Current evidence outlines the importance of main‑
taining a positive genital self‑image when optimizing
the emotional, sexual, and health‑care needs of women.
Whether conservative methods or cosmetic genital sur‑
gery are effective, and how they compare with regard to
boosting genital self‑image in women who have a low
genital self‑esteem, is not yetclear.
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Motivation
Reasons for the desire for labiaplasty. Western women
have an increasing desire for genitals with an absence of
pubic hair and small labia minora, resembling prepubes‑
cent female genitals in appearance40,41. This increasing
popularity of cosmetic genital surgery can be viewed as
another manifestation of the pursuit of the ‘perfect body’.
However, the perception of ‘perfection’ depends on cul‑
ture and exposure. Women are often exposed to unre‑
alistic, idealized images of female genitals and do not
have a good idea of the true extent of natural variations
in genital appearance. Magazines containing images of
genitals rarely show a full genital image or depict gen‑
ital images without protruding labia minora28. A doc‑
umentary video called ‘The Labiaplasty Fad?’ made
by an ABC Australia current affairs programme called
Hungry Beast, posted on the video streaming website
YouTube, and on the Internet page of photographer Nick
Karras (www.nickkarras.com)42 provides some insight
into the ethical code used by Australian unrestricted
soft‑ pornography magazines regarding labia minora.
According to the documentary, the Australian classi‑
fication guidelines state “Realistic depictions may con‑
tain discreet genital detail but there should be no genital
emphasis.” This statement seems to have been inter‑
preted as having no protruding labia minora in images
of naked women; thus, labia minora are frequently
edited out of the images in these magazines42. Exposure
to pictures that create a biased reference can lead to an
altered genital self‑image, especially in younger women,
as they could be more susceptible to these images than
older women. Current evidence suggests that labiaplasty
requests are predominantly based on dissatisfaction with
the genital appearance and not on functional complaints.
Idealized images presented in the media might provide
women with an abnormal perception of normality12;
however, whether this skewed perception motivates
them to request labia minora modification is not clear.
Currently, patient motivation can be divided into two
broad categories: physical complaints and social factors.
A number of physical complaints involving the
labia minora have been reported, including pain,
infection, discomfort during various physical activ‑
ities (including sexual intercourse), and difficulties
with personal hygiene43. However, with the exception
of sexual intercourse and satisfaction, physical com‑
plaints are not reported to be the leading motivation
for women to request labiaplasty44. The leading moti‑
vations for seeking surgery are emotional dissatisfac‑
tion with genital appearance and dissatisfaction with
sexual relationships44,45. Women requesting surgery
refer to anxiety about their current sexual partner see‑
ing or touching their genitals or the possible inhibition
of future sexual relationships owing to the appearance
of their genitals46. Satisfaction with relationships in
general was negatively correlated with the consid‑
eration for labiaplasty47, and women who reported
receiving negative comments about their genitals in
previous sexual relationships or who had been subject
to sexual abuse as a child had an increased likelihood
of requesting surgery48.
Other factors that are positively associated with
an increased desire for labia minora cosmetic surgery
include reduced overall satisfaction with life and not hav‑
ing a romantic relationship at the time of the treatment
request49. Women seeking labiaplasty do not necessarily
have a higher incidence of depression or anxiety than
those without the desire for surgery, but they do have
a generalized negativity towards overall body image,
with a considerable proportion meeting the diagnostic
criteria for body dysmorphic disorder48,49. Current evi‑
dence suggests that motivation for labiaplasty has both
psychological and emotional origins rather than being
determined by physical difficulties. This theory is rein‑
forced by the finding that 75% of specialists in sexual
health choose to refer women who request labiaplasty
to psychological services before considering any surgical
interventions14.
Thus, the most common argument for performing
labiaplasty if no physical abnormality exists is that it
improves genital self‑image and self‑esteem and, thereby,
sexual function. A negative genital self‑image is a cause
of sexual dysfunction50. Thus, alleviation of negative
self‑image could improve sexual function50. However, the
argument could also go the other way; sexual dysfunc‑
tion could affect the way people feel about their genitals,
and a negative self‑image could be the consequence50.
Both arguments provide support for counselling women
who request labiaplasty before performing surgery, as
this process could reveal the underlying reason for the
request4. Knowing the underlying reason can aid refer‑
ral. Women who requested a labiaplasty were signifi‑
cantly more likely to have experienced negative remarks
about their genitals than those who did not desire the
procedure (P < 0.0001)51. Sources of negative comments
were mostly previous sexual partners (64.3%), but other
sources recorded included peers, mothers, sexually abu‑
sive fathers, sons, and health‑care professionals32,51. Özer
etal.32 reported only negative remarks from themother.
A combination of the pursuit of the perfect vulva
and exposure to idealized images of female genitals
might cause feelings of shame and doubt about wom‑
en’s genitals. Physical complaints are mentioned,
with the exception of sexual intercourse and satis‑
faction, but these complaints are not reported to be
the leading motivation for women to request labiaplasty.
The leading motivations for seeking surgery are emo‑
tional dissatisfaction with genital appearance and
dissatis faction with sexual relationships. Negative com‑
ments from others have a negative effect on genital
self‑image and can lead to the wish for a labiaplasty.
The attitude of physicians towards labiaplasty.
