PROCEDURE DETAILS FOR LABIAPLASTY IN THE OFFICE

“How do you do a labiaplasty” is question I answer everyday.  Although it is not rocket science it takes the precision of an engineer, the eye of an artist, and the hands of a drummer.  The steps are simple but the execution of the steps can be daunting.  If you are healthy, with no major medical problems, and do not have extreme anxiety, you can choose to have your procedure in our comfortable office.  Let me give you an overview of the whole series of steps once you have decided on getting a labiaplasty in the office.

Before you came in for your surgery, my staff had already given you pre-op instructions days before.  You would have known not to eat and drink anything for eight hours prior to your surgery time. You would already have the anesthetic cream.  You would already have picked up the pain pills, antibiotics, and estrogen cream from your pharmacy.  You would have taken your first antibiotic pill the morning of your surgery.  You would have placed the numbing cream over the labia and maybe into the vagina a bit.  You would have covered the cream with Saran wrap and worn your panties or panty hose over the Saran wrap to prevent messiness and loss of anesthetic medication.

My staff will welcome you and bring you into your own private room where you can relax a bit away from the rest of the world.  My medical assistants and nurses will make sure you have had all your questions answered and will ask you the basics such as what time did you eat last and are you pregnant?  They will check your vital signs, make sure your bladder is empty, and check a pregnancy test.  This is typically the time I come in and welcome you, explain the procedure in detail, and go over the risks, benefits, and options one more time.  Finally, you sign your consent once comfortable and knowledgeable that your questions are fully answered and that you indeed want to continue. 

We then go to our photography room and take your “Before” pictures.  We are fanatical about taking quality photographs for you.  You will appreciate the efforts exerted in our quest for quality.  Weeks later when you look at your own “After” pictures and compare the two you will understand our fanaticism. 

Usually we give you an oral anti-anxiety drug, like Ativan or Valium, right after your consent is signed.  We also give you an oral nausea medication right at the beginning to fend off any nausea during the procedure.  Next come a few injections in your upper arm or buttock to reduce the pain and the possible cramping or salivating.  The pain medication we use can be Demerol, Morphine, Dilaudid, and Toradol.  The medication preventing excess salivation is called Atropine.  These injections also help keep you from feeling woozy or lightheaded.  Notice we do not give you an I.V. at all.  It is such a safe protocol I developed and modified over the past ten years.

After you receive all our shots you will go to the procedure room and lay in a comfortable bed.  We put monitors on you and just watch you for several minutes to see how you react to the medications before we actually start doing surgery.  This is probably the time you feel like you just had a couple of Margaritas or Martinis!  “Comfortably Drunk” is what we call it.  You are easily talking to me, responding to questions, watching FOX News on TV, listening to your iPod, or even reading a magazine.  If you are a “cheap date” and feeling tired and comfortable after one set of shots then we start with surgery.  However, if you are fully awake and not showing any signs of being “Comfortably Drunk” we may choose to give you a second dose of narcotics.  By the way, for those who do not like shots at all, we can give all but one of the medications orally.  You have to plan a bit ahead because the oral meds take a bit longer to take effect. 

Now is the time I place your legs in its proper position just like you were getting a Pap smear.  I wipe off all the numbing cream and use my markers to draw and outline the surgical plan.  Since your vulva is numb it usually feels a bit strange to see someone touching you but you can’t feel it.  We would have already talked about the look you want and how much or how little labia minor or majora to remove.  You have a hand mirror during this process to help me define and draw out the plan of action.  Next is the cleaning and prep work with betadine or chlorhexidine to sterilize the surgical field.  Soon to follow is the covering blue drape that ensures a sterile field.  You are now ready for the actual start.

This next step is the most uncomfortable but also the shortest and quickest.  I have to place local anesthesia with a very small needle on the areas I am working on.  Typically, this is the labia minora or majora, clitoral hood, and maybe the introitus (the very beginning lower region of the entry into the vagina).  You are allowed to cuss and swear during this minute!  Go ahead, I won’t take it personal.  If you are having a vaginoplasty also then I have to numb up the inside of your vagina.  That is an extra thirty seconds.  This is when I get compared to a dentist and my maternal heritage is put into question.  I then check all areas to make sure you are completely numb.  If you are not feeling anything sharp then we go to the next step. 

Next, you hear the whirl of the smoke evacuator or the increase volume of the TV or stereo.  I go ahead and start the delicate and carefully planned surgery.  I follow the surgical markings on your labia with the minimally traumatic Ellman Surgitron.  It is such a fantastic tool because it is a relatively cool tip that has lateral thermal damage measured in microns instead of in millimeters when one uses a 980 Diode laser you read about when a surgeon does “laser” surgery to rejuvenate a vagina.  The Ellman is without comparison in its finesse.  Since I first started using the Ellman several years ago I have noticed more plastic surgeons and gynecologists using the Ellman (also known as RF or Radio Frequency) when doing labial/vaginal work.   To help me with certain bleeding sites I also have a ConMed 5000 unit in my office surgical suite.  It is a superior cautery unit. 

There are two basic techniques to labiaplasty of the labia minora.  I am partial to one and avoid the other like the plaque.  The “V” technique discussed on some reality TV shows is one preferred by many plastic surgeons.  Unfortunately, it is wrought with complications in my opinion.  The edges of the V are brought together with fine sutures but they unfortunately pull apart often enough for me not to feel comfortable with the technique.  There is too much tension and not enough suture strength; too much tension and a variable blood supply to regenerate the edges together.  I have to repair these “labiaplasty-gone-bad” cases from other surgeons often enough to realize the faults of this technique.  Most gynecologists use the technique that sculpts the edges to the size desired without the high-tension “V” incision.  There is less wound breakdown and fewer problems with restoration of blood flow.  I personally favor this sculpting technique because of its precision and flexibility.  You do not have to guess how the top will line up with the bottom.  The edges always line up.  The knock on this technique is that there are the color discrepancies of the inner labial lips as compared to the outer labial skin.  This is true in the short term but over the long term the color issues are non-existent because nature has a way for the edges to eventually match in color. 

Once all undesired labial tissues are removed the suturing begins.  Fine but strong sutures are used in several layers to ensure proper wound healing.  Many various suturing methods can be used but I prefer to stay with a tried-and-true technique I have developed over the years.  This multi-layer approach is the technique I teach all my trainees.  It is the safest method of all to ensure wounds do not open up and at the same time preserving the most natural of looks. 

So now you are pretty much done.  You are comfortable and awake.  I will take off the drapes, clean you up, and give you a mirror to view your new you.  A few pictures follow, you go to your private room and change, have a glass of water if you wish, then go home with your driver.  Your post-op instructions and handouts will be reviewed just one more time before you leave and go off painlessly into the outside air.  Your post-op appointment will be set and my personal cell phone number will be given to you so that you always feel that I am available.  You will be numb for another couple of hours but be sure to use your pain meds and ice packs for your comfort.  Be a princess sand don’t do too much.  You can walk and eat what you like.  You can drive the next day.  Read the section on “Recovery Time” and you will get a good feel of what to expect in the weeks to come. 

Red M. Alinsod, M.D., FACOG, FACS, ACGE
South Coast Urogynecology, Inc.
31852 Coast Highway, Suite 200
Laguna Beach, CA  92651
red@urogyn.org
949-499-5311 Office 
949-499-5312 Fax