Labial surgery for well women: a review of the literature
Dr SM Creighton, Consultant Gynaecologist, University College London Elizabeth Garrett Anderson Institute of Women’s Health, 2nd Floor North, 250 Euston Road, London NW1 0PG, UK. Email firstname.lastname@example.org
This review investigates the quality and content of published reports relating to labial surgery for well women. Electronic databases were searched for relevant articles between 1950 and April 2009. Forty articles were identified, 18 of which included patient data. The specification of the study design was unavailable in 15 of the 18 papers; the remaining three were retrospective reports. No prospective, randomised or controlled studies were found. All reports claimed high levels of patient satisfaction and contained anecdotes pertaining to success. Medically nonessential surgery to the labia minora is being promoted as an effective treatment for women’s complaints, but no data on clinical effectiveness exist.
Increasing numbers of healthy women are seeking surgery to create morphological changes to their normal vulva. Once considered the special domain of glamour models, female genital cosmetic surgery is being mainstreamed in economically affluent nations. Many procedures exist in the medical and marketing literature for correcting the normal vulva. These include vaginal rejuvenation, designer vaginoplasty, G spot amplification and revirgination.1
A popular first request to change genital morphology in Westernised societies is partial excision of the labia minora. There are two main types of procedure utilised: labial trimming or amputation, where the labia are trimmed and then oversewn,2,3 and wedge resection, where a V- or W-shaped portion of the labium is excised and then sutured.4–7 These procedures can be performed using a laser for dissection, and further variations have been described to prevent postoperative stenosis of the introitus, such as a ‘Z-plasty’.8 De-epithelialisation techniques also remove a wedge of skin, but aim to preserve the interstitial tissues.
Procedures are offered mainly by gynaecologists and plastic surgeons. Surgery is generally presented as an unproblematic solution for women’s concerns about their genitals.
The primary aim of this article was to systematically review the literature on cosmetic labial surgery to:
- • confirm the types of surgical technique;
- • identify the indications used to justify surgery;
- • identify immediate and latent complications;
- • identify clinical effectiveness;
- • provide an overview of the quality of the research methodology in this area;
- • suggest directions for further research, taking on board professional and ethical concerns.
A search of the following databases was performed: Embase, 1980 to March 2009; Medline, 1950 to March 2009; ISI Web of Science, 1900 to March 2009 including conference proceedings.
The search terms chosen were ‘labial hypertrophy’, ‘labial reduction’, ‘labioplasty’, ‘nymphectomy’ and ‘labia minora’, used within the title of the article. Furthermore, citation lists from all identified articles were checked to ascertain that all possible studies were included in the review. Exclusion criteria were disorders of sexual development, congenital anomalies, trans-sexual gender reassignment surgery, female genital mutilation, exposure to androgens, genital tumours and other acquired physical illnesses. Only English language articles were included.
All papers were retrieved and classified according to the type of labial surgery performed. Papers offering patient data were further examined. Details of study design, surgical technique, nature and incidence of complications, length and type of follow-up were reviewed. Outcome data were classified where possible into relief of physical symptoms and appearance concerns and impact on sexual well-being.
Evaluation of research methodology
Type of paper
The first labial reduction procedure was published in 1976.9 Between 1976 and 2000, six papers were published on this topic. Between 2001 and 2005, nine papers were published and, from 2006 to the current date, a further 25 papers were identified.
Forty articles were obtained, 21 of which contained patient data. Of the 21, 18 were reports of surgical procedures.2–19 The remaining three papers were as follows: one qualitative study of patient experience after labial reduction,20 one study of patient indications for surgery,21 and one survey of women’s attitudes to their labia.22 Of the remaining 19 of the 40 publications that did not include surgical results, one was a description of a technique,23 five were letters on points relating to the surgical technique,24–28 and three were discussions of the surgical technique.29–31 The final ten papers were all discussion papers, reviews or recommendations relating to the ethics and practice of cosmetic genital surgery, all of which have been published since 2007.32–41
The rest of this review focuses on the 18 papers reporting surgical procedures. Of these, seven originated from the USA and the rest from Europe, Asia, Oceania and South America.
