Complications of Female Incontinence and Pelvic Reconstructive Surgery (Current Clinical Urology) 2nd ed.

18. Complications of Cosmetic Gynecologic Surgery

Dani Zoorob1, 2 and Mickey Karram1, 2  

(1)

Division of Female Pelvic Medicine & Reconstructive Surgery, The Christ Hospital, University of Cincinnati, 2123 Auburn Avenue, Suite 307, Cincinnati, OH 45219, USA

(2)

Department of Obstetrics/Gynecology, University of Cincinnati, Cincinnati, OH, USA

Mickey Karram

Email: mickey.karram@thechristhospital.com

Abstract

Whether called cosmetogynecology or genitoplasty, the desire for enhancement of the genitalia is becoming more prevalent. As this field grows and is more in demand, surgeons have devised various techniques in the hopes of generating better outcomes. In the recent past, there has been a tremendous amount of direct to consumer marketing of these modalities by individual surgeons, promising improved sexual function.

Whether called cosmetogynecology or genitoplasty, the desire for enhancement of the genitalia is becoming more prevalent. As this field grows and is more in demand, surgeons have devised various techniques in the hopes of generating better outcomes. In the recent past, there has been a tremendous amount of direct to consumer marketing of these modalities by individual surgeons, promising improved sexual function.

The objective of this chapter will be to briefly discuss these various techniques and how to best avoid and manage complications when they occur.

Labioplasty

Labioplasty, also known as labial rejuvenation, is a term used to indicate surgical enhancement of the labia minora.

The documented origin of labioplasty dates back to the Pharos in Egypt [1]. This practice, although modified, has persisted in the African continent with variations as minor as modification of the labia minora up to extensive resection of all external female genital organs including both labia majora and minora as well as the clitoris.

Amongst the earliest modern medical references discussing labioplasty is that of Hodgkinson and Hait [2] where they discuss the functional and aesthetic standpoints. Over the years, multiple procedures by Alter [3], Rouzier [4], Choi [5] and others were devised with varied outcomes and complications inherent to the different techniques used. Although less commonly used, the term labioplasty may encompass the augmentation or reduction of the labia majora.

A common nonaesthetic indication for labioplasty is dyspareunia, which usually occurs in women with labial hypertrophy due to the labia being pulled inward during intercourse. Other indications include vulvar irritation and discomfort with the use of underclothes or during ambulation or exercise. Some patients report an inimical impact on hygiene, especially when menstruating. The negative psychological impact of the “unnatural” or abnormally appearing labia, even if subjective, is also a frequent reason to consult a physician.

When performing a labioplasty, the essential goals [67] should include the reduction of the hypertrophied labia minora with maintenance of the neurovascular supply, preservation of the introitus, optimal color/texture match, and minimal invasiveness.

While many systems to stage the severity of this condition exist, there is still no consensus on how best to define and classify labial hypertrophy. One system divides the classification into three stages: none (no edges protruding beyond the labia majora), mild (1–3 cm beyond the labia majora edges), severe (>3 cm). Another system described by Felicio [8] divides labial hypertrophy into four stages: I (<2 cm), II (2–4 cm), III (4–6 cm), IV (>6 cm). Franco and Franco [9] describe a similar classification. However, Rouzier et al. [4] considered that the normal maximal length of the labia minora should not exceed 4 cm whereas Radman [10] considers it to be 5 cm (Fig. 18.1).

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Fig. 18.1

Massive hypertrophy of the labia minor in a young woman with cerebral palsy

A myriad of surgical techniques have been reported in the literature, including simple resection, wedge resection with modification of excisions, VY and Z-plasties, and de-epithelialization (Figs. 18.2 and 18.3).

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Fig. 18.2

The technique for simple excision of enlarged or hypertrophied labial skin. (a) Excess skin to be removed is marked. (b) Skin is excised. (c) Interrupted sutures reap proximate the edges of the labia

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Fig. 18.3

Technique for Z-plasty. (a) Skin is to be excised. (b) Skin is excised and to be reapproximated transversely with fine interrupted sutures. (c) Completed repair

In simple resection, the excess or protuberant labial tissue is removed using scissors, a scalpel, or even a laser [11], in an elliptical or straight line. The edges are thereafter reapproximated with sutures, preferably simple interrupted, to ensure appropriate healing while maintaining the new contour. Depending on the defect or abnormality, the resection is preferably made while preserving a regular labia minora edge. Hodgkinson and Hait [2] and Maas and Hage [12] suggested a remnant minimal depth/length of 1 cm of labia minora. A novel technique called “Lazy S” reported by Warren [13] is reported to assist in reducing the likelihood of contractures and phimosis of the labia minora. This technique involves marking the area to be resected in an S shape—rather than an ellipse or straight line—prior to infiltration with local anesthetic and then resecting along the broadly wavy tract. It is reported that once healing occurs, the wavy line would take a relaxed appearance with little tension at the periphery of the tissue, giving a more “natural” and esthetic look.

