Labia Majora Augmentation: A Systematic Review of the Literature

Abstract

Background

Currently, there is no standardized approach for labia majora augmentation and controversies still exist regarding this subject.

Objectives

This systematic review aimed to assess the evidence in the literature regarding labia majora augmentation.

Methods

On November 20, 2016, we conducted an online search of published articles in the Medline, Embase, and Cochrane databases. All articles describing labia majora augmentation were included in this review.

Results

Nine studies were selected for inclusion in the systematic review. Only 2 studies were prospective trials. The most commonly used technique was fat grafting with a total of 4 articles and 183 patients. The mean total injected fat volume ranged from 18 mL to 120 mL per session. Two articles described hyaluronic acid injection techniques. The total injected volume of hyaluronic acid ranged from 2 to 6 mL per session. Three articles used surgical techniques for labia majora augmentation. All included articles did not report any major or life-threatening complications. All techniques demonstrated high satisfaction rates.

Conclusions

Labia majora augmentation appears to be a safe, efficient technique with a high satisfaction rate and no reported major complications. However, further randomized controlled trials are warranted.

Level of Evidence: 4

With the prevalent media coverage of explicit material and “external genitalia grooming,” the demand for female genital aesthetic procedures has been steadily increasing.^1,2 According to the American Society for Aesthetic Plastic Surgery, 8745 labiaplasty procedures were done in 2015, with a 15% increase compared to 2014.³

Like other body areas, female genitalia are affected by the normal process of aging.⁴ The decrease in hyaluronic acid, collagen, and fat result in volume loss, rhytids development, and an increased minora to majora ratio with a seemingly prominent labia minora.⁵ These age-related changes not only affect the physical appearance of the female external genitalia but also disrupt sexual functioning.^6,7 The sexual self-esteem decreases, resulting in a significant psychosocial impairment.^6,8-10 To address these issues, the number of publications devoted to external genitalia rejuvenation is constantly growing. Most of the articles describe labiaplasty techniques and vaginal tightening procedures with a good outcome and a low complication rate.^1,4,11-13 However, the approach of female genitalia rejuvenation is marked by a relatively low number of articles devoted to labia majora augmentation procedures. Currently, there is no standardized approach for labia majora augmentation and controversies still exist regarding this subject. This systematic review aims to summarize and compare all available data to guide current practice and provide a road map for future research.

METHODS

On November 20, 2016, the first 2 authors (S.J. and E.K.) conducted an online search of published articles in the Medline, Embase, and Cochrane databases. The initial search was done using the following combination of keywords: (“labia majora” OR “labium majus”) AND (augmentation OR enhancement OR enlargement). All articles published before the search date were evaluated for inclusion. Studies related to the augmentation of labia majora were selected based on their titles and abstracts and were obtained and read in full. The reference list of each study was manually screened for additional articles. All articles describing labia majora augmentation were included in this review. Excluded studies were those lacking a detailed description of the augmentation technique. The first 2 authors (S.J. and E.K.) unanimously agreed on the final selection of the included studies.

RESULTS

The initial search of the database and the manual screening of the references yielded 89 results, 23 of which were duplicates. Of the 76 unique articles, 19 were retained based on assessments of their titles and abstracts and 57 were excluded because they were not related to labia majora augmentation. Following full-text review, 10 articles were excluded because they did not provide a clear description of the augmentation technique and 9 studies were selected for inclusion in the systematic review (Figure 1).

All included studies were published between 2007 and 2016 with a total of 226 patients. The mean age of patients was 43.6 years (range, 17-68 years). Only 2 studies were prospective trials.^12,14 Two were retrospective cohorts,^5,15 3 were case reports,^6,16,17 and 2 only described a technique for labial augmentation.^18,19 None of the included studies had a control group. Three studies were done in Europe,^5,12,16 2 in Turkey,^14,15 2 in Brazil,¹⁹ 1 in Egypt,¹⁷ and 1 in the United States⁶ (Table 1).

