Keywords: Genitalia, female - Vulva - Clitoris - Surgery, plastic - Plastic surgery procedures
INTRODUCTION
Female genital plastic surgery consists of a set of procedures that encompasses
the surgical aesthetic and/or functional approach to the woman’s intimate region
with the aim of achieve a more aesthetic shape of the labia minora and adjacent
regions, such as the clitoris, the clitoral foreskin, mons pubis, and labia
majora. The most common among procedures are nymphoplasty or labiaplasty, which
aim to improve and modeling of redundant tissue, as well as asymmetries, if
any[1 ].
Labiaplasty brings great benefits to female sexual function, especially in
factors such as pain and pleasure[2 ]. The woman undergoing the surgical procedure also reports
improvement in self-image; however, when the improvement is exclusively linked
to the labia minora, the untreated clitoris can be observed more by the patient
post-operatively[3 ].
In some cases, there is an excess clitoral hood and hypertrophy of the clitoral
gland. When the measurement is greater than 35mm, clitoral hypertrophy is
suggested[2 ]. The average
clitoris must be less than 5mm wide and 16mm long[4 ].
Currently, several techniques are described for performing nymphoplasty or
reduction of labia minora. Labiaplasty is a surgical procedure to reduce the
size of the labia. This intervention is most commonly carried out in labia
minora, but it can also occur concerning the labia majora[5 ]
[6 ].
The elliptical or longitudinal technique was initially described by Hodgkinson
& Hait[7 ]. It is the most
performed technique in the world[6 ], followed by the “V” shaped technique or wedge technique,
described by Alter[8 ]. The
combination of the longitudinal technique with wedge resection is also carried
out[9 ].
W-shaped resection, Z-plasty, posterior resection, and epithelial resection as
well are techniques described for the resection of labia minora. However, these
are not so common as the previous ones[10 ]
[11 ]
[12 ]
[13 ].
Surgical resection of excess labia minora can be associated with resection of the
clitoral hood in its lateral, cephalic region or both[1 ]
[5 ]
[8 ]
[14 ]
[15 ]
[16 ] and can be
associated or not with clitoripexy, which means the fixation of the clitoris to
the pubis[8 ]
[11 ]
[14 ]
[15 ]
[16 ]
[17 ]
[18 ]
[19 ]
[20 ].
In cases of lipodystrophy in the pubic region, in the mons pubis, it is possible
to perform liposuction of this region[21 ].
Another classification also described is that of Motakef, which refers to the
protrusion of labia minora in relation to the labia majora. The author defines
class I (0 to 2 cm of protrusion), class II (2 to 4cm of protrusion), and class
III (greater than 4cm of protrusion). The letter “A” is added for cases of
asymmetry and the letter “C” for cases of excess clitoral hood. In this
classification, cases of hypotrophy and sagging of the labia majora. These signs
become evident as women age[22 ].
According to the most recent data released by the International Society of
Aesthetic Plastic Surgery in 2020, referring to procedures performed in 2019,
the Brazil is the champion country in the number of labiaplasties,
nymphoplasties, or labia minora reduction surgeries. There were 20,334 compared
to 13,697 in the United States, considering a total of 142,119 of this type of
surgery performed worldwide. Furthermore, in comparative between the years 2016
and 2020, at a global level, the performance of this procedure increased by 3%,
despite the drop, when compared to 2019 and 20202[3 ]. The specialties that perform this type of
procedure in the greatest proportion are plastic surgery and urogynecology. It
is estimated, therefore, that these data must be even greater, since, in the
present study, only data relating to plastic surgery is included.
Several factors are associated with the growth in the number of procedures. Among
them are greater access to information, sexual freedom, a greater number of
professionals trained and cultural and paradigm changes concerning
sexuality[24 ]. The main
sources from which the results regarding the dissemination of nymphoplasty are
extracted refer to websites, videos, and reports in newspapers, magazines with a
large circulation and women’s magazines. In these vehicles, in general, the
opinions of experts and some testimonials from women are presented.
Material produced by doctors themselves is also very common, mainly plastic
surgeons and gynecologists, whether on their personal pages or in professional
profiles on social networks, on their clinic websites, as well as YouTube
channels[25 ].
Other surgical procedures in the genital area aim, in addition to hypertrophy of
the labia minora, enlargement and/or reduction of the labia majora, as well as
reduction of the clitoris and/or clitoral hood.
There are different types of vulva and, not always, the woman feels uncomfortable
with her genital area from an aesthetic point of view. Thus, the intention to
alter or improve the appearance of external genitalia and undergoing cosmetic
genital surgery is not always present.
