WARNING: The following text contains explicit information and imagery about female genitalia and related surgical procedures. Do not continue if you do not wish to see these images. These pages should also not be viewed by those persons under the age of 18.
Labiaplasty—“Labial Reduction/Beautification” for Large Labia
A woman’s labia minora (the lips) of the vulva, which stretch on each side of the vaginal opening from the clitoral hood to the perineum, come in all shapes and sizes. There is a large span of normality in size, ranging from small strands to larger “elephant ears. The fact that something is in the range of normality doesn’t mean that you as an individual are comfortable with the size and appearance. Just as the size of your nose or breasts may make you unhappy, the same can be true of your labia.
In many instances, women are born with large labia; others may develop the condition following childbirth or with age. Labiaplasty is surgery to reduce/modify labial size. Women seek labiaplasty consultation for possible revision of the size of their labia for two reasons: functional or aesthetic (or a combination of the two).
Functional reasons for labiaplasty/labial reduction can include discomfort or irritation experienced when wearing tight pants or while engaging in sports such as cycling or other physical activities. Other functional reasons include hygiene difficulties and large lips getting in the way sexually.
Aesthetic (beautification) reasons for labiaplasty, whether with or without reduction of “floppy” hood size, include self-consciousness and self-esteem issues or simply a desire to achieve a better look. Women seeking aesthetic labiaplasty do not wish to see a large protrusion of their hypertrophic hood or labia dangling out from between the outer lips (labia majora.)
There are several different techniques that a physician may use to reduce the labia and their appearance, and a qualified physician will take the time to determine which is most appropriate for your specific situation and goals. All involve reduction and resculpting. The two most popular techniques are Linear Resection and V-wedge. A linear resection involves the use of a straight or arced incision along the outer edge of the labia minora in order to remove excess tissue. This can then be closed with an absorbable, under the skin suture line. The V-wedge resection removes a v-shaped wedge of tissue on the outer edge of the labia. The edges of the incision are then closed together and sutured to maintain a natural looking outer edge. Both techniques, and variations that a specific physician may choose, provide good results with little to no nerve damage as long as they are performed by physicians with considerable skill and experience in the procedure.
Many women requesting labiaplasty surgery also wish to reduce the size of a robust clitoral hood. Occasionally a patient wants hood reduction as a stand-alone procedure, or separation of a hood that has become so fused as to disallow protrusion of the clitoris during arousal. Artistically reducing the hood is the pinnacle of genital plastic expertise.
On this page I share just a few of the more than 800 labiaplasties that I have performed. Space limitations prevent me from posting them all. Around 55% are by V- or V-Y Wedge modifications; about 45% by linear/trim. I am totally comfortable with both techniques. I decide which to use on a case-by-case basis. An exceptional genital plastic/cosmetic surgeon is an artist who decides which technique to use based on patient anatomy, thickness or thinness of tissue, shape and position of the hood, color, expected patient ability to rest well during recovery, and of course the patient’s outcome desires.
I perform almost 100% of my surgeries in my office surgical suite under local anesthesia, a safer and less invasive method and certainly a cheaper option, though the “asleep-in-the-hospital” option is available for those who find it more comfortable. I perform a 2-to-3-layer closure using fine, monofilament non-inflammatory 5-0 Monocryl underneath and fine, quickly absorbable 5-0 Vicryl Rapide for the skin. I use either individual sutures or a hidden sub-cuticular suture line where possible. No “baseball stitching”: instead I use fine surface sutures that dissolve quickly, with the incision held together by the sutures underneath. This leaves no suture marks or rippling for weeks after.
A Personal Note from Dr. Goodman:
How should you decide who to consult, and who should do your surgery? It is important that you do your homework! Look for either a trained plastic or cosmetic Gyn surgeon. You can find them by carefully reviewing websites, looking specifically for genital plastic/cosmetic surgeons who SPECIALIZE and who are very experienced in labiaplasty, vaginal rejuvenation, perineoplasty & vaginoplasty. BE CAREFUL with doctors who tout “minimally invasive” laser or radiofrequency but who are not skilled with surgical options. Look for labiaplasty surgeons who can either PROVE to you that they’ve taken a specialized course with either myself, Dr. Matlock, Dr. Alinsod, Dr. Halperin, Dr. Ostrzenski, or a surgeon who has performed AT LEAST 50 to 100 cases and can prove this to you by providing you with before and after photos on their site. If they have performed fewer than 20 of these procedures, don’t let them operate on you.