Of the 18 papers, five specified labial amputation, ten specified variations on wedge resection and three did not give information about the technique used. With the labia made smaller, the clitoris often becomes more prominent, and surgery may be extended to reduce the clitoral hood. Involvement of the clitoral hood is sometimes subsumed under labial surgery. One paper mentioned that reduction of the clitoral hood was sometimes necessary to achieve a pleasing cosmetic result,16 but did not give the numbers of cases in which this was required. In one of the 18 papers, labial minora reduction was performed in addition to concomitant cosmetic surgery to the labia majora.19 No other reports addressed the absence or presence of involvement of other genital tissue.
None of the 18 studies was randomised, controlled or prospective. Fifteen of the 18 papers presented as case reports or case series with no description of methodology or study design and, of these, three alluded to the use of nonstandardised questionnaires given out to patients.11,13,16 Three of the 18 papers were reviews of retrospective notes and, of these, one was combined with a clinical examination and nonstandardised questionnaire with no description of tool development.7
Nine papers presented follow-up data, with the length of follow-up unspecified. Of these, five did not describe how the results were obtained and four reported the use of a questionnaire for data collection with insufficient procedural information to determine the degree of objectivity.7,11,13,16 All questionnaires were nonstandardised.
Of the four studies using a questionnaire, one asked 14 questions requiring ‘yes’ or ‘no’ answers about postoperative pain, satisfaction with labial size, satisfaction with aesthetic result and pain during intercourse.7 In one study, a postal questionnaire asked about changes in sensation, complications, change in sex life and happiness with the operation.16 In one study, an ‘informal questionnaire’ of patient satisfaction was administered, although it was unspecified as to whether this was in clinic or by post.11 Patients chose their response amongst the categories of ‘very satisfied’, ‘satisfied’, ‘mixed’, ‘disappointed or regretted their decision’.19 In one study, no details were given about the questionnaire and the mode of administration; this study reported patient satisfaction with functional and aesthetic outcome as ‘very satisfied’, ‘satisfied’ or ‘not satisfied’.13 All remaining papers claimed high levels of patient satisfaction with no details of method for ascertainment.
All 18 studies mentioned cosmetic outcomes with scanty details as to ascertainment or evaluation. In one paper, the postoperative aesthetic evaluation was performed by an ‘independent surgeon’, although all authors were from the same department of plastic surgery.11 In the remaining 17 papers, cosmesis appeared to represent the opinions of the service providers.
In terms of the incidence and nature of complications, five of the 18 papers did not address this topic, eight specified that there were no complications and six reported the presence of complications, with five offering details that included infection, bleeding and wound dehiscence. In three papers, wound dehiscence was minor and did not require resuturing. In the two larger case series, the re-operation rates were 2.9%16 and 7%;7 indications for re-operation included wound dehiscence and dissatisfaction with appearance. Fifteen reports did not address gynaecological or obstetric problems, and the remaining three reported only that there was no dyspareunia after surgery.
Indications for surgery
Verbal complaints of vulval discomfort are mentioned in all of the papers, including the inability to wear tight underwear or pants18,21 and discomfort on sitting or whilst exercising.1,21 One study also mentioned chronic yeast infections5 and one mentioned personal hygiene during menses.6
Dissatisfaction with genital appearance was given as an indication for surgery in all of the papers. No attempt to compare preoperative labial dimensions against published norms42 could be detected beyond authors’ perceptions, such as ‘grossly enlarged’,5‘look like spaniels’ ears’7 and ‘deformed’.19 Medical photography of the labia at the larger end of the spectrum was included to support such contentions in 16 of the 18 reports. Two papers indicated that only women whose labial dimensions fell outside predetermined limits were operated on.7,11 Two case reports gave preoperative labial diameters,2,5 and one gave diameters for the removed specimen of labia.4 In one paper, the authors created their own classification for abnormality without an explanation of its derivation, and patients who were normal by their own classification had also been operated on.13
Anecdotes of psychological and sexual difficulties were also offered as indications, including poor self-esteem,8 teasing by siblings5 and parental concern.17 None of the papers referred to nonsurgical solutions as a possibility.