Another technique is wedge resection, which is reported to reduce hypersensitivity and contour irregularities upon healing. The wedge system targets the most hypertrophied region in the labia minora and resects it all the way to its base in a V or wedge form. This in turn allows for a smaller exposed healing area; however, depending on the resection required, it might be deep enough that it reaches the proximity of the labia majora. Multiple variants of this procedure have been devised including Z-plasty and VY and the Matarasso modification/Star wedge resection [6]. The initial description of the technique was by Alter [3]. It involved a V-shaped wedge resection of the area with the most excess tissue identifiable. Maas and Hage [12] reported the wedge technique to strictly involve a W-shaped resection margin in the labia minora with no involvement of the clitoral dorsal hood, prepuce or fourchette. The advantage of this technique (also known as the Zig-Zag technique) was reported to be less likelihood of dyspareunia and introital obliteration. This technique is reported by some to induce loss of the pigmentation along the border of the labia minora despite the more natural contour being generated. In 2008, Alter [14] published the extended central wedge technique, a modification of his previous wedge resection, producing a more esthetic look, with the possibility of resection of excess tissue in the clitoral hood. This was based on the follow-up of previously operated patients. Among the modifications was one reported by Munhoz et al. [15] where the wedge is resected from the inferior aspect of the labia minora and a superior pedicle flap is developed. This is reported to provide a better esthetic look due to a more homogenous tinting of the labia.

In 2000, a novel technique devised by Choi and Kim [5] was reported to preserve tint, texture, sensation, and the neurovascular supply to the labia minora. This technique involved the central de-epithelialization of both labia minora on both sides with suturing of the new edges together.

In 2011, Alter [16] described the use of YV advancement flaps for the reconstruction of either absent, abruptly terminated, distorted, or scalloped labial edges. Being the closest match to labial tissue, clitoral hood tissue is mobilized in such a manner as to release two parallel folds—including the Dartos fascia and blood supply—from around the clitoris and rotating them on each side to form the labia minora.

Relative to the labia majora, Salgado et al. [17] reported that grafts of fat pads as well as fat injections could improve the atrophied look in some patients. Felicio [18] reported up to a maximum of 60 mL of fat injected into each labia majora per session, while requiring a drain if more is to be implanted or a continuation of the procedure 6 months later. Labia minora injections are also possible. Labia majora augmentation is reported to assist in increased comfort and sexual satisfaction, possibly due to acting as a shock absorber and possibly due to increased fullness and firmness of the labial tissues. Relative to hypertrophied labia majora, the option of resection in an elliptical or S-shaped incision may be necessary. However, the closer the final incisional edge to the labia minora, the more inconspicuous the scar is. Miklos and Moore [19] reported use of a semilunar incision on the medial border of the labia majora. The possibility of ­lipoplasty could assist in avoiding large incisions and shorten the recovery period and reduce postoperative pain, however, the need for repeat or touch-up surgery may be required.

Labioplasty Complications

A variety of complications have been reported with labioplasty surgery. As a multitude of different techniques and modifications have been described, it is essential that the surgeon undertaking these procedures be intimately familiar with the anatomy of the external genitalia and its surrounding structures.

Infection: The perineal area seems less susceptible to infection compared to other regions of the body but the potential for abscess formation does exist and it is mandatory to follow the universal guidelines for surgical site cleansing prior to initiating surgery. Although no definitive recommendations for labioplasty have been set by any society, the routine gynecologic surgical antibiotic prophylaxis is advisable.

Surgical site breakdown: The possibility of contractures, tissue breakdown along the suture line, flap necrosis, edge necrosis, irregular resorption, phimosis of the clitoral hood, new onset of dyspareunia, loss of sensation or hyperalgesia may occur in the resection areas.