In all the included articles, the main indication was cosmetic except for one report that used fat grafting for labia majora reconstruction.¹⁶

The most commonly used technique was fat grafting with a total of 4 articles and 183 patients.^12,14,16,19 The mean total injected fat volume ranged from 18 mL to 120 mL per session. To increase the fat graft survival, the injection was done in multiple layers (Figure 2). If additional volume was needed, new injections were done after a period of 4 to 6 months.^16,19 Wound dehiscence was observed when lipofilling was associated with a labia minora reduction procedures.¹⁴

Two articles described hyaluronic acid injection techniques for labia majora augmentation.^5,18 The total injected volume of hyaluronic acid ranged from 2 to 6 mL per session. The concentration of the injected hyaluronic acid was 19 to 20 mg/mL. The site of injection was the subcutaneous tissue with or without deeper injection under the Dartos muliebris fascia of the labia majora (Figure 3). If additional volume was needed, the injection was repeated after a duration of 2 to 4 months. Only mild and transient adverse events were noted with hyaluronic acid injections such as hyperemia, edema, ecchymosis, and palpable nodules.

Three articles used surgical techniques for labia majora augmentation.^6,15,17 Of those, 2 studies described flaps for labia majora augmentation.^15,17 Both were associated with additional procedures. One study described a labia majora flap augmentation associated with labia minora reduction.¹⁵ The protruding part of the labia minora was not resected but instead it was de-epithelialized and transposed into the labia majora (Figure 4). The other study reported a labia majora flap augmentation associated with a thigh lift.¹⁷ An adipofascial flap was raised from the inner thigh and transposed to the labia majora (Figure 5). Adverse events reported with these techniques included hematomas, flap necrosis, and pain. One article described the use of dermal fat grafts for labia majora augmentation.⁶ Two 10 × 2 cm grafts were crafted from the resected abdominoplasty skin island. These grafts were inserted into the labia majora (Figure 6).

All included articles did not report any major or life-threatening complications. Hyaluronic acid related adverse events were: transient hyperaemia during the first 30 minutes posttreatment,^5,18 transient oedema for a few days,⁵ mild ecchymosis,^5,18 and small bumps that were corrected with light massage,⁵ intralesional corticosteroid,¹⁸ or hyaluronidase injection.¹⁸ Lipofilling was associated with swelling¹⁶ and wound dehiscence when combined to labia minora reduction.¹⁴ An inner thigh flap was only used in one patient for labial augmentation. It resulted in a unilateral hematoma that was evacuated using forceps which led to the flap necrosis. The resulting deformity was corrected with lipofilling.¹⁷ Thirty percent of patients who had a labia minora flaps for labia majora augmentation complained of transient pain, pruritus, and discomfort.¹⁵ Two lipofilling articles did not mention the adverse events but were included in the review because they clearly described the augmentation technique.^12,19 All techniques demonstrated good satisfaction rates. Fasola and Gazzola used the Global Aesthetic Improvement Scale to evaluate the results.⁵ Cihantimur used a visual analogue scale to evaluate patient satisfaction (9-10: very happy, 6-8: happy, 0-5: unhappy).¹⁴ Vogt et al,¹⁶ El Danaf,¹⁷ and Salgado et al⁶ reported single cases and all 3 patients were satisfied with their results. Krabagli et al did not use a satisfaction questionnaire but noted that all patients were satisfied with the results.¹⁵ Three included studies did not evaluate the patient satisfaction^12,18,19 (Table 2). Table 3 summarizes the important findings of this review. The quality of this systematic review was assessed using the PRISMA checklist (Appendix A, available online as Supplementary Material at www.aestheticsurgeryjournal.com).

DISCUSSSION

Labia majora augmentation is a relatively new technique. In 2007, Felicio was the first to describe the enhancement of deficient labia using autogenous fat grafting. ¹⁹ Since then, a wide range of different techniques has been reported. This practice has spread geographically as our included studies originated from Asia, Europe, Africa, North and South America.

We found that the mean age was 43.6 years. In fact, the greatest demand for labia majora augmentation is in the fifth decade of life, when the early signs of aging begin to appear.⁵ Some younger women can also benefit from this procedure as the youngest reported patient in our review was 17 years old. Therefore, labia majora augmentation is not only an antiaging intervention but also a beautification procedure.