OBJECTIVE
The objective of this study is to describe the boomerang surgical technique and
the surgical results. The vulva procedure is performed extensively to improve
the aesthetics of the region, including repositioning of the clitoris and
resection of the clitoral hood, reduction of labia minora and labia majora
augmentation, when indicated.
METHOD
A retrospective, analytical study was conducted to evaluate the medical records
of 48 consecutive patients who underwent female genital aesthetic surgery at a
private plastic surgery clinic (Instituto Tatiana Turini de Cirurgia Plástica)
and at the Hospital Regional Asa Norte (HRAN), in Brasília, Brazil, between July
2017 and July 2021. The study was carried out following the ethical standards of
the 1964 Declaration of Helsinki and its subsequent changes. The study was
approved by the Research Ethics Committee of the Education and Research
Foundation, under number 4842358. All patients signed the Free and Informed
Consent Form for the procedure, use of clinical data, and photographic records
for scientific and publishing purposes. Patient anonymity was guaranteed.
The patients presented type III hypertrophy (labial hypertrophy that extends to
the entire clitoral hood), according to the classification by Cunha et al.26
([Figure 1 ]) with or without clitoral
hypertrophy, which justified the procedure that extends to the clitoral hood.
Some patients still had sagging and reduced volume of the labia majora. The
standard vulva can be seen in [Figure 2 ].
Figure 1. Hipertrofy type 3.
Figure 2. Standard vulva.
Pre-operative and post-operative photographs were taken with a frontal view.
(where the upper limit is half the distance between the xiphoid and the navel
and the lower limit are the knees with the legs positioned at the same width as
the shoulders and with the arms behind of the body). And lithotomy position
(with knees flexed and thighs flexed and abducted) at an angle of 45º in the
previous vertical position.
Surgical procedure
The patients were operated on by the same plastic surgeon under local
anesthesia, neuraxial block or general anesthesia, in a lithotomy
position.
When the procedure was performed under local anesthesia, precautions taken
were to administer an anti-inflammatory and an analgesic tablet orally one
hour before surgery.
The incision area was outlined with a marking pen, with the patient in the
position of lithotomy. The incision line was marked in the shape of a
boomerang on the clitoral hood (preputial skin), extending to the groove
between the labia majora and minora. Posteriorly, the excess labia minora
was marked for resection ([Figure 3 ]).
There was attention to the width minimum of 1cm for positioning within the
margins of the labia majora ([Figure 4 ]). Resection of the labia minora is performed longitudinally, with
excision of the mucosa throughout its extension. The hemostasis of this
region is of great importance. The asymmetry in the pre-labiaplasty surgery
is not uncommon. Therefore, care must be taken when marking the labia minora
so that they are as symmetrical as possible post-operatively. Another
important precaution is to maintain the scar in the region of the anterior
vaginal wishbone.
Figure 3. Preoperative marking of the boomerang technique.
Figure 4. Incision at 12 o’clock made towards the suspensory ligament
of the clitoris.
Antisepsis was performed with aqueous chlorhexidine in the vulva and vaginal
introitus region and degerming chlorhexidine and alcoholic chlorhexidine in
adjacent regions such as the lower abdomen and thighs. Lidocaine spray of
10% was used in the operated region 15 minutes before infiltration using 2%
xylocaine solution, in the labia minora, bonnet, and region close to the
pubic periosteum, normally no more than 20mL of infiltration is used.
After skin resection, using the boomerang format in the clitoral hood region,
an incision and dissection was made at 12 o’clock towards the clitoral
suspensory ligament in the bulbar region ([Figure 5 ]). The clitoral body was sutured to the anterior pubic
periosteum using 4-0 nylon. Excess tissue from the labia minora was removed
by longitudinal resection performed in a medially inclined plane, leaving
minimal and hidden scars. Removal of excess tissue must be carried out
carefully to avoid excessive resection. Clitoripexy was performed with a
point in the clitoral body, bulb region at 12 o’clock, and fixed in the
periosteum of the pubis and synthesis of the labia minora and clitoral hood
with continuous stitches using 5.0 catgut thread.
Figure 5. (A) Preoperative and (B) six-month postoperative photographs
of a patient standing.
Hemostasis was achieved by electrocauterization. Finally, a continuous stitch
using 5.0 catgut thread was performed. Vicryl 5-0 rapid may be an option for
suturing this region. Postoperative care includes the use of vaginal cream
with lidocaine, calendula, menthol, witch hazel oil, and copaiba. This cream
was created by the surgeon himself with pharmaceutical assistance. Hygiene
after urinating and bowel movements and the use of underwear for
incontinence are also post-operative guidelines.
Data on surgical outcomes and complications were collected by reviewing the
patients’ medical records. Numerical data is demonstrated as mean, standard
deviation (SD), and ranges.
RESULTS
In this retrospective analytical study, the medical records of 49 patients who
underwent the procedure described during the study period were reviewed. One
patient was excluded from the analysis due to her age being under 18 years old,
thus totaling 48 patients. More than half of the sample (64.68%) had access to
the surgical procedure via the Unified Health System (SUS).
Data analyses were carried out using the IBM SPSS (Statistical Package for the
Social Sciences) 23, 2015 program. The significance level used throughout the
study was 5%.
In the procedures performed, local anesthesia was the most prevalent form of
anesthesia, being applied to 39 patients (81.25%), mainly in cases where only
intimate surgery was performed. Epidural anesthesia was performed in 12 patients
(12.5%) and general anesthesia in three (6.25%), as shown in [Table 1 ]. Epidural and general anesthesia
occurred in combined surgeries, such as mammoplasty and liposuction, which have
the highest recurrence among procedures performed together with female genital
plastic surgery.
Table 1.
Item
n
%
Age
range
18 to 27 years
old
8
16.67
28 to 37 years
old
20
41.67
38 to 47 years
old
14
29.17
≥ 48 years
old
6
12.50
SUS / Private
SUS
31
64.58
Particular
17
35.42
Resection of excess labia minora
No
1
2.08
Yes
47
97.92
Anesthesia
Local
39
81.25
Epidural
6
12.50
General
3
6.25
Refinement
No
42
87.5
Yes
6
12.5
Complications
No
45
93.25
Yes
03
6.25
Combined surgery
No
39
81.25
Yes
9
18.75
Total
48
100.00
The patients’ ages ranged between 18 and 48 years (SD: 9.68). The majority of
patients (41.67%) were aged between 28 and 37 years, with an average of 36.25
years (+ 9.76%) and a median of 35.5 years. Nine patients were married or had a
marital partner and nine were single ([Table 1 ]).
As shown in [Table 1 ], there were three
cases of early complications (6.25%), two of labia minora hematoma and one of
wound dehiscence. Only three patients (6.25%) sought medical advice to undergo a
secondary procedure due to late complications from surgeries performed with
other surgeons.
Surgical refinement was performed on six patients. In one case, this practice was
performed to improve small asymmetry, through small unilateral resection; in
another case, there was also redundancy of the labia minora, in which a new
resection was performed of fabric. In three cases, clitoral plication surgery
(clitoripexy) was performed in patients who previously had clitoral hypertrophy
secondary to hormones. There were no cases of infection. For most patients, it
was the primary surgery, that is, they had never had surgery on the vulvar
region previously.
According to [Table 2 ], it can be seen that
the majority of patients (97.65%) underwent resection of the labia minora. And
in 85.4% of cases, labiaplasty was performed comprehensively, in which the
procedure included the clitoral hood and clitoris. Hood resection using the
boomerang technique was performed in 87.5% of patients. The association of fat
grafting in the labia majora was performed in six patients (12.5%). In just
three cases (6.28%), labiaplasty was performed alone. There were no cases of a
decrease in sensitivity, only one patient reported increased sensitivity due to
greater exposure of the clitoris, but without any harm to sexual intercourse and
orgasm.
Table 2.
Female genital plastic surgery
Female
genital areas
N
%
Labia minora
(nymphoplasty/labioplasty)
3
6.28
Labia minora + labia majora
1
2.08
Labia minora +
clitoral hood + clitoris
41
85.4
Labia minora + clitoral hood
1
2.08
Labia minora +
posterior vaginal wishbone
1
2.08
Clitoral hood + clitoris
1
2.08
Total
48
100
When asked about the improvement in sexual activity after the procedure, 83% of
patients reported improvement during sexual intercourse and self-confidence in
their body and 12% of the total reported that there was no difference in their
sexual performance. No patients reported worsening. And one patient did not have
sexual intercourse after the procedure.
Pre-operative and post-operative photographs of patients included in this study
can be seen in [Figures 5 ]
[6 ]
[7 ]
[8 ]
[9 ]
[10 ]
[11 ] to [12 ].
Figure 6. (A) Preoperative and (B) six-month postoperative photographs
of a patient in the lithotomy position at 45°.
Figure 7. (A) Preoperative and (B) 20-day postoperative photographs of
a patient standing.
Figure 8. (A) Preoperative and (B) 20-day postoperative photographs of
a patient in lithotomy position at 45°.
Figure 9. (A) Preoperative and (B) six-month postoperative photographs
of a patient standing.
Figure 10. (A) Preoperative and (B) six-month postoperative photographs
of a patient in the lithotomy position at 45°.
Figure 11. (A) Preoperative and (B) two-month postoperative photographs
of a patient standing.
Figure 12. (A) Preoperative and (B) two-month postoperative photographs of a
patient in the lithotomy position at 45°.
DISCUSSION
Patients undergo labiaplasty for a variety of reasons. Miklos &
Moore[27 ] evaluated 131
labiaplasty patients who underwent surgery only due to aesthetic complaints
(37%), only functional complaints (32%), such as discomfort and pain, or
functional and aesthetic complaints (31%). In this study, patients sought
labiaplasty only because of aesthetic complaints (44%), demonstrating their
great interest in improving genital appearance, due to aesthetic and functional
complaints (33.33%), due to aesthetic, functional, and psychological complaints
(5.56%) and due to functional complaints (5.56%).
Many techniques for reducing labia minora have been described. However, few
studies describing clitoral hood treatment were found in the literature.
Hamori[28 ] described the
inverted V resection to reduce the redundant clitoral hood.
Oppenheimer[15 ] showed
“horseshoe labiaplasty”, a technique based on recontouring circumferential area
of the labia minora and clitoral hood. Xia et al.[20 ] demonstrated in his work, the resection of the
clitoral hood in the region of the sulcus associated with the resection of labia
minora. Li et al.[11 ] described
the technique in L. Yang & Hengshu[13 ] described the technique in which they adapted the
W-plasty to resect both the labia minora as for the hood.
Gress[14 ], in her technique,
described the reduction of the labia minora and the clitoral hood, combined with
glans repositioning. After the resection of a segment of tissue cranially about
2 to 3 cm long (seen as the caudal extension of the hood clitoris), a segment of
skin below the clitoris and a rectangular segment of skin above the clitoral
hood are removed and the wound margins are brought together. This study
demonstrates that approximately 35% of patients, after the technique, improved
sexual aptitude in which there is combined resection.
Mañero Vázquez et al.[29 ] carried
out, in their work, the resection of the clitoral hood in its lateral portion
associated with the plication of the clitoral body next to the periosteum at 4
and 8 o’clock. Unlike the present study, in which resection of the clitoral hood
is performed in its cephalic region with a point at 12 o’clock resulting in the
rise of the clitoris.
There is already widespread concern about the treatment of the vulva, which is
not limited to correction of hypertrophy of the labia minora, but includes
repair of the clitoral hood, involving the treatment of redundant clitoral hood
and clitoral hypertrophy[14 ]
[18 ].
The term “clitoral relocation” (or repositioning) was first used by
Lattimer[30 ], in 1961,
to describe the treatment of the result of congenital hypertrophy of the
clitoris, which came from maternal use of anabolic steroids during pregnancy.
Concerns about loss of clitoral sensitivity are consistent with neuroanatomical
studies of the fetal clitoris, showing that the greatest nerve density is
located within the tunica of the dorsal aspect of the clitoris[31 ]. The surgical technique
described in this study, the 12-hour innervation is not affected, but care must
be taken to treat the 11- and 13-hour innervation due to the presence of nerve
endings originating from the pudendal nerve.
The clitoral hood is a structure that covers and protects the clitoris (glans)
when it has a normal size of about 2 cm long. However, in cases such as
hypertrophy of the clitoris or redundant clitoral hood, reduction of the labia
minora alone can lead to to unsatisfactory results, drawing attention to the
clitoral hood, which was not so evident before the procedure. In contrast,
removal of excess skin with exposure of the glans can result in increased
sensitivity of the clitoris[19 ]
[31 ].
In the preoperative evaluation, patients may also present nodular edema in the
labia minora, in the form of redundant tissue, which can be addressed by tissue
repositioning, with positive results in a lithotomy view.
CONCLUSION
The boomerang technique described is a surgical procedure to improve excess
tissue in the region of the clitoral hood associated with excess labia minora.
Such technique is reproducible and has a low complication rate and high
satisfaction rate, providing aesthetic and/or functional benefits to the
patient.
Bibliographical Record Boomerang para plástica genital estética feminina. Revista Brasileira de Cirurgia Plástica
(RBCP) – Brazilian Journal of Plastic Surgery 2024; 39: 217712352024rbcp0861pt.