Care following surgery whether immediately postoperatively or few weeks out is mandatory. No set criteria is available in the literature denoting particular postoperative wound care. However, it is advisable that postoperative patients observe pelvic rest for a minimum of 4–6 weeks to ensure adequate healing with time and avoid trauma to the surgical site. Felicio [18] reports that ice packs and NSAIDs are ideal for postoperative edema and swelling. He also recommends ensuring that labioplasty is not concurrently performed with perineoplasty due to the intense swelling resulting in prolonged discomfort persisting up to 6 months. In addition to the discomfort, the likelihood of suture-line breakdown is much higher with the swelling. Thus staging the enhancement procedure would be advisable for both patient care and outcome.

Whether preceded by a wound hematoma or not, the development of a wound dehiscence is particularly ominous. Generalized flap degeneration or necrosis is more commonly seen in patients with sutures that have been placed tightly across the edges or when there is excessive traction on the attached tissue or flaps. It is crucial that when a flap is to be mobilized, the surgeon needs to ensure the persistence of the blood supply to allow the flap to survive as well as incorporate appropriately into the transposition site. Distal flap necrosis and subsequent gap formation in the labia may ensue if the vascular supply is not preserved. Additionally, in YV advancement flaps, the de-vascularization due to extensive undermining or extreme skinning prior to mobilization particularly endangers the survival of the transposed flap. Thus, ensuring minimal vessel distortion when mobilizing tissue with the least possible rotation/torque applied allows for better tissue survival.

Bleeding: Hemorrhage and the possibility of hematomas may be encountered based on the vessels severed. Arterial blood vessels usually require active control by cautery or suture ligation, whereas venous bleeders may need less aggressive management including pressure applied to the area involved or simple application of hemostatic agents.

The acute worsening of pain postoperatively may indicate the expansion of a hematoma, specifically if the labioplasty involved the labia majora. In addition to the psychological impact on a patient, the formation of a hematoma could potentially require drainage as well as prolonged courses of antibiotics, and ultimately exploration to control the bleeding vessel. This can be attempted initially by freeing the suture line and then evacuating the hematoma. Since not all hematomas are associated with arterial bleeding, the use of fibrin clotting agents could be useful at times when persistent minimal venous oozing is noted. While multiple agents exist, there are no studies identifying the benefit of one vs. another in the setting of labial hematomas.

Dyspareunia: Postoperative dyspareunia is known to occur more with wedge excisions as well as simple resection due to the newly formed exposed labial edge. Multiple studies [2022] have been done to assess the innervations in hypertrophied labia compared to normal sized ones with no evidence of variability relative to size. However, postoperative hyperalgesia has been noted to occur, especially with associated infection, severe inflammation, or severe edema ensuing postoperatively. If swelling occurs and the tissue perfusion is impacted, the possibility of labial retraction and contracture (called phimosis if involving the clitoral hood) may occur as the healing process continues. This contracture may in turn cause severe dyspareunia that may require reoperation due to inability to achieve penetration.

Suture granulomas and scarring: The use of running sutures may predispose to contracture formation. Compared to simple interrupted sutures, the use of running locked sutures at the edges may predispose to a rugged or irregular labial edge due to localized necrosis or skin retraction. The use of simple interrupted sutures is preferred in simple excision procedures. The various studies available in the literature report the use of a variety of suture material with none proven to be superior to the other. When using absorbable sutures, the use of vicryl and monocryl would be ideal, although the use of chromic sutures in the study by Choi and Kim [5] also had good outcomes. Use of nonabsorbable sutures is theoretically associated with the least reaction at the suture site with possibly better cosmesis; however, it is less convenient to use due to the discomfort endured by the patient upon removal of the sutures. To ensure better outcomes, it is advisable to inquire preoperatively about any history of vicryl-associated suture granulomas. The removal of any permanent sutures should be carried out within 1 week of surgery to assist in healing while ensuring the pressure on the incision site is lower since the edema will have partially receded by then. When left too long, the sutures can potentially develop epithelialized tracts and this may have an unsightly appearance.

Maas and Hage [12] reported that simple amputation of the protuberant labium will generate a stiff and weakly healed edge along which irritation and potential retraction. The stiff edge formation is mostly due to extensive local fibrosis developing when healing. A technique called “Lazy S” reported by Warren [13] is reported to assist in reducing the likelihood of contractures and phimosis. This technique involves marking the area to be resected in an S shape. With healing, the wavy line takes a relaxed appearance with little tension at the margin. The homogenous or gradual labial pigmentary changes need to be preserved in order to ensure esthetic outcomes. The sudden change from dark pigmented folds to lightly pigmented labial folds is not advisable. The de-epithelialization and zig-zag techniques preserve this best.

