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 any1.
Labiaplasty brings great benefits to female sexual function, especially in factors
such as pain and pleasure2. 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-operatively3.
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 suggested2. The average clitoris must be less than 5mm wide and 16mm long4.
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 majora5,6.
The elliptical or longitudinal technique was initially described by Hodgkinson & Hait7. It is the most performed technique in the world6, followed by the “V” shaped technique or wedge technique, described by Alter8. The combination of the longitudinal technique with wedge resection is also carried
out9.
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 ones10-13.
Surgical resection of excess labia minora can be associated with resection of the
clitoral hood in its lateral, cephalic region or both1,5,8,14-16 and can be associated or not with clitoripexy, which means the fixation of the clitoris
to the pubis8,11,14-20.
In cases of lipodystrophy in the pubic region, in the mons pubis, it is possible to
perform liposuction of this region21.
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 age22.
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 202023. 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 sexuality24. 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 channels25.
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 1 - Hipertrofy type 3.
Figure 2 - Standard vulva.
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 3 - Preoperative marking of the boomerang technique.
Figure 4 - Incision at 12 o’clock made towards the suspensory ligament of the clitoris.
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.
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 - Sociodemographic and surgical characteristics of patients undergoing female genital
plastic surgery procedure, Brasília, DF, Brazil, 2022.
|
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 |
Table 1 - Sociodemographic and surgical characteristics of patients undergoing female genital
plastic surgery procedure, Brasília, DF, Brazil, 2022.
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 - Distribution of operated genital areas of study patients, Brasília, DF, Brazil, 2022.
| 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 |
Table 2 - Distribution of operated genital areas of study patients, Brasília, DF, Brazil, 2022.
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 to 12.
Figure 5 - (A) Preoperative and (B) six-month postoperative photographs of a patient standing.
Figure 5 - (A) Preoperative and (B) six-month postoperative photographs of a patient standing.
Figure 6 - (A) Preoperative and (B) six-month postoperative photographs of a patient in the lithotomy
position at 45°.
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 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 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 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 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 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°.
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 & Moore27 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. Hamori28 described the inverted V resection to reduce the redundant clitoral hood. Oppenheimer15 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 & Hengshu13 described the technique in which they adapted the W-plasty to resect both the labia
minora as for the hood.
Gress14, 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 hypertrophy14,18.
The term “clitoral relocation” (or repositioning) was first used by Lattimer30, 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 clitoris31. 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 clitoris19,31.
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.
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1. Instituto de Cirurgia Plástica Tatiana Turini, Brasília, DF, Brazil
2. Hospital Regional da Asa Norte, Brasília, DF, Brazil
3. Centro Universitário de Brasília, Brasília, DF, Brazil
Corresponding author: Tatiana Turini SGAS II St. de Grandes Áreas Sul 616, Conjunto A, Lote 116/117, Sala 1, Asa Sul,
Brasília, DF, Brazil., Zip code: 70200-001, E-mail: tatianaturini@hotmail.com
Article received: August 18, 2023.
Article accepted: February 4, 2024.
Conflicts of interest: none.