The most commonly used labial augmentation technique was lipofilling. Injected volumes varied widely between studies. The volume of injected fat ranged from 18 mL to 120 mL per treatment session. Multiple sites can be injected such as the mons pubis, the anterior and lateral labia majora, and the posterior labia majora. The injection should be done in multiple layers to increase the fat survival (Figure 2). Lipofilling can be used either for cosmetic enhancement of the labia majora or reconstruction of an ablated labium. In the latter case, lipofilling offers a natural appearance with the improvement of both skin and preexisting scar quality with no additional scarring.¹⁶ Cosmetic labia majora augmentation may also offer some functional benefits as some patient may report greater sexual satisfaction with intercourse.¹⁹

The hyaluronic acid injection can be done in a subcutaneous plane only (Figure 3). Good injection technique is crucial to avoid common palpable nodules and bumps. The concentration of the hyaluronic acid used for labia augmentation should be high: 19 to 20 mg/mL. Hyaluronic acid has many advantages when compared to other filler products. It has a low risk of allergic and immunogenic reactions²⁰ and it can be reversed with hyaluronidase if the patient requests it or in the case of ischemic complications.²¹ With hyaluronic acid, retouching can be done as soon as 2 to 4 months after the initial injection whereas retouching with lipofilling should be done 4 to 6 months after. Fat grafts suffer from the unavoidable loss of a certain amount of volume.⁶ The injected fat will be slowly and partially resorbed within the first few months. Thus, when using fat grafting, more time is needed to assess the final result and decide if additional volume is needed.

In comparison to fat grafting and hyaluronic acid, dermal grafts may offer an advantage in terms of longevity.⁶ These grafts are slowly replaced by fibrosis.²²

Some authors choose to combine various aesthetic approaches to the female genitalia treatment. Felicio reported his 17 years of experience in more than 500 labial procedures.¹⁹ He described the concomitant injection of fat in both the labia majora and the labia minora. Cihantimur and Herold performed genital beautification by combining labia minora reduction, labia majora augmentation, brightening by laser, mons pubis liposuction, and vaginal tightening.¹⁴ Similarly, Karabgli et al enhanced the female genitalia by performing additional labia minora reduction.¹⁵ Laser labioplasty, can also be used in adjunct to other surgical gynecologic interventions without increased adverse events.²³

Adverse events reported in all included studies were minor and transient. In addition to hyperemia, edema, and ecchymosis that are common to all treatment modalities, surgery carried the additional risk of wound dehiscence, hematoma, and flap necrosis. Pulmonary embolism has also been described with hyaluronic acid injection into the vulva.²⁴

In this reviewer’s opinion, tailoring the treatment to specific patient anatomy is key to optimize results. When facing a minor hypertrophy of the labia minora and a marked labia majora tissue loss, hyaluronic acid injection or autologous fat transplantation are both attractive options. Augmentation of the labia majora in these cases can help mask the labia minora. In the case of major labia minora hypertrophy, a reduction labiaplasty can be done with concomitant labia majora augmentation^1,11,14,15 (Figures 7 and 8). Surgery is also warranted when different procedures are needed such as concomitant thigh lift.¹⁷

There are many limitations to this review. Only 2 of the included studies were prospective trials. The absence of a randomized controlled trial prevented us from doing a traditional meta-analysis to compare the different techniques and limited our systematic review to a form of pooled analysis. The large amount of variability between studies, especially in the satisfaction measurement methods restricted the interstudy comparison. Another important bias was the publication bias, as only published articles were evaluated.

CONCLUSIONS

Labia majora augmentation appears to be a safe, efficient technique with a high satisfaction rate. It can be done for aesthetic, reconstructive, or functional indications, alone or in conjunction with other procedures. Future adequately designed randomized controlled trials are needed to compare the different techniques and assess their impact on functional outcomes.

Supplementary Material

This article contains supplementary material located online at www.aestheticsurgeryjournal.com.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES