The objective of this video is to illustrate the normal anatomy and neuroanatomy of the vulva and describe one technique for labioplasty. The structures that comprise the vulva extend inferiorly from the pubic arch and include the mons pubis, labia majora, and menorah, clitoris, and vestibule of the vagina. Previous studies have shown wide variation in the normal appearance and dimensions of these structures. The mons pubis is a triangular area of tissue which overlies the anterior aspect of the pubic bone. It consists of hair-bearing skin and underlying adipose tissue. The labia majora are lateral folds of hair-bearing skin and adipose tissue which extend inferiorly from the mons and meet in the midline at the posterior foreshort, anterior to the anus. They contain the distal ends of the round ligament and have a rich supply of sebaceous, apocrine, and eccrine sweat glands. The length of the normal labia majora from the most superior aspect of the clitoral hood to the posterior foreshort ranges between 7 to 12 centimeters. In this patient, the labia majora measures 7.5 centimeters in length. The labia menorah are hairless skin folds located medial to the labia majora. The anterior folds unite in the midline to form the prupus or clitoral hood. The posterior folds insert into the underside of the clitoris to form the frenulum. This line demarcates the transition between the keratinized epithelium of the labia menorah and the non-keratinized epithelium of the vestibule of the vagina. It serves an important anatomical landmark when describing the location of lesions. Normal labia menorah length ranges from 2 to 10 centimeters measured from the frenulum of the clitoris to the posterior foreshort. The normal width of the labia menorah varies from 0.7 centimeters up to 5 centimeters extending laterally from the hymen. Here we demonstrate how to appropriately measure the width of the labia menorah. The clitoris is an erectile organ. It consists of a midline shaft capped with a round tubercle known as the glans and two crura which are located in the superficial compartment of the perineum. Direct stimulation of the clitoris leads to female orgasm. The clitoral length measurement is taken by retracting the clitoral hood and measuring from the base of the clitoris to the glans. The average clitoral length is approximately 2 centimeters with a range of 0.5 to 3.5 centimeters. The average width of the glans is 5.5 millimeters. The vestibule of the vagina includes the area between the hymen and heart's line laterally, the frenulum of the clitoris anteriorly, and the posterior foreshort posteriorly. The area between the hymen and the posterior foreshort is known as the fossa navicularis. The external urethral meatus is located within the vestibule of the vagina superior to the vaginal opening or entroitis. Two periurethral glans, also known as Skeen's glans, are located at the posterior lateral aspect of the urethral meatus. Glans also line the urethra longitudinally and aid in urethral lubrication. Obstruction of Skeen's glans can cause significant discomfort to the patient and often time these women present with irritative urinary symptoms and an anterior vaginal wall mass. There have been speculation regarding the existence of the G-spot, also known as Grafenberg's spot, first described in 1950. The erogenous zone was claimed to be 1-2 cm from the urethra on the anterior vaginal wall. However, review of the literature has failed to provide objective evidence of this entity. The greater vestibular glans, known as Bartholin's glans, opens into the posterior lateral aspect of the vestibule at approximately the 5 and 7 o'clock position. Multiple minor vestibular glans are located concentrically within the vestibule. The vulva is innervated by the pudendal nerve, which originates from the anterior rame of the 2nd through 4th sacral nerve roots and exits Alcock's canal just medial to the ischial tuberosity. Branches of the pudendal nerve include the dorsal nerve of the clitoris, the perineal nerve, and the inferior rectal nerve. The posterior femoral cutaneous, ilioinguinal, and genital femoral nerve also supply the vulva. The dermatomal distribution of the vulva is demonstrated here. The bulbocavernosis reflex involves S2 through S4 nerve roots. Gently tapping the clitoral pupus stimulates the sensory afferent component of the dorsal nerve of the clitoris. This sensory information is transmitted to the motor efferent component of the inferior rectal nerve at the level of S2 to S4, resulting in the bulbocavernosis reflex. The vulva derives its vascular supply primarily from the internal pudendal artery, a branch of the internal iliac artery. Like the pudendal nerve, the internal pudendal artery also exits from Alcock's canal where it divides into several branches, including the dorsal artery of the clitoris, the perineal artery, and the inferior rectal artery. The external pudendal artery originates from the external iliac artery to