Postoperative labial asymmetry: A complication that has been reported is inability to perceive the length of labial tissue necessary to be resected once they have been infiltrated with local anesthetic. The distortion incurred intra-operatively by the solution injected could render the margins irregular and not easily identifiable and thus it is imperative to mark the area for excision prior to any local injection. This helps prevent over-resection and provides the appropriate aesthetic result. It would be prudent that the delineation be done immediately preoperatively while the patient is awake, as well as preferably initially in the office during the surgical scheduling appointment so the appropriate change in labial size that is medically advisable compared to the patient’s expectations can be determined.

Vaginoplasty

Vaginoplasty refers to modifications in the vagina to incur visual, sexual, or functional improvement. Its indications remain vague but usually include the desire for enhancement of vaginal aesthetics and improvement and augmentation of the sexual experience. Ostrzenski [23] considers it a transformation involving both anatomy and function to allow for heightened sensation in intercourse. Typically, aesthetic vaginoplasty is primarily a perineoplasty. It involves restoring the normal visual anatomy of the region of the perineum/and posterior fourchette.

At all times, the vaginal canal should have a perpendicular relationship relative to the perineum. Having had an episiotomy or laceration during parturition, many women have been inadequately repaired and end up with an introitus that has a large membranous portion covering the posterior fourchette. This membrane often causes dyspareunia due to friction and stretching. This is usually due to an iatrogenic mal-approximation of musculature and overlying skin resulting in the perineum not having sufficient support and thus dyspareunia develops due to significant stretching and pulling of the thinned-out portion of this vulvovaginal structure (Fig. 18.4). The “membrane” itself does not have any physiologic purpose and thus it is advisable to have the “membrane” resected when restoring normal anatomy to the perineum.

Moving deeper into the vagina, the presence of significantly redundant tissue inside, whether following any surgical procedure or even if present naturally, could be reported as unappealing to the sexual partner. In rejuvenation and vaginoplasties, this may be considered as a potential repair site, where excess rugae may be excised, cauterized, or lasered. Certain areas to be targeted while resurfacing are episiotomy skin/mucosal tags or laceration repair sites, areas of previous colporrhaphies where dog-ears/tags have developed, as well as possible breakdowns in the repairs. Another form of rejuvenation, called mucosal tightening/lateral colporrhaphy, involves excision of a wedge of vaginal mucosa after which the raw edges are sutured together. A case series by Adamo and Corvi [24] showed a 95% improvement in sensation after such a procedure.

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Fig. 18.4

The skin of the labia minor has been previously sewn across the midline, most likely at the time of the repair of a midline episiotomy

At times, band-like adhesions may be noted extending across the vagina due to varied resorption and healing after any kind of repair (Fig. 18.5). Sometimes strictures may be seen across the vagina. Severing these adhesion bands may be accomplished by using a cautery that is allowed to go deep into the vaginal wall—releasing the adhesion at its base if possible.

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Fig. 18.5

Band of perineal scar tissue in a young patient following the repair of a perineal laceration

This typically allows for restoration of the normal vaginal caliber. Healing in such cases may require secondary intention closure rather than ­surgical mucosal overlay. Recent studies have aimed at the regeneration of vaginal rugae to effect augmentation of sensory-coital pleasure. Loss of this rugation may occur with age as estrogen production dwindles, as well as in areas with site-specific defects. Studies have also shown that the anterior vaginal wall has denser innervation relative to the posterior wall [2527] particularly distally. Attempts at regenerating rugae using linear laser stratification with vaporization up to the vaginal fascia was noted to improve sexual satisfaction in a prospective observational study but in only 20% of the test subjects [23].

Typically occurring postpartum, many women develop a widened genital hiatus as well as vaginal laxity. Prior to surgical repair aimed at tightening of the vagina itself, pelvic floor rehabilitation should be initiated to ensure adequate muscular toning of the vagina. In general, only a perineoplasty is required for tightening the genital hiatus but some may consider doing a posterior colporrhaphy (Fig. 18.6). Studies done to assess dyspareunia following colporrhaphy show that it is less frequent if perineorrhaphy involving the levators is avoided.