Lowenstein etal.14 conducted a multinational survey
during the 2012 European Society for Sexual Medicine
meeting in Amsterdam in which 360 physicians in the
field of sexual medicine stated their attitude towards
female genital plastic surgery (FGPS). The majority
of participants (270, 75%) believed that women seek‑
ing FGPS should be referred to a psychiatrist or psy‑
chologist for consultation before surgery. Labia minora
>5 cm in width was thought by most physicians to be
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hypertrophic (270, 75%)14. Reistma etal.52 asked plas‑
tic surgeons, gynaecologists, and general practitioners
to look at four pictures of vulvas with labia minora of
different sizes. Plastic surgeons were significantly more
likely to think that the largest labia minora looked dis‑
tasteful and unnatural and consider the size to be an
indication for labiaplasty than gynaecologists or gen‑
eral practitioners (P < 0.01). Plastic surgeons were also
significantly more open to performing a labiaplasty
irrespective of an absence of physical complaints or
labia minora size than gynaecologists (P < 0.01). A sig‑
nificant difference between male and female physicians
was also reported, with men being more predisposed to
performing a labiaplasty (P < 0.01)52. Surgeons perform‑
ing vulva surgery for aesthetic reasons might also be at
risk of unintentionally mistaking pelvic floor disorders
for physical complaints caused by hypertrophic labia53.
Manifestations that can be mistaken for burden caused
by the labia are dyspareunia, small wounds or tears in
the vulva area, and a burning sensation in the genital
region. Performing surgery will increase pain and pelvic
floor overactivity, slow wound healing, and be another
negative experience towards the vulva region. Health‑
care providers attending the 2013 European Society
for Sexual Medicine meeting in Amsterdam were at
an increased likelihood of referring patients seeking
labiaplasty for counselling; however, plastic surgeons
were more likely than gynaecologists to have an image of
an idealized vulva52. Thus, whether a labiaplasty is per‑
formed is influenced by the opinion of vulva appearance
held by the consulting doctor. A labiaplasty is surgical
reduction of the labia minora, so it is a physical altera‑
tion not a treatment for sexual or vulvar complaints such
as dyspareunia. In our opinion, a labiaplasty should not
be offered as a treatment for genital complaints, as they
might not be resolved by the surgery.
Surgical techniques
Different views on the optimal surgical technique for
labiaplasty, in order to obtain an aesthetically and func‑
tionally satisfactory result, have been presented. Overall,
11 different techniques have been reported, which can
be categorized into three groups: edge resection; wedge
resection; and central resection (FIG.2).
Edge resection. In an edge resection, excess labial tissue
is removed by resecting the most protruding part of the
labia minora. This removal can be performed either in
a straight line that follows the curve of the labia1, in a
lazy S‑shaped resection54, or in a W‑shaped resection22.
A curved resection is chosen to forestall contraction of
the scar (FIG.2A). The straight excision can be completed
using a scalpel, diathermia, or a combination of both;
some surgeons use a clamp to first crush the site of inci‑
sion and then to minimize blood loss1 (FIG.2Aa). Chavis
etal.1 do not mention whether a scalpel or diathermia
was used, but the labia minora was reshaped using
subcuticular polyglycolic acid sutures. Felicio etal.54
introduced an S‑shaped resection in order to reduce the
effects of scar contraction, to interrupt the straight line,
and to increase the length of the scar (FIG.2Ab). Maas
etal.22 further developed this idea by using a double‑
W‑shaped incision, which starts alternately on the inner
and outer side of the labia minora so that the tissue can
be folded into place easily. The Z‑plasty, a widely used
technique within plastic surgery, is used to reduce the
extent of scar contraction (FIG.2Ac).
Wedge resection. Wedge resection techniques are the
most popular labiaplasty techniques. These techniques
include various modifications that have been made to
improve aesthetic results (such as preserving the shape
and colour of the labium) or to prevent loss of function
or sensation. The wedge is marked first on the smallest
labium if a difference in size is present, and this marking
is then transferred over to the other labium. Infiltration
of local anaesthesia is performed using xylocaine and
adrenaline. The reduction is achieved by resecting the
wedge that was marked and incising the skin with a
scalpel and the labia tissue with diathermia. The labia
are approximated in layers using vicryl 4.0, and the skin
is closed using vicryl 4.0 or 5.0 or monocryl 5.0; inter‑
nal dogears can be corrected easily. The location of the
wedge can be adjusted to the most protuberant part of
the labia minora. The central wedge resection can be per‑
formed with or without first identifying and preserving
the main labial artery55,56 (FIG.2Ba). Giraldo etal.3 even
use a predesigned template to perform a 90° Z‑plasty
in order to prevent scar contraction (FIG.2Bb). When
reduction of the clitoral hood is also desired, a central
wedge can be combined with a “lateral anterior curved
excision of redundant lateral labium and excess lateral
clitoral hood”56. The wedge can also be placed posteri‑
orly, which is a posterior wedge resection23,57, or inferior
wedge resection and superior pedicle flap reconstruc‑
tion can be performed58 (FIG.2Bc). The greatest advan‑
tage of the wedge reduction technique is the fact that
the labia cannot be reduced too much; with edge resec‑
tion, care must be taken to leave enough labia minora
length that the patient does not experience inconven‑
ience when wearing underwear, dryness, infections,
vaginal discharge, or stretching of the vaginal introitus
during intercourse. Thus, the wedge reduction is rela‑
tively safe, as the labia cannot be over‑reduced. Most
surgeons experience central or edge dehiscence during
wedge resection, but this occurrence is not reported as a
complication in the literature.
Central resection. Other techniques proposed in order
to preserve the original texture, contour, and pigmen‑
tation of the labial edge include de‑ epithelialization21
and fenestration59. Choi etal.21 described a de‑
epithelialization technique using a triangle‑shaped
marking centred in the labia minora. After injecting
lidocaine and adrenaline, the central marked part of the
labia minora is de‑epithelialized (FIG.2Ca). The rough
edges are sutured together with catgut21. Ostrzenski
etal.59 first applied lidocaine–prilocaine cream (in a 2.5%
to 2.5% ratio) and an ice pack 30minutes before sur‑
gery and determined and marked the amount of tissue
to be removed centrally in the labia minora in a ‘bicycle
helmet’ shape (FIG.2Cb). Lidocaine and adrenaline were
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injected into the labia minora and also at the superficial
part of the deep branch of the perineal nerve and the
posterior labial nerve. Excision is performed with a scal‑
pel15, and the inner and outer surface of the labia minora
are sutured separately without suturing the erectile tissue
betweenthem59.
Ellsworth and colleagues15 developed an algorithm
for selection of the type of reduction that should be
used for specific widths of labia minora hypertrophy
by comparing the positive and negative aspects of
each technique on the basis of their own experience
of 12 procedures performed on patients. The surgeon
chose one of three reduction techniques (edge exci‑
sion, inferior wedge resection, or de‑ epithelialization)
on the basis of the degree of hypertrophy and the
patient’s requirements regarding labial edge colour
and contour15. Gonzalez etal.5 modified the Franco
Nature Reviews | Urology
A Edge resection
a b c
a b
a b
c
B Wedge resection
C Central resection
Fig. 2 | Surgical technique for labiaplasty. A|Edge
resection is a technique in which excess labial tissue is
removed by resecting the most protruding part of the labia
minora. Aa|The straight excision, which follows the curve
of the labia in which the labia minora was reshaped with
subcuticular polyglycolic acid sutures, can be completed
using a scalpel, diathermia, or a combination of both. Some
surgeons use a clamp to first crush the site of incision and
also to reduce blood loss. Ab|An S‑shaped resection is used
to reduce the effects of scar contraction, to interrupt the
straight line, and to increase the length of the scar. Ac|A
double-W-shaped incision technique starts alternately on
the inner and outer side of the labia minora so that the
tissue can be folded into place easily. The Z-plasty, which is
a widely used technique within plastic surgery, is used to
reduce the extent of scar contraction. B|Wedge resections
are the most popular labiaplasty techniques. These
techniques also include various modifications that improve
aesthetic results (such as preserving the shape and colour of
the labium) or prevent loss of function or sensation. The
wedge is marked first on the smallest labium if a difference
in size is present, and this marking is then transferred onto
the other labium. The reduction is achieved by resecting the
wedge that was marked, which is accomplished by incising
the skin with a scalpel and the labia tissue with diathermia.
The location of the wedge can be adjusted to the most
protuberant part of the labia minora. Ba|The central wedge
resection can be performed with or without first identifying
and preserving the main labial artery55,56. Bb|A predesigned
template can be used to perform a 90° Z-plasty in order to
prevent scar contraction. When reduction of the clitoral
hood is also desired, a central wedge can be combined with
a “lateral anterior curved excision of redundant lateral
labium and excess lateral clitoral hood”56. Bc|The wedge
can also be placed more posteriorly, which can be termed a
posterior wedge resection23,57 or inferior wedge resection
and superior pedicle flap reconstruction58. C|Central
resection is used to maintain the original texture, contour,
and pigmentation of the labial edge and includes de-
epithelialization21 and fenestration59. Ca|A triangle‑shaped
marking centred in the labia minora allows for the de-
epithelialization of the area. The rough edges are sutured
together with catgut. Cb|Ostrzenski etal.59 marked the
amount of tissue to be removed centrally in the labia minora
in a ‘bicycle helmet’ shape. Excision is performed, and the
inner and outer surface of the labia minora are sutured
separately, without suturing the erectile tissue between them.
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classification in 2015 by adding two further dimensions
(location of hypertrophy being anterior (A), central
(B), or generalized (C) and adding symmetric (S) and
asymmetric (AS) classifiers), which give a more com‑
plete description. However, best‑fit techniques were
not proposed5. We believe that the best technique to
use is the technique that the surgeon is most confident
performing given their own previous experience.
Outcomes of labiaplasty
Few studies report on the surgical outcomes of
labiaplasty (TABLE2). Those that do report outcomes
have a mean cohort size of 65 patients, a variable fol‑
low‑up period, and mostly poorly defined outcomes.
