Nearly a quarter century ago, plastic surgeon Gary J. Alter, M.D., says he knew there had to be a better way to do the traditional trimming labiaplasty.
“The main two types of labiaplasty are the trimming labiaplasty, where the doctor trims off the labium, which means there’s an incision line along the entire length of the labium,” says Dr. Alter, assistant clinical professor of plastic surgery, UCLA School of Medicine. “The other type is the central wedge labiaplasty, which I invented about 24 years ago. In that labiaplasty, I do not trim.”
Rather, Dr. Alter, who gave a course on the wedge approach recently at The Aesthetic Meeting 2018 in New York City, removes a central wedge from the most protuberant part of the labium.
“The outer portion of the V excision is usually curved lateral and anterior to excise redundant lateral labium and excess lateral clitoral hood,” he describes in a study on the topic published in 2008 in Plastic and Reconstructive Surgery.
The result isn’t a long suture line going down the length of the vaginal opening. Instead, it’s a horizontal suture line that crosses the labium.
“It leaves the normal labial edge, and it’s really difficult for anybody to determine that you’ve had a labiaplasty done,” he says.
Dr. Alter says he doesn’t do trimming labiaplasty because he doesn’t think it’s a good aesthetic operation.
“What you want to do when you do an aesthetic operation is to maintain normal anatomy, while making it look more like one’s aesthetic ideal. We don’t want to create big scars or create an abnormality…,” he says. “Some people can get a reasonable result from a trimming labiaplasty, but, in general, I don’t think it gives as natural an appearance — especially, in somebody who has a wide or thick labium.
The 2008 publication modified the central wedge excision to reduce the labia minora approach Dr. Alter first reported in 1998. The more recent study of 407 patients who had labia reductions from 2005 to 2006, found the central wedge reduction with lateral clitoral hood reduction is safe, effective and a patient-pleaser, with few complications.
That’s not the case with trimming labiaplasty, Dr. Alter says. About a third of his practice today is doing reconstructions on women who have failed labiaplasty. Most of those women had prior trimming labiaplasty, according to the plastic surgeon.
“Sometimes you see a patient where the doctor removed all the labia. Or they have bad asymmetry or scalloping. It just looks terrible. There is also a higher incidence of chronic discomfort from a trimming labiaplasty because the incision line is so long, and it’s right along the vaginal opening, where clothes, underwear and intercourse directly impact it,” he says.
Almost any woman who wants a more aesthetically pleasing labia is a candidate for the central wedge approach. There are ancillary procedures that can be done to customize a woman’s results. For example, Dr. Alter says he can do a central wedge labiaplasty on a woman who has a long labium; then, remove some labia from the inside and outside, but not on the edge, to make the labia less prominent.
One of the advantages of the wedge is the natural looking results. One of the disadvantages is it takes longer for surgeons to do the surgery. Dr. Alter says it takes him an hour and a half to two hours to do a routine labiaplasty with the wedge. Whereas, it might take 30 minutes to do the trimming approach.
“If the doctor is not very compulsive with any technique and doesn’t really seek symmetry and care with the scar line, then he’s going to get a bad result. It takes time to do it right,” he says.