Only one of the 18 reports mentioned previous episodes of genital surgery specifically, where four of 407 women had undergone previous surgery to the labia minora.16 It is not known whether the other reports addressed this variable.
These 18 studies included a total of 937 cases. Two papers did not give the ages of the patients undergoing surgery. The age range in the rest of the papers was from 18 months to 68 years. The majority of procedures were performed on patients between the ages of 16 and 35 years. Of the nine papers that reported the length of follow-up, the follow-up period ranged from 1 to 3 months for seven papers, and two reported the follow-up of a proportion of their patients for up to 6 years;6,19 attrition and representativeness were unspecified.
Anecdotes pertaining to success were identified in 16 of the 18 papers, such as ‘exceedingly pleased’,10‘had no difficulty in wearing tight pants’8 and ‘went on to marry a professional golfer’.28
Two papers did not refer to any postoperative outcomes, whilst the remaining 16 referred to patient satisfaction. As described above, four papers reported a questionnaire evaluation. For the remaining papers, the expression of satisfaction was presumably obtained by questions posed by service providers to recipients as to whether they were satisfied or pleased or had any regrets. Twelve of the 16 papers reported that all patients were totally satisfied with the procedure, and four of 16 attempted to separate between satisfaction with cosmesis, physical improvement and overall satisfaction. All four described high rates for satisfaction with cosmesis (91–100%) and physical improvement (93–98%). One study elicited postoperative verbal reports of sexual function, and stated that 71% of women reported an ‘improved sex life’ and 23% reported that they could reach orgasm more easily.16
This review was initially planned as a systematic review. However, it soon became clear that the available literature was extremely rudimentary and precluded the use of the recommended methodology on the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Quality of Reporting Meta-analyses (QUORUM) checklists. However, a methodological examination, such as this, of the current available literature has a valuable role to play in exposing deficits in our knowledge and, hopefully, will act as a springboard for future better planned and conducted studies.
This review has identified almost 1000 published cases of cosmetic labial surgery. Because the majority of such procedures are performed in the private sector, where audit and publication are not required, and because advertisement, especially via the Internet, is widespread,32 these figures are likely to represent the tip of the iceberg. No prospective studies were found. Follow-up was not carried out for most studies and, where available, it was of short duration with unspecified or suspect methodology. There was no attempt to compare preoperative morphological measurements with published criteria42 to assess the need for intervention. Surgery appeared to have been offered on demand, justified by verbal reports of physical and psychological difficulties that were not formally evaluated, pre- or post-surgery.
Claims of patient satisfaction mostly reflected anecdotes or were based on providers questioning recipients as to how they felt about the intervention after it had taken place. Future research on patient satisfaction needs to take account of the influence of demand characteristics (influences of researchers’ expectations on subjects’ responses) and social pressure. In any case, satisfaction and absence of regret can be accounted for by ‘cognitive dissonance’43– a well-documented human tendency to justify an irretrievable choice to reduce the tension generated by conflicts and dilemmas. However carefully obtained, consumer satisfaction should not be confused with clinical effectiveness.
Vulval discomfort caused by genital protrusion was most commonly cited as an indication for surgery. To proceed to irreversible anatomical correction without further investigation is simplistic. For example, men tend not to complain about physical symptoms associated with genital protrusion despite potentially having more reason to do so. Women’s complaints are clearly influenced by psychological factors – their feelings and expectations relating to their genitals will influence their experience of discomfort. In a detailed qualitative analysis, some women have admitted to strategically positioning physical symptoms to access surgery.20 These issues render verbal reports of vulval discomfort unsafe as indicators of treatment and outcome, without further clarification.