The level of evidence of all studies was 4, a low level
of evidence based on the Centre for Evidence‑Based
Medicine levels, which range from 1 to 560. Outcomes
evidence for labiaplasty is currently insufficient, but
some studies have provided an evaluation of patient
satisfaction with the wedge resection method in enough
patients to enable analysis of patient reported outcomes
(between 113 and 407 patients) 13,23,61. In one study
including 163 patients, 93% were satisfied with the ana‑
tomical results of surgery 1month after surgery. Of the
98 women who completed satisfaction questionnaires,
81 (83%) patients were satisfied with the results, 87
(89%) were satisfied with the aesthetic results, and 91
(93%) were happy with the functional outcomes. Only
four women in this cohort would not undergo the
same procedure again23. In another study, 166 out 407
patients returned their postoperative satisfaction ques‑
tionnaires. Most of these women were pleased with
the results of surgery, with the average score being 9.2
out of 10 and 10 being most pleased. Overall, 93% of
women experienced an improvement in self‑esteem,
71% had an improved sex life, and 95% had reduced
levels of discomfort. The complication rate was low
(4% of patients)13. In a study involving 113 women, 15
reported experiencing transient symptoms, including
swelling, bruising, and pain, one patient had bleeding,
and four needed revision surgery; however, no major
complications were reported61. The results of these three
studies suggest that labiaplasty does not cause too much
discomfort and improves satisfaction and self‑esteem.
Unfortunately, the conclusions of these studies are not
comparable with the outcomes of other surgical tech‑
niques reported. Patients requesting labiaplasty should
be provided with all the information required in order
to make an informed decision on their treatment.
Sometimes this procedure causes discomfort, pain, and
swelling for a few weeks, but the proportion of women
experiencing these issues is very small. Furthermore,
if women expect to be free of sexual problems, talking
to them about the fact that labiaplasty is a reduction of
labial tissue not a cure for sexual problems and insecu‑
rity is very important. Levels of genital anatomy aware‑
ness need to be increased in the general population,
expectations of women requesting labiaplasty should be
explored and adjusted if necessary, and patients should
be informed of the risks and potential vulva results, all
without compromising the autonomy of the patient62.
Complications. Overall, low complication rates have
been reported, most of which are minor complications
(TABLE2). Out of sixteen studies, four had no data on
complications1,39,55,63, four reported uneventful recov‑
ery21,56,59,64, and four detailed minor complications,
such as bleeding, pain, haematoma, swelling, and
minor wound dehiscence3,22,57,61. Four studies reported
more considerable complications that sometimes
needed a second procedure or revision.13,23,58,65. Three
of these studies also mentioned sexual problems after
labiaplasty. Alter etal.13 reported that nine women
experienced a negative change in sexual sensation.
Moreover, five women had orgasm difficulties, four
women reported decreased labial sensation, and one
had increased pain during intercourse13. Rouzier etal.23
indicated that 64% of women had postoperative pain,
45% experienced postoperative discomfort, and 23%
had entry dyspareunia for between 3 and 90days23.
In another study, one woman complained of a slight
aching introitus, two experienced reduced sexual
arousal, one had discomfort wearing tight clothes,
and one woman regretted the labiaplasty65. However,
reoperations (mostly performed for aesthetic reasons)
were reported in up to 7.9% of patients. Unfortunately,
long‑term data are limited, and variable durations of
follow‑up monitoring have been reported.
In a study by Veale etal.65 including 23 women,
26% of women reported one or more minor adverse
effects at a 3‑month follow‑up point. However, 17
women (74%) reported having no adverse effects, 96%
of women had clinically significant improvements in
Genital Appearance Satisfaction (GAS) scale results at
3months after surgery (P < 0.0005), and 91% still had
significant improvements at the long‑term follow‑up
point (P < 0.0005). Furthermore, Cosmetic Procedures
Scale‑Labia scores at the 3‑month follow‑up point
showed significant improvement (P < 0.0005), which
also remained significant at long‑term follow‑up
assessment (P < 0.0005). The results of both of these
questionnaires suggest that women had improved
levels of satisfaction and reduced levels of concern
regarding the appearance of their genitals. Adverse
effects occurred in 26% of women and included dif‑
ficulty with urination, pain at the vaginal opening,
reduced levels of sexual arousal, noticeable scarring
of the labia minora producing a jagged appearance,
slight aching on one side of the vaginal entrance,
and discomfort wearing tight clothes. One patient
expressed regret about having the surgery65. Alter and
colleagues13 concluded that complication rates could
be higher than was reported in their study, as only 123
patients of a total of 407 included in the study (30%)
were examined at 2weeks postoperatively, and only
166 patients (41%) responded to the questionnaire.
This loss of patients to follow‑up monitoring outlines
a problem with studies that are mostly conducted in
private clinics13.