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Fig. 18.6

The technique of vaginoplasty and reconstruction with the sole aim of tightening the vaginal introits. (a) Note the wide genital hiatus, which easily allows the insertion of four fingers. (b) A diamond-shaped piece of tissue to be excised is marked. (c) The tissue has been removed, and deep stitches are taken through the perirectal fascia and levitator muscles to build up the posterior vaginal wall. Great care is taken to avoid the creation of a posterior vaginal wall ridge. (d) The upper portion of the posterior vaginal wall is closed in preparation for perineal reconstruction. (e) After perineal reconstruction, the introits allows the insertion of only two fingers. (f) Completed repair; note the perpendicular relationship between the posterior vaginal wall and the perineum

Complications of Vaginoplasty

Depending on the procedure used for vaginoplasty, a myriad of complications may occur.

Laser and cautery-related complications—If the laser is used to create rugae, the avoidance of damage to the fascial layers is important. Currently, there are no recommendations for the depth of vaporization but it is best to avoid reaching the glistening fascial layer so as to avoid iatrogenic development of site-specific defects. The laser vaporization, if not used judiciously, may incur damage to any of the underlying tissues including the bowels, bladder, and urethra. Furthermore, it is advisable to avoid prolonged tissue exposure—of the same spot—to avoid peripheral damage by heat conduction. As with the laser and due to significant peripheral heating of adjacent tissues, caution is advised with extensive use of monopolar cautery. In procedures of resurfacing where the extra rugae or skin tags in vagina are removed, it is best to brush rather than attempt to cut or shave the rugae. The brushing technique, as its name implies, involves rapid and superficial back and forth cautery tip motion. This modality will result in removal of only the necessary tissue particularly since the extent of the cautery is well visualized and controlled. If the cautery tip is placed on the vaginal mucosal tag and activated continuously until the tag shrivels, the underlying tissue may be damaged by the heat generated from the tag degeneration and accordingly may result in a potential area of necrosis that could impact the integrity of vaginal walls. This in turn may predispose for vesicovaginal or rectovaginal fistulas. If reporting new onset fluid leakage or foul odor on intercourse, then a detailed pelvic exam with assessment for fistulas should ensue. Furthermore, it is important to inform the patient of the significant discharge that will develop after surgery which could last for weeks as the sloughing occurs. Pain should be absent to minimal with this type of procedure and the patient should recover rapidly. If the patient develops worsening pain or if pain develops days after surgery, then the likelihood of damage to an adjacent structure is very high. The development of fever is unlikely unless an infection has occurred. The use of the cautery to create relaxing incision when vaginal strictures exist is highly successful in resolving the constrictions as long as bleeding is controlled and vessels are avoided. Being familiar with the vascular anatomy of the vagina prior to any surgery is crucial. It is advisable to use simple interrupted sutures to control hemorrhage of actively bleeding tissues since cautery may sometimes make further suturing difficult, especially if retraction of the vessel occurs with unsuccessful cautery. The sutures applied should preferably be placed perpendicular to the band that was released so as to maintain the newly developed caliber. The use of any form of energy in the vagina increases the risk of stricture and fibrotic band formation, even if the initial surgery was for the release of strictures.

Persistent postoperative dyspareunia—The vaginal innervation is densest anteriorly and distally. If colporrhaphy is primarily performed for rejuvenation and not defect repair, then the risk of dyspareunia is lower but is least when a perineoplasty is not performed. Severe superficial dyspareunia has been reported when the perineoplasty involved levator muscle plication. The discomfort classically occurs when the introitus is tightened significantly. The pain is usually muscular-related and not neurogenic in nature, but the dyspareunia can be quite significant at times, resulting in abstinence instead of enhancement of the sexual experience.

Pelvic muscle dyssynergia—The use of Botox described by some for alleviation of Levator ani spasm has been reported in the literature with notable results. It has been described for the rejuvenation process as well; however, the associated complications, although rarely encountered, can potentially last for a few months until the medication wears off. Judicious injection could help avoid the development of retroperitoneal hematomas and internal bleeding, pelvic muscle dyssynergia, urinary and fecal incontinence and obstruction, pelvic abscess formation, permanent neural damage, leg and pelvic weakness, and new onset of referred pain. Careful assessment and application of Botox are necessary while ensuring an injection that is not too deeply placed.

Site-specific augmentation complications—To increase sensation to both partners, injections of fat or fillers into the vagina, and even grafts, have been described. The placement of grafts is potentially associated with erosions and dyspareunia as well as bowel and bladder perforation. Despite it being typically injected into the labia majora in vaginal rejuvenation, some have used fat to create ring formations within the vagina with the hope of providing an enhanced sexual experience. The complication that may ensue is severe edema that could potentially impact urination as well as abscess formation and vaginal mucosal wall breakdown with ulcer formation—with the breakdown developing immediately postoperatively or potentially during intercourse. Another potentially injectable and often topical form of treatment for vaginal rejuvenation is mesotherapy which uses herbs and chemicals to induce lipolysis or change tissue consistency and thus theoretically enhance vaginal sensation. Since these compounds have not been tested adequately for vaginal use, they should be avoided as they may create irritative and potentially damaging effects resulting in sclerosis and significant sloughing of the epithelium causing pain and copious discharge.