Who should you STAY AWAY FROM?
While even the best trained female genital cosmetic surgeon can achieve a poor result, virtually all of the “botch jobs” come from Ob-Gyns who have not been properly trained and who do not have the needed experience for this procedure. Fine and meticulous plastic technique is not taught in Ob-Gyn residency training programs, and neither is aesthetic labiaplasty or vaginal tightening for sexual improvement reasons. The only thing that an untrained Ob-Gyn is likely to know about labial surgery is “cutting them off.” They have virtually no idea how to aesthetically trim and sculpt the clitoral hood. Additionally, while general Ob-Gyns know how to repair the vagina for defecation difficulties (called a “posterior repair”), this procedure WILL NOT tighten the vagina for any length of time, nor will it produce the “before-I-had-babies look” of the opening that many women are looking for with vaginal rejuvenation. I participate in a large number of medical legal reviews of malpractice cases involving labiaplasties. Every one of these mutilations has been performed by general Ob-Gyns.
THE FIRST SURGERY IS THE ONLY CHANCE YOU HAVE TO GET IT RIGHT. While revisions of “botched” or “mutilated” labiaplasties can be performed by premier genital plastic surgeons such as myself, revisions frequently cost much more than would have been the case had the original surgery been performed by the right surgeon in the first place.
Please do not hesitate to contact our office for any questions. Dr. Goodman offers free consultations about these procedures, generally lasting 5-10 minutes. For information specific to you and your wishes and anatomy, a personal in-person or telephone consultation (with photos) should be booked.
How long does it take to recover from labiaplasty and/or vaginoplasty?
For external work (labiaplasty; reduction clitoral hood, superficial reconstruction of the vaginal opening…), you should really take it easy, mostly around the house, for 4-5 days, and, although you may return to relatively sedentary activities at work/home, you shouldn’t “push it” for another ~ 5 days. At 10-14 days after surgery (after your first post=op visit, and you are “cleared,” you may begin modest exercise, and return to normal basic activities. You may exercise fully at ~ 3-4 weeks, and climb back on your bike or lover in ~ 4-6 weeks after your surgery.
For internal work (vaginoplasty; “vaginal rejuvenation”), the recovery is similar, but add ~ 5-7 days to everything. Do not go back to internal sexual intimacy until cleared to do so by your surgeon (usually 5-6 weeks after surgery.) Also, you may need a period of gently vaginal stretching prior to comfortable intercourse. And, don’t forget: this is the time to work on vaginal muscular strengthening exercises!
Does insurance cover any of this surgery?
Generally, no- genital plastic/cosmetic surgery is considered to be just that: not “medically necessary…”
However, if a portion of the surgery is considered medically necessary (for example, in situations involving urinary incontinence or certain types of prolapse/symptomatic pelvic support conditions), your surgery may cover a portion of the costs, including a good part of the facility and anesthesia fee. If this is combined with some purely plastic work (e.g. vaginal or perineal tightening/reconstruction), your surgeon may accept insurance payment for the medically indicated part, and bill additionally for that portion, not covered by your insurance, that is purely aesthetic.
How do I pick a surgeon to do my work?
Do your homework! Read as much as you can online about techniques and procedures from legitimate (translation: NON-advertising) sites. Visit at least 2 potential surgeons, using the rating sheet that you can easily download from the educational site, www.genitalplasticsurgeryinfo.com (go to “Choosing a Surgeon”).
Who to choose: A surgeon who has performed at least 25 procedures of the type you request; a surgeon who is adept at more than one technique for the work you wish done. (Make sure you see at least 10-15 “before and after” photos of his/her work; look for anatomy similar to yours, and see what (s)he has done with it.) Choose a surgeon who is clearly aware of the sexual aspects of your situation, and asks specific questions relating to this area. Choose a surgeon who gives you the option (for labial and superficial vaginal work) of having the surgery in an office setting under local anesthesia; this will make it much less costly, without the Surgicenter fee.
Who NOT to choose: A novice genital plastic surgeon; one who has taken a 2-day course; one who tells you that (s)he can get the procedure covered by insurance, when it is really a cosmetic/plastic/elective surgery (usually only novices do this; also, the insurance company can later make you pay them back the whole fee) If you do not live in the surgeon’s area, do not choose a surgeon who has no specific arrangements for your aftercare.
How does vaginoplasty and perineoplasty (sometimes nicknamed vaginal rejuvenation) potentially improve sexual function?
1) By repairing, elevating, and strengthening the perineum and “perineal body” (the area just outside of and below the vaginal opening) and, if indicated, bringing the pelvic floor muscles into better apposition, both the “angle of attack” and the tightness of the vaginal opening are changed, leading to better gripability of the penis at the opening, and more pressure of this thrusting organ against the clitoral complex. (**But remember, a series of pelvic floor physical therapy sessions to bring you better in touch with, and build up your muscular strength in this area will significantly enhance your post-surgical results (and sometimes eliminate the need for surgery at all) Any surgeon who does not evaluate your muscular strength and offer you the adjunct of pelvic floor P.T. is not doing his/her job well (I always include P.T. in my post-op plans and, if not covered by your insurance, pay for the first 2 P.T. sessions!)
2) Frequently, after childbirth (especially a big baby; long and difficult delivery, etc.), the upper vagina will become significantly stretched, leading to looseness and little friction between penis or toy in the upper vagina. There are no muscles in your uppermost vaginal wall, so if you are considerably stretched, with looseness between the penis and vaginal wall, only a surgical procedure will minimize this enlargement. By surgically repairing the fibrous fascia of this area (to strengthen), and by removing wedges of vaginal skin, the size of this area may be minimized for a tighter grip.
3) Re: labiaplasty, anything that minimizes discomfort and labial rearranging, anything that, in the opinion if its “wearer” beautifies this area, anything that improves self-esteem will, by its nature, improve sexuality and sexual function.
Our research1 and that of others2-5 confirm these improvements in sexual satisfaction. Our study (1) is the largest outcome study of genital plastics published in the world thus far.
1) Goodman MP, Placik OJ, Benson RH III, Miklos JR, Moore RD, Jason RA, Matlock DL, Simopoulos AF, Stern BH, Stanton RA, Kolb SE, Gonzalez F. A large multicenter outcome study of female genital plastic surgery. J Sex Med 2010;7:165-77 2) Rouzier R, Louis-Sylvestre C, Paniel BJ and Hadded B. Hypertrophy of the labia minora; experience with 163 reductions. Am J Obstet Gynecol 2000;182:35-40. 3) Pardo J. Sola P, Guiloff E Laser labiaplasty of the labia minora. Int J Gynec Obst 2005;93:38-43. 4) Alter GJ. Aesthetic labia minora and clitoral hood reduction using extended central wedge resection. Plast Reconstr Surg. 2008;122:1780-89. 5) Pardo J, Sola V, Ricci P, Guiloff E, Freundlich D. Colpoperineoplasty in women with a sensation of a wide vagina. Acta Obstet et Gynec 2006; 85:1125-28.
What is laser vaginal rejuvenation (LVR) and designer laser vaginoplasty (DLV) that I read about on many sites?
“LVR” and “DLV” are patented, marketing terms only, devised by a very skilled and clever plastic/cosmetic Gyn in Los Angeles (David Matlock M.D.), as a marketing tool to set apart the work that he does so well. Dr. Matlock teaches his techniques to other surgeons from around the world, for a very significant fee (~$50,000). When they have completed his 3-day course and paid the fee, they are allowed to use these terms and advertise on websites sponsored by him.
“DLV” is actually Dr. Matlock’s patented term for labiaplasty; “LVR” is his term for vaginoplasty. By using a laser (which is only a tool, not a technique, similar to an electrosurgical or radiofrequency electrode, scalpel or plastic surgery scissors: it is only one of the several tools that can be safely and effectively utilized to perform the surgery) they can set themselves apart advertising-wise. Much more important than the specific tool however, is the surgeon’s experience and the hand that is wielding that tool! (And physicians utilizing a laser need to charge more to pay for that expensive toy!)
What’s the big deal where writers for women’s magazines and many Gyns and University types are against female genital plastic/cosmetic surgery?
AHhhh… First, you must understand that the vast majority of writers for women’s magazines are free-lancers who would sell their souls to the devil for a buck! Most either have a pre-conceived bias one way or the other, and selectively write to prove their point, or fabricate what will appeal to the magazine they hope to sell their work to… Bad news, conflict, and controversy sells! Very little honest and investigative journalism here.
It’s a very interesting situation: The very same writers who shout for autonomy and women’s rights, become parental, judgmental and puritanical (very similar to many of your Gyns and primary care practitioners when it comes to genital plastic/cosmetic procedures.
I see the exact same thing here as I’ve observed in the past with breast augmentation in the 1960s and 70s, liposuction in the 70s and 80s, and advanced operative laparoscopy in the 80’s. In fact, when a small group of U.S. Gyns (myself among them) began to perform minimally invasive endoscopic surgeries through the scope, including tubal, ovarian and uterine surgery (this was in the days prior to “Lap Cholycystectomy”, laparoscopic appendectomy, and so many other minimally-invasive surgical procedures considered standard today), we were laughed at, and called surgical gymnasts by the medical establishment.
It helps if you understand that doctors in a position of medical political power, especially in a University setting, universally pan any procedure that they themselves have not discovered or that they are not good at. And, since ALL of the advances noted above (virtually all plastic procedures, the entire field of minimally-invasive surgery, and now female genital plastic/cosmetic surgery) start in the community, jealousy, snobbery, and, in the case of writers, the desire to make a buck, takes precedence.
What are the risks of genital plastic/cosmetic surgery?
All surgery carries known risk; the bar is set higher for elective cosmetic/plastic procedures.
Risk consists of known possibilities for a given procedure, but is very much a function of experience and aptitude as well. Simply put, a risk for a complication or a less-than-satisfactory outcome exponentially increases especially with novice surgeons (less than 25 procedures) and surgeons who know only one procedure (one-trick ponies…).
That said, here are the risks of genital plastic/cosmetic surgery procedures:
Labiaplasty and Clitoral Hood Reduction: Poor, or protracted healing process; incision separation, ongoing pain with sexual intimacy; cosmetic results not up to expectations.
Vaginoplasty/perineoplasty (“vaginal rejuvenation”): Poor or protracted healing; over- or under-tightening (if over-tightened expect a 1-3 month time-frame of progressive stretching exercises to put things right.); injury to bladder or bowel; infection/abscess; results not up to expectations (Remember. A pelvic floor exercise program facilitated by your surgeon is mandatory if you are to reap maximal benefits from your costly surgery; beware of the surgeon who does not offer you this advantage.)
Who to be aware of (risk-wise): Surgeons who do all their cases using only one approach; surgeons who have performed less than 25-50 procedures; surgeons who tell you “…No problem… we’ll just trim a little off…” or tell you that they will bill insurance for your cosmetic/plastic work (usually only novice surgeons do this, as a way of getting patients when they are starting out; it’s Insurance Fraud as well, and you could end up holding a very expensive bag with the insurance company). Also, be aware of surgeons who appear to not take into account the very sexual nature of these procedures, and do not quiz you about this aspect. Trust your intuition!
Explain the surgical techniques for Labiaplasty. Is one better than another?
Although there are other techniques, the most frequently utilized technique (mostly because this is the technique utilized by a leading surgeon who has trained many other genital cosmetic surgeons) is a linear resection (aka trim or curvilinear resection), closely followed by the modified V-wedge, and more distantly by the inferior flap amputation/superior flap rotation technique. Most novices start out with this technique.
In the sculpted linear resection technique, the bulk of the labia are removed via a curved or straight vertical incision, essentially removing a large portion of redundant labum, carefully re-approximating the inner and outer cut edges. This gives the so-called “Barbie” and rim looks.