Complication rates are low, most complications are
minor, and complications tend to resolve by them‑
selves, but the more severe complications have consid‑
erable consequences, including revision surgery and
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Reference,
level of
evidence60,
and n
Age
(years)
Technique Follow‑up
monitoring
duration
Method of
assessment
Complications Results Satisfaction
1, 4, and 1 30.0 Edge reduction NA Clinical
assessment
NA NA Exceedingly
pleased
55, 4, and 2 Young
women
Wedge reduction
(identifying main
artery)
NA Clinical
assessment
NA Excellent cosmetic
results with smooth
symmetrical
contours, minimal
scarring, and relief
from symptoms
NA
56, 4, and 4 26.5
(range
24–32)
Wedge reduction 1 week Clinical
assessment
Uneventful recovery NA Pleased and
satisfied
22, 4, and
13
30.0
(range
19–42)
W-Shaped edge
resection
2 months to
6years and
continuous for
some patients
Clinical
assessment
1 haematoma; 1 suture
gave way
No discomfort in
sexual activity
All happy
23, 4, and
163
Median
26.0
(range
12–67)
Posterior wedge 1 month for 98
patients; mean
30months
(6–109months)
Clinical
assessment
In 17%, second
procedure warranted
improvement;
64% experienced
postoperative pain;
45% experienced
postoperative
discomfort; 23% had
entry dyspareunia for 3
to 90days
4 said the size of
labia minora was
too large; 8 said the
size of labia minora
was too small; 4
would not undergo
this procedure
again
83% rated
procedure as
satisfactory; 88%
achieved the
expected aesthetic
result
21, 4, and 4 26.5
(range
13–40)
De-epithelialization
reduction
NA Clinical
assessment
No complications NA All satisfied
3, 4, and 15 34.0
(range
22–45)
Central wedge
with a 90° Z-plasty
Mean
30months
(6–80months)
Clinical
assessment
2 minimal dehiscence
of the surgical borders
Problems of
discomfort and
anxiety resolved;
improved
self-esteem and
confidence socially
and in personal
relationships
NA
58, 4, and
21
38.0
(range
31–49)
Inferior wedge
reduction with
superior pedicle
NA Clinical
assessment
1 distal flap
necrosis; 1 small
local haematoma; 1
superficial infection; 2
wound dehiscence; 1
distal flap necrosis and
wound dehiscence
18 said the
cosmetic result
was good or very
good; 3 said the
cosmetic result was
satisfactory
20 very satisfied;
1 satisfied with
the aesthetic
appearance of the
external genitalia
13, 4, and
407
32.4
(range
13–63)
Central wedge 4 months Clinical
assessment
18 substantial
complications: 12
revisions (separation
or scar stretching); 3
wanting revisions; 3
chronic discomfort;
9 negative change
in sexual sensation:
5 orgasm difficulty;
4 decreased labial
sensation; 1 increased
pain during intercourse
NA 166 were pleased
with the surgery;
95% had improved
self‑esteem; 71%
had improved
sex life; 95% had
improvements
in feelings of
discomfort; 98%
would undergo
labia minora
reduction again;
22.9% had a
positive increase in
sexual sensation
57, 4, and
22
35.0
(range
19–57)
Posterior wedge Mean
3months
(2weeks to
1.5years)
Clinical
assessment
1 minor wound
dehiscence; 1
haematoma
No paraesthesias
or pain or problems
with penetrating
vaginal intercourse
NA
Table 2 | Studies reporting outcomes of labia minora reduction procedures
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sexual problems. In our opinion, the largest issue is
the labiaplasties that end up too short, as women feel
amputated or experience sexual problems and pain.
Sometimes reconstruction in these instances is not possi‑
ble, and these women have more physical problems after
surgery than before. However, labia being too short has
not been reported as a complication. If increased atten‑
tion was paid to potential complications during counsel‑
ling of women requesting labiaplasty, women might not
be so dissatisfied when complications dooccur.
Reference,
level of
evidence60,
and n
Age
(years)
Technique Follow‑up
monitoring
duration
Method of
assessment
Complications Results Satisfaction
Table 2 (cont.) | Studies reporting outcomes of labia minora reduction procedures
59, 4, and 3 24.0
(range
22–27)
Fenestration
reduction
At least
6weeks
Clinical
assessment
No complications Medical and
emotional
symptoms and
signs resolved;
body self-image
and confidence
improved
Pleasing surgical
outcomes
that exceeded
subjects’ aesthetic
expectations
64, 4, and 6 13.6
(range
11–16)
Edge reduction 6 weeks Clinical
assessment
No complications NA All satisfied
61, 4, and
113
31
(range
18–64)
Edge reduction 3 months Clinical
assessment
15 transient symptoms:
swelling, bruising,
and pain; 1 bleed; 4
required revision; no
major complications
were reported.
NA All satisfied
63, 3, and
120
32.7
(range
18–63)
Female genital
plastic surgery
(including labia
minora reduction)
At least
24months
Prospective,
cohort, case-
controlled
study
NA Index of Sexual
Satisfaction: study
group resembled
control at 6months
and >1year after
surgery; body
dysmorphic
disorder and Female
Genital Self-Image
Scale: study group
resembled control
group at 1year
after surgery; Body
Esteem Scale:
study group scored
better than control
group at 1year after
surgery
NA
39, 3, and
37
34.1
(range
21–58)
Edge reduction
and clitoral hood
reduction
At least
12months
Prospective
evaluation of
sensitivity with
Semmes-
Weinstein
Monofilaments
and Sexual
Function
Questionnaire
NA Median increase
in sensitivity at
6months; increase
in number of
sexual relations
at 6months;
increase in orgasm
frequency and
strength
NA
65, 3, and
39
34
(range
25–43)
25 labial
trimmings, 9
central wedge
reductions, 3
de-epithelization
techniques,
2 superior
pedicle flap
reconstructions
11–42 months Prospective,
case-
comparison
study
Long‑term: 6 had
one or more adverse
effects: 3 experienced
issues with urination;
2 had aesthetic
concerns; 1 had slight
aching introitus; 2 had
reduced sexual arousal;
1 had discomfort
wearing tight clothes; 1
experienced regret
Labiaplasty group
scored higher on
the PISQ initially;
at 3months
after surgery, the
labiaplasty group
scored lower on
GAS and COPS-L;
at long-term
follow-up point,
the improvement
in GAS and COPS-L
remained significant
8 had very much
improved function;
6 had much
improved function;
5 had moderately
improved function;
4 had slightly
improved function;
3 had no change
COPS-L, Cosmetic Procedures Scale-Labia; GAS, Genital Appearance Satisfaction; NA, not available; PISQ, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire.
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Satisfaction. High percentages of favourable patient
satisfaction are observed within follow‑up monitoring
periods in 11 of 16 studies1,13,21–23,56,58,59,61,64,65 (TABLE2).
However, satisfaction was usually not measured inde‑
pendently using standardized measures. In one study
in which postoperative sensitivity after a labia minora
and a clitoral hood reduction procedure was measured,
a sexual function questionnaire was also administered39.
The questionnaire was given at baseline, 2weeks,
3months, 6months, and 12months postoperatively to
the 37 women involved in the study. The results showed
improvements in the extent of labial sensitivity and sex‑
ual function, including significant increases in sensitiv‑
ity at the left and right labial locations (P = 0.046 and
0.027, respectively) and significant increases in orgasm
frequency (P = 0.013) and of orgasm strength (P = 0.006)
at 6months postoperatively. Whether these increases are
the result of labia minora excision or the clitoral hood
reduction is not known. A significant 44.1% increase in
the number of sexual relations (P = 0.011) was reported
and occurred because of decreased embarrassment and
increased confidence in genital appearance, suggesting
that the procedure has positive psychological effects.
In addition to these outcomes, 90% resolution of body
dysmorphic disorder was observed in a group of nine
patients at 3months after the procedure. This result
means that their labia had less or no effect on their
functioning, sexual or otherwise39.
In a prospective, case‑controlled cohort study, 120
women who underwent genital plastic surgery were
compared with those of a demographically matched
group of women who had not requested a labiaplasty63.
At 6months, 12months, and 24months after surgery, the
study population resembled the control group with regard
to Index of Sexual Satisfaction results. Furthermore,
women who underwent surgery reported slightly bet‑
ter scores on both the Index of Sexual Satisfaction and
the Body Esteem Scale than women who did not have
surgery. However, body dysmorphic disorder and FGSIS
scores did not differ between groups63.
Results from studies show improved levels of sen‑
sitivity and sexual function after surgery. However,
generally, women who have not had surgery and who
have relatively large self‑assessed labia minora size,
and, therefore, increased surface area, had more satis‑
fying sex, more frequent sex, and more intense orgasms
than women with relatively small labial surface area38.
During counselling, the positive effect of having large
labia should be addressed.
The limitations of all these studies are small sample
size and few studies reporting on satisfaction, complica‑
tions, and outcomes. These limitations combined with a
lack of long‑term data means that making reliable con‑
clusions regarding postoperative outcomes for patients is
currently not possible. In general, the data on outcomes
seem positive, with few long‑term problems. Good
patient‑reported outcome measures (PROMs) need
to be developed, as does a reliable method of gather‑
ing quantitative measures on sensation before and after
labiaplasty. In PROMs, such as the FACE‑Q developed
by Klassen and colleagues66, patients themselves indicate
the issues that matter to them. Klassen etal.66 created
the questions within the FACE‑Q together with patients
and using words familiar to the patients, which makes
the questionnaire very reliable and also recognizable
to the people who answer it. A desire for a Genital‑Q
exists, as it could be useful for aesthetic surgery,
reconstructive surgery, patients with disorders of sex
development, and maybe even after givingbirth.
Ethical aspects
Social pressure and autonomy. Vulvar cosmetic sur‑
gery is largely seen as a medically unnecessary proce‑
dure by organizations involved in feminist or sexology
issues, with justification for the procedure based on the
belief that it improves the psychological well‑being of
the patients13. The psychological effects of discontent
with genital appearance can potentially be considerable,
causing feelings of shame and low self‑esteem, but these
effects can be largely attributed to societal pressures. A
conflict between autonomy in wanting to change your
genital appearance and altering your body to meet an
opposed idealized genital image can, therefore, exist.
These psychosocial aspects of genital appearance are
intertwined with ethical viewpoints, and arguments
both for and against the procedure are well developed
on bothsides.
A comparison between labiaplasty and the practice
of FGM has been made. FGM is perceived as an unac‑
ceptable practice that results from inappropriate and
harmful societal pressures owing to cultural rituals,
and genital pricking has been banned by the WHO67.
This argument has been extended to the practice of
vulvar cosmetic surgery in economically developed
countries, in which extensive genital modifications,
including labiaplasty and reduction of clitoral tissue, are
considered acceptable and are legal in many European
countries. Johnsdotter and Essén argue that a consist‑
ent and coherent international position, focused on
key social values including protection of children, bod‑
ily integrity, bodily autonomy, and equality before the
law, is required, and nondiscriminatory policies need
to be formed to remove the discrepancy in societal
perceptions of genital cutting67.
Regardless of this argument, vulvar cosmetic surgery
is currently available in many Western health‑care insti‑
tutions. The argument in support of this availability does
not discredit the value of social intervention and pre‑
vention mechanisms in reducing the need or desire for
surgery but rather states that the unfortunate perception
of normality, combined with the strength of marketing
and media in many countries, means that the procedure
should be available to those who could benefit from it 68.