supply the most superior aspect of the labia majora. The labia majora's abundant blood supply has important implications in the use of Amartey's fat pad for vaginal fistula repair. Because of its dual blood supply from both the internal and external pudendal arteries, Amartey's fat pad can be detached either anteriorly or posteriorly before it is tunneled to the site of repair. Female genital cosmetic surgery has remained a highly controversial topic. In certain cases, this is medically indicated rather than an elective procedure. One example is congenital labia minora hypertrophy. When deciding the most appropriate technique to use, the patient's goals must be considered. Proper communication with the patient regarding postoperative expectations are imperative. The patient should be aware that the labia will look different, with potential risks of visible scar, infection, bleeding, wound separation, asymmetry, discoloration, contraction, pain, dyspareunia, as well as altered sensation. Linear resection was the first technique described in case reports. It involves removal of excess tissue with re-approximation of the epithelial edges. Benefits include lighter labia minora skin tone. Central V-wedge resection of the central portion of the labia minora is another technique that could be used to preserve labial edge color. A modification of this is the inferior wedge resection and superior pedicle flap reconstruction, where a V-wedge is removed between the 3 and 6 o'clock position, followed by superior labial advancement to the posterior foreshed. Risks with this modification include increased bleeding and compromise to the vascular supply, causing distal flap necrosis. Another modification is a central wedge resection and a 90-degree Z-plasty. A central wedge is being removed. However, the medial incision forms a Z, creating three triangular tissue flaps. By transposing these flaps, this changes the length of the incision. The benefits of using this technique allow for releasing suture line tension, mobilizing tissue, and lengthening scar. The last technique describes deepithelialization. Steps include removal of the central epithelium on both the medial and lateral aspects of the labia minora, re-approximation of the epithelium with a running or interrupted suture. This technique maintains the pigmentation at the edge of the labia minora while decreasing excess tissue. This patient presents with complaints of labial burning and irritation due to rubbing of her clothing, invagination of her labia during intercourse, and splaying of her urinary stream. Her right labia minora measures 5 centimeters while her left labia minora measures 8 centimeters. We discuss with the patient her preoperative goals. She felt her right labia minora was normal and wanted her left labia minora to match this in size, contour, and color. We opted for the traditional linear resection. The procedure is performed under local and IV sedation. We recommend the use of plastic instrument set to aid in fine surgical technique. First, mark the area for resection prior to any further manipulation. The resection should not cause tension on the suture line. Keep in mind that over resection can cause significant scarring and retraction or compromise blood supply. Next, inject the epithelium with local anesthesia. Our preference is quarter percent marcaine with epinephrine, both for hydrodissection and vasoconstriction. Using a monopolar pinpoint cautery tip on 20 watts pure cut, the incision is made along the epithelium of the labia minora using the prior marking as a guide. Alternatively, scalpel diode laser or radiofrequency laser can be used. Following incision made with pinpoint cautery, the remaining tissue can be transected using cautery. Hemostasis is assured to prevent hematoma formation. We recommend using 3-O absorbable monofilament polyglycaporone suture to re-approximate the epithelium with vertical mattress sutures. Care should be taken to re-approximate the tissue rather than strangulating the tissue which can lead to ischemia and necrosis. The patient will place an ice pack to her vulva for the next 24 hours to help with both pain and edema. We recommend the use of anesthetic ointment to help with pain. The patient will return in 7 days for suture removal to prevent any scarring for the optimal surgical aesthetic. In conclusion, in certain cases there are medical indications for labioplasty. It is important to have a clear communication with your patient regarding goals and expectations. In the operating room, surgical planning by marking the labia helps prevent over-resection. We recommend monopolar pinpoint cautery for fine dissection and fulguration. We recommend absorbable monofilament vertical mattress sutures which should be removed on post-operative day 7 for optimal surgical aesthetics. Thank you and we would like to acknowledge the following individuals.

vulva

labioplasty

structures

surgical techniques

communication with patients