Verbal complaints of sexual difficulties have also been cited as a reason for surgery. However, the nature of these complaints has not been investigated, rendering it difficult to determine how best to evaluate the impact of surgery. Surgery may damage the nerve supply and is associated with impaired sensitivity when objectively assessed,44 and with impaired sexual function.45 Sensitivity and long-term sexual function constitute an important focus for future research.
Dissatisfaction with appearance is, by its very nature, a psychological phenomenon. Advertisement unfailingly promotes a homogenised, nonprotruding and smooth-skinned aesthetic that communicates female sexual immaturity.32 In the absence of rival representations, these select images are distorting public perceptions, setting a new benchmark for women. Widespread negative perceptions of normal female genitals are reflected in service providers’ own degradation of their patients’ vulva.7 Interrogation of prejudicial language will lead to improvement in the quality of the medical literature, the responsibility for which rests with authors and editorial boards.
A large number of procedures are performed on adolescents,17,18 and even on young children.15 If genital anomalies are indeed identified, children and adolescents should receive ongoing care and support from specialist paediatric teams. If anomalies are not identified, children and parents should be offered education and support. The labia minora continue to develop in childhood and, especially, in adolescence. Any asymmetry may correct itself during pubertal development; if the contralateral labium starts to grow at this stage,17 previous procedures may lead to further asymmetry prompting more operations. Furthermore, the human anatomy is not a stable entity and continues to change throughout the lifespan; postoperative cosmesis is likewise impermanent. The younger the patient at the point of first operation, the more lifetime operations she is likely to have. Again, only quality research using prospective and longitudinal designs can confidently determine trajectories.
Longitudinal research is also needed to investigate the potential increase in obstetric complications. The amount of genital tissue removed in cosmetic labial surgery is comparable with types I and II female genital mutilation, which are associated with perineal trauma, postpartum haemorrhage and increased neonatal death.46 Although a planned caesarean section may circumvent risk, it is important to bear in mind that many of the nations in which cosmetic labial surgery is being marketed are also those with unacceptably high caesarean section rates.47 Furthermore, it is difficult to predict how a young woman seeking labial surgery now will feel about the increased likelihood of a caesarean section in 10 or 15 years.
The similarities between cosmetic labial surgery and female genital mutilation are worrying. The ostrich response to the issues thus far is unhelpful to patients, doctors and the general public. Arguments in favour of the former based on the idea of patient autonomy must answer to the context in which women are making these choices. Where decisions to operate on healthy sex organs are triggered by a perceived defect informed by commercial pressure, where reliable information on risks and benefits is unavailable and where there is no provision of alternatives because there is no concerted effort to develop them, the ethics behind informed consent are vastly compromised.
Professional bodies have ethical and scientific reasons for concerns about female genital cosmetic surgery.1 Our review has identified mainly anecdotes on which consumers and service providers can base their decisions. An acknowledgement of the need for quality research could not be discerned in the literature.
Quality multidisciplinary research to examine women’s concerns about their genitals is a priority for the field; without this, it is impossible to define criteria of clinical effectiveness from women’s perspectives. Proof of principle will be the next stage, and prospective evaluation must focus on morphological, physical, psychological and sexual parameters, and on adverse events. The field is some way away from randomised controlled methodology, which will ultimately be required.
The burden of care for the worried well is of concern to public and private health services commissioners. Better research will pave the way for randomised comparisons between surgical and nonsurgical interventions (e.g. education and support) for cost-effectiveness, taking into account overall health care utilisation (e.g. further cosmetic surgery, mental health treatment), for the same and/or related problems in the short and longer term.
Disclosure of interests
Contribution to authorship
L-ML designed the study and wrote the paper. LM performed the literature review and wrote the paper. SC designed the study and wrote the paper. All authors had access to all of the data and take responsibility for the integrity of the data.
Details of ethics approval
Ethics committee approval was not required.
This work was undertaken at UCLH/UCL who received a proportion of funding from the UK Department of Health’s NIHR Biomedical Research Centres funding scheme.