To support this argument, Borkenhagen and Kentenich68
state that, in order for the procedure to take place, it
must be strictly regulated by a set of guidelines, enabling
optimum patient autonomy and nonmaleficence. The
guidelines presented require that the patient’s motiva‑
tions for undergoing surgery are explored thoroughly,
that a medical indication for surgery is present, that the
patient is aware that no scientific evidence exists that
psychological or physical complaints will diminish, and
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that risks, including infections, change in sensibility, dys‑
pareunia, adhesions, and scars, are discussed. These fac‑
tors need to be fully addressed during patient–surgeon
consultations before each procedure68.
Physician viewpoint. Physicians have expressed dif‑
ferent viewpoints on the justifications for performing
labiaplasty. Arguments in favour of labiaplasty, according
to some physicians, include a patient’s right to autonomy,
the fact that the majority of patients undergo labiaplasty
for functional reasons and not for aesthetic reasons,
and the fact that vulvar surgery is more comparable
to cosmetic breast surgery than FGM69–71. This argu‑
ment is based on autonomy in altering your own body,
whereas cultural genital cutting can be caused by societal
pressure rather than an autonomousdesire.
Arguments against labiaplasty include the issues that
literature on the complications of surgery is currently
lacking and that women seeking labiaplasty need educat‑
ing about the realities of genital anatomy and diversity72.
Furthermore, physicians could be tempted to undertake
medically unnecessary procedures when presented with
patients who pay them for the service73.
Various health‑care professionals’ opinions and indi‑
vidual justifications for performing the procedure are
also presented in survey results. These results showed
that female gynaecologists were more likely to consider
labial hypertrophy a “condition driven by societal influ‑
ence” and offer only reassurance to their patients than
male practitioners, who were more likely to perform
the procedure on the grounds that labial hypertrophy
is a “bothersome quality of life condition”74. Other data
suggest that plastic surgeons are more likely to describe
images of a large labia minora as distasteful and unnat‑
ural than gynaecologists and general practitioners52.
Health‑care professionals need to be aware of their per‑
sonal predisposition in regard to labia minora appear‑
ance when making clinical decisions regarding their
patients. The physician’s preference should not be used
to guide or influence the decision of women in regard to
genital alteration — it should not convince or discourage
them from their personalideas.
Age. Data presented in several publications indicate
that women <18years of age might also request or
even undergo labiaplasty6,13,19,21,23,46,64, with the youngest
patient being only 11years old6. In the Netherlands, the
minimum age for genital surgery or cosmetic surgery is
18years old because of the physical and psychological
effects this kind of surgery can have75. The performance
of this surgery on children makes the need for ethical
discussions on this topic much more urgent. Whether
genital cutting before the age of 18years old is ethical
and whether we should alter the genital appearance of
children so that they will meet an idealized image are
major ethical questions. Counselling at a young age
should be aimed at making the period until the age of
18years old bearable. Those who are against perform‑
ing labiaplasty outline the parallels between labia minora
surgery and FGM, which also often occurs in childhood
and reduces or removes labia minora67.
Guidelines have been developed by the NVPC, the
Dutch Association of Esthetic Plastic Surgery (NVEPC)
and the Dutch Society for Obstetrics and Gynecology
(NVOG)75, the Royal College of Obstetricians and
Gynaecologists (RCOG) and the British Society for
Paediatric and Adolescent Gynaecology (BritSPAG)76,
the American College of Obstetricians and Gynecologists
(ACOG)4, and the Society of Obstetricians and
Gynaecologists of Canada (SOGC)77 to aid health pro‑
fessionals dealing with the growing number of adoles‑
cents seeking genital cosmetic procedures4,75–77. These
guidelines state that the obstetrician–gynaecologist
providing care for adolescents who present with an inter‑
est in genital modification should have good working
knowledge of the nonsurgical alternatives for improv‑
ing comfort and appearance, indications, and timing of
surgical intervention and referral. When surgery is indi‑
cated, education and reassurance is often the first step,
but assessment of the maturity and emotional readiness
of the patient and screening for body dysmorphic dis‑
order should also be undertaken. These guidelines also
state that labiaplasty in girls <18years of age should be
considered only in those with considerable levels of con‑
genital malformation, those with persistent symptoms
believed to be a direct result of labial anatomy, or those
with both. Furthermore, these guidelines assert that sur‑
gical alteration of the labia that is unnecessary for the
health of an adolescent <18years of age is a violation of
federal criminal law4,75–77.
The ethical discussion is often a debate between the
right to choose (autonomy) and being a victim of exter‑
nal pressures. In our opinion, a line should be drawn at
the treatment of underage women (girls <18years old)
when no medical indication exists. The performing of
labiaplasty on children makes the ethical discussion on
the topic important. During adolescence, young women
develop sexual awareness and sexual self‑image. Girls
and adolescents requesting labiaplasty are unlikely to
have a fully developed concept of genital normality.
Surgical genital modification in this young population is,
therefore, a controversial practice. In our view, building
a realistic concept of genital normality in these women
through education is much more relevant to their
presenting complaint than offering surgery.
Improving education
Evidence on the outcomes of labiaplasty is still lack‑
ing; however, whether counselling and education are
effective in alleviating dissatisfaction or a low genital
self‑esteem is not clear. Education in schools could be
a way of increasing knowledge of vulvar anatomy, gen‑
ital appearance, and the variations in genital anatomy
present in both women and men. This education might
strengthen genital self‑esteem and appreciation, leading
to an improved body image and increased overall self‑
esteem and quality of life. A major hope is that education
will result in reduced levels of insecurity during sexual
development and sexual activity and increased enjoy‑
ment of sexuality. Education on normal genital appear‑
ance could improve sexual function and also reduce the
desire for genital surgery3,22,39,51,63.