The modified V-wedge is performed by removing a central V-shaped wedge of labum and re approximating the more modestly-sized upper and lowermost edges of labum, giving a more natural edge, preserving the labial architecture. A modification of this technique, called Y-modification was designed by Dr. Michael Goodman MD to include redundancies/extra skin of the clitoral hood in one, rather than several, surgiacl incisions. The flap technique is similar, except that here, the lower half of the labum is resected, and the upper portion is brought down and sutured to the lower edge, minimizing size and re-shaping the labia.
Which technique is best for you depends on your individual anatomy, your cosmetic desires, and your surgeons training. Ideally, it is best to have a surgeon who is skilled in more than one technique. “If all you have is a hammer, everything looks like a nail…” If your surgeon knows only one method, you may not get the most ideal results for your anatomy.
One technique is really no better than the other. Do what your surgeon is skilled in. The advantage of the linear resection is that more tissue can be removed, and that your labia end up pinker, as your natural edge (which may be dark colored) is removed, leaving the pinker skin color of the inner part of your labia. The downside is that this technique is more likely to have a complication of post-operative edge sensitivity, less feeling, and can, especially in less experienced hands, can result in too much labia being removed, with a greater risk of discomfort and deformity.
The advantages of the wedge are more natural looking labia and less potential for loss of sensation and pain; disadvantages include the risk of separation of the edges, and sometimes having less tissue removed than you’d hoped for.
Again, the best is if your surgeon knows 2 or 3 different techniques. Then (s)he can tailor surgery exactly for YOUR anatomy and YOUR individual cosmetic choice, rather than trying to adjust your differing anatomy to the only technique he or she knows. Only see surgeons who are skilled in multiple approaches!
What is the ‘G-spot’ and what is the difference between a clitoral and vaginal orgasm?
The “G-Spot” is less of a spot than an area below the upper vaginal wall, about 1 inch or so up in the vagina from the urethral opening. It is directly below and to either side of the urethra, the tube that empties urine from the bladder to the outside. It is not a constant anatomical structure and varies somewhat in size and position in different women. It is actually the roots of the clitoris. The clitoris, clitoral hood, and the outer portion of the vagina, as well as the urethra and labia, are in reality a unified structure that together play important roles in sexual response, and respond to sexual stimulation in a unified manner.
The thicker the space directly below the urethra, the more likely a woman is to have vaginal spread from her orgasm, originating in the body of the clitoris, below the clitoral hood. Vaginal orgasm occurs when the orgasm originating in the clitoris (analogous to the male penis) spreads down through the crus and crurae (the base of the clitoral body) into the G-spot area. Of course, the uterine contractions that frequently accompany orgasm, especially if your partner ejaculates into the vagina- prostatic fluid contains prostaglandins, which stimulate the uterus- helps. Pressure against the G-spot, whether by finger(s), toys, or the direct stroke of the penis, kneading the clitoral body against the pubic bone help with this orgasmic spread.
Childbirth, especially with tears, and loss of muscular strength, loosens the vaginal opening, leading to less clitoral and G-spot pressure, and weakens the gripping muscles of the pelvic floor. This is why vaginal tightening operations that elevate the perineum (re-establishing the anatomical curve often lost secondary to childbirth) and repair separated musculature, especially with added pelvic floor physical therapy, are so effective.
What is the normal size of a woman’s labia?
Like breasts and noses, labia come in an amazing array of shapes, sizes, and colors. And, like these other organs, there is a wide range of normality. No two women’s labia look exactly alike and, usually, the two sides are not exactly the same in an individual woman. Many women have petite labia, while others are more well endowed. The average width of a woman’s labia is about 1 inch. Obviously, many women are smaller, or larger. Some women’s labia begin in multiple folds from a generously endowed clitoral hood; others hoods are more spare, and there is only one fold. Sometimes the labial edges are pink, sometimes tan, ofttimes considerably darker. Sometimes thick, at times thin, frequently folded on itself. Sometimes the labia end well above the base of the vaginal opening, frequently the labia trail well below the opening.
It’s all normal. But, just because it’s normal (like very small breasts, or breasts that have lost their shape after bearing children) doesn’t mean that a woman is satisfied with the appearance and might, exactly like having breast size augmented or reduced, wish to change the appearance and size to one that better suits her desires.