Clitoroplasty

The first well-documented corrective clitoral surgery dates back to 1934 where Young [28] described a clitoridectomy. As time passed, studies in the mid- to late-1960s ascertained the need and importance of the clitoris in the sexual experience.

Clitoroplasty can involve the increased exposure of clitoral tissue which may augment sexual enjoyment. It may also involve the removal of tissues to assist in an enhanced visual genital appearance, especially when combined with labioplasty and possibly vaginoplasty. Furthermore, clitoroplasty may involve the repositioning and resizing of the clitoris especially in women with evidence of hypertrophy—particularly if afflicted with hyperandrogenism.

Various techniques have been described to surgically manage clitoromegaly. One technique involves resecting the excess tissue from the clitoral hood and then reapproximating the edges with concurrent reduction in the clitoral size by resecting part of its corpora then attaching it to the periosteum [29].

With the desire for increased sexual pleasure, a procedure for exposing the clitoris has been devised. Clitoral unhooding involves resection of tissue covering the clitoral tip, at times circumferentially, thus exposing it more, much like circumcision in males. A similar procedure is the reduction of the clitoral hood which involves repositioning of the tissues overlying the clitoris with the help of sutures rather than actual tissue resection. This usually allows for increased stimulation during intercourse and accordingly heightened sexual pleasure.

Complications of Clitoroplasty

Hemorrhage and necrosis of the clitoris—When reducing, advancing, or repositioning, the clitoris, the likelihood of severing of the vascular supply is high. Undiagnosed, this could result in withering and death of the reattached clitoral tip. Partial resection of the clitoris, which is often done in certain types of female genital mutilation (sometimes misleadingly called “circumcision”), will usually have a marked negative impact on intercourse and is associated with significant blood loss. The blood supply to the labia minora as well as the clitoris arises from the posterior labial, perineal, and dorsal clitoral branches of the pudendal artery. The neurovascular bundle lies at the dorsal side of the clitoris, covered with fatty tissue padding and with the suspensory ligament of the clitoris lying beneath it. Ensuring appropriate dissection is crucial to avoiding these complications.

New-onset clitoral pain—When reduction of the clitoris involves resection or repositioning of the clitoris, it is crucial to safeguard the neurovascular connection between the tip of the clitoris and the body [30]. The interruption of the neural pathway could render the clitoris insensitive and its contribution to the sexual experience rendered absent, thus nerve sparing techniques have been devised and their use is advised.

The posterior labial and perineal branches of the pudendal nerve (S2–S4) predominantly supply sensation to the labia minora with the clitoris receiving additional autonomic innervation from the hypogastric and pelvic plexuses. Anecdotally, the entity of persistent postoperative pain generated at the periosteal clitoral insertion site as well as throughout the clitoris occurring with arousal has been reported.

Contractures around the clitoris—Contracture of the incision line may result in phimosis and theoretically strangulation of the clitoral tip especially if multiple gynecoplasty procedures are done simultaneously. Due to the edema that develops postoperatively, it is advisable to avoid using a running suture line and use widely spaced interrupted sutures instead.

In cases of clitoral reduction, development of contractures along the suture lines as well as long standing pain are risks the patient needs to know about preoperatively—these develop more often in association with infection and hematomas. In clitoral unhooding, both the amount of tissue excised as well as the closure techniques are crucial. The complete exposure of the clitoris causing hypersensitivity could become bothersome due to the continuous friction with the patient’s clothes. Furthermore, the appearance of the clitoris, if excessively unhooded, might be unsightly.

Conclusion

As women become more aware of the their genital appearance in comparison to what is publicized as normal or ideal, more women turn to surgical alternatives for cosmetic or perceived sexual enhancement. This is an evolving field with different techniques continuously being developed to achieve both better outcomes and reduced risks. Since cosmetogynecology deals with improvement of quality of life, it is crucial that the enhancements are what the patient desires and are within the limits of safe surgical practice. Patients who are considering such procedures should be fully aware of the various potential complications discussed in this chapter.

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