Reconstruction of the labia minora
It is a sad reality that the number of botched labiaplasty operations has taken a quantum leap in recent years. Almost one in five of the surgical procedures in our clinic now is to reconstruct the labia minora after inadequate surgery performed elsewhere.
Why is this happening?
The main reason is that labia minora reductions are still viewed as trivial procedures with the approach “we’ll soon snip that off”. Many plastic surgeons and gynaecologists have little experience of intimate surgery but still carry out these surgical procedures.
Operations on the genitalia should be invested with the same significance as procedures on the breast or the face, or even more so, as they concern not only functional and aesthetic aspects but also sexual sensation.
The most common errors and their consequences
An unsuccessful operation always brings considerable disappointment and sometimes even traumatic effects with severe mental stress. Especially when the surgical procedure was primarily intended to improve or even eliminate physical and psychological problems and the decision for surgery was not undertaken lightly. But, instead of the looked-for improvement, the situation is now even worse.
Depending on the complication or inappropriate treatment, a botched labiaplasty may give rise to the following problems: an aesthetically unacceptable appearance with an increased feeling of shame, pain on exercise or at rest, sensory disorders or even loss of sensation, deviation of the urine stream, exposure of the introitus with recurrent inflammation of the vagina, burning, itching, skin irritation, and considerable mental anguish.
Some of these conditions may be improved or eliminated by reconstruction, while others are extremely difficult or impossible to ameliorate. In any case, the road to recovery may be long, often needing more than just one corrective procedure and requiring resolution and strength.
What are the most common iatrogenic deformities caused by botched operations?
1. A “microphallus”
The most common deformity after a botched labiaplasty is excessive shortening of the labia minora in the segment below the clitoris alone, while the clitoral hood and the part above are inadequately shortened and tightened. This results in the appearance of a microphallus (“little penis”), which is even more pronounced when there is also clitoral protrusion that has not been corrected.
When the aim is to achieve coherent tightening of the labia minora over their entire length, i.e. from mons pubis to perineum, there is no sense in using a technique that is intended to reduce the labia minora only in the segment below the clitoris, such as the wedge resection described by Garry Alter. It is therefore extremely important to check the anatomical findings prior to the operation and determine the desired final appearance.
Excessive reduction of the labia minora below the clitoris, no correction of the labia minora around the clitoris and above, no correction of the clitoral protrusion.
The labia minora may shrink some more once the swelling has gone down after the operation. This fact should be taken into consideration and the labia minora not made too short. In the ideal case, they have a height of about 1 cm (taken from the base) but can be more or even less. The desired result should be discussed prior to the operation. Care must always be taken to ensure that the introitus is covered. If too much tissue is removed from all three segments of the labia minora (i.e. above the clitoris, around the clitoris hood, and below the clitoris), reconstruction is extremely difficult and only possible using vaginal skin.
As a rule, the removal of too-little tissue is not such a problem, as further reduction is always possible. Although it is annoying, revision surgery is usually quite straightforward. Undercorrection is mostly seen around the clitoral hood and above the clitoris (see 1.)
4. Frayed wound margins
Another very common deformity is frayed edges to the wound. This deformity is primarily due to a poor suture technique and the use of suture threads that are too thick. The genital area is put under considerable strain during walking and other movements. Even so, thick sutures cannot be used here, as they tend to cut through the tissue leaving unsightly saw-edged wound margins. These frayed edges will never smooth out by themselves and always have to be corrected. Mechanical stability should therefore be ensured by numerous small stitches using absorbable sutures inserted with a special technique.
Surgical techniques such as the wedge resection often leave conspicuous scars; the wound margins are sometimes under so much tension that gaps may result.
6. Pronounced asymmetry
As a general rule, the two labia minora should be the same length after the operation. It is always very difficult to achieve exact geometrical symmetry, as the labia minora may heal differently even when precise measurements were made prior to the operation. In every case, however, the results should appear symmetrical to the naked eye. If not, it usually means that the surgery was not performed exactly the same on the two sides. Complications such as wound healing disorders or infections may also cause visible asymmetry.
7. Contour defects
If the excess tissue is not removed along a previously drawn line but freehand without measurement or marking, then the wound margins may turn out wavy or show a defect in the contours. Correction is not usually difficult.
8. Mixed picture
It is, of course, possible for the previously described problems to occur to various extents in combination.
Possible reconstruction techniques
In each individual case, it has to be decided what can be done to correct an unsatisfactory situation.
As a rule, frayed wound edges can be smoothed out, contour defects and gaps can be closed, and undercorrection can be revised. It is, however, more difficult to replace tissue when too much has been removed.
Reconstruction is more complicated in the case of overcorrection or a microphallic (“little penis”) deformity (see 1 and 2) and a complete repair may not always be possible.
There are basically two possibilities for restoring the labia minora:
- Reconstruction using excess tissue lying above the clitoris
- Reconstruction using vaginal skin
This technique consists of freeing two longitudinal flaps lateral to the shaft of the clitoris and rotating them downwards to be inserted and fixed into the remaining labia minora tissue. The vascular supply of these flaps comes via the tissue bridges left at the base of the flaps.
If the previous approach is not possible, especially when there is no available excess tissue above the clitoris, the labia minora have to be reconstructed using vaginal skin. A skin incision along the free edge of the remaining labia splits the labia minora into an inner and outer section. The inner part in particular is detached as far as the vagina and mobilised outwards under tension. The new labial wall thus formed is fixed and held erect with sutures.
Skin grafts do not come into consideration for reconstruction purposes, as the graft is not sensitive and the appearance is aesthetically inferior.
As with any surgical procedure, complications of wound healing may have a negative effect on the expected results. It is important not to put the area under stress too soon after labia reduction, as the wound may not heal properly and cause visible changes. You should therefore follow your doctor’s instructions without fail and avoid any kind of friction, in particular sexual intercourse, for at least six weeks after the operation.
The most important thing you can do is to check out and choose your surgeon with the greatest care, as the majority of problems and the most severe complications arise as the result of a botched operation.