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One study reported the effects of counselling on the
desire for hymen reconstructive surgery78. The inves‑
tigators conducted a series of interviews consisting of
education, discussion of alternatives, and instructions
for self‑examination during a first visit, a second visit
that involved an educational examination, a third visit
in which a decision on operation or an alternative ther‑
apy was made, and a fourth follow‑up visit. Women
were informed about the hymen and blood loss myth
and empowered to talk to their future husband. Of
the women who received surgery (n = 19), 17 did not
experience blood loss during first marital intercourse.
Participants frequently choose conservative methods,
such as pelvic floor exercises, and only 29% decided to
receive surgery78. These results suggest that counsel‑
ling and education can inform a woman’s decision as to
whether to undergo surgery.
Many medical schools and schools in general through‑
out the world already have programmes to educate high
school students on issues regarding sex and sexual devel‑
opment. For example, in the Netherlands, a sex educa‑
tion programme is run by the International Federation
of Medical Students Association Standing Committee on
Reproduction and AIDS. This organization trains medical
students to educate high school students on the subjects of
reproduction, STI and HIV, and enjoying sexual encoun‑
ters. Many teenagers are more open about subjects such as
sex or the pleasure associated with having sex and not only
the dangers associated with sex (these aspects being highly
important but also very delicate subjects) when talking
with peers than with adults, who could be in a position
of authority. This education programme provides a good
opportunity to discuss genital anatomy, natural variations
in appearance, and function. Most importantly, education
could normalize the variations in the way that students
perceive the human body and maybe reduce the effect of
social or conventionalmedia.
Currently, much information is accessed through the
Internet and social media and reliable information is
hard to find, mostly owing to modified images of genita‑
lia. Furthermore, parents might attempt to limit or con‑
trol information gained by their children via the Internet
concerning sex; however, many young people gain access
despite being restricted in this manner. These factors
might enhance the prevalence of misinformation and,
therefore, affect genital self‑image negatively. Creating a
web‑based learning environment where people can chat
with experts, ask questions, play games, and find infor‑
mation could be a solution to providing reliable, easy to
find information. In an era of eHealth, this web‑based
learning environment could be the best way to reach
young people. Ideally, this platform would be developed
by young people for young people using their vocabulary
and meeting their expectations. Such an environment
would enable children to educate themselves in a fun,
anonymous, and safe way in the privacy of their own
room. Subjects that could be covered include genital
anatomy variation, body image, self‑ esteem, relation‑
ships, sexuality, and pleasurable consensual sex along‑
side conventional topics, such as STIs and HIV. Delivery
of education must be in the vocabulary of the target
group, be appealing, and behonest.
Future research should evaluate the effects of coun‑
selling and education on genital self‑image and desire for
surgery. Observed effects could form the basis for estab‑
lishing recommendations for treatment and improve
the care of women requesting labiaplasty. Combining
the effects of counselling with the effects of treatment,
whether surgical or not, could improve our understand‑
ing of patients’ desires and whether their expectations
have been reached. This information could contribute to
improved treatment of patients who request surgery that
is not medically indicated, as a part of a well‑informed,
shared‑decision‑making process.
Conclusions
Dissatisfaction with genital appearance is the primary
motivation of women who request labiaplasty, but phys‑
ical complaints associated with the labia minora, such
as pain, infection, discomfort during various physical
activities including sexual intercourse, and difficulties
with personal hygiene, are also reported. The clinician
must evaluate the patient fully when presented with
a desire for aesthetic surgery (including psycholog‑
ical testing and educational physical examination) in
order to preoperatively identify mental health issues or
pelvic floor disorders and distinguish those issues from
patients who have true labial hypertrophy. For those
women who have true hypertrophy without a pelvic
floor element and whose motivation is of a psycholog‑
ical nature, several options for counselling and edu‑
cation about genital anatomy, variation, and function
might be useful in reducing the desire for cosmetic sur‑
gery. Unfortunately for those women who maintain a
wish for labiaplasty, only inconclusive evidence is avail‑
able for each of the different surgical techniques, which
illustrates the urgent need for PROMs, preferably a
Genital‑Q. A balance must be reached in which women
are protected from undergoing unnecessary surgery but
their autonomy is respected.
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Author contributions
M.Ö., I.M., and E.P.J. researched data for the article. M.Ö.
decided the content. M.Ö. and I.M. wrote the manuscript,
and M.Ö. and M.G.M. reviewed and edited the article before
submission.
Competing interests statement
The authors declare no competing interests.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
Review criteria
Relevant papers were sourced from the Medline, EMBASE,
and PsycINFO electronic databases between June and
October 2016. The keywords and index terms, including
applicable MeSH and Emtree terms, were applied to each
database. Search terms were generated under three broad
headings referring to subject matter: labia; surgery; and
self‑contempt. The following corresponding MeSH terms were
applied to Medline searches: “labia and vulva”; “surgery and
operative”; and “self‑contempt”. Reference lists were checked
for relevant articles. Experts in the field were contacted for
relevant articles. No restrictions were placed on date of pub‑
lication. The search was limited to publications in the Dutch,
English, or German language. Information from commentar‑
ies, conferences, and published abstracts was excluded.
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