Hello, Down There!

The word, “plastic,” in plastic surgery is derived from the Greek word, “plastós,” or to mold. No, it does not mean, “Oh my goodness, Susan got so much surgery that she looks plastic now.” (Although that is an epidemic that we will discuss in a future blog topic.)  Yes, one common area that women ask us to mold is their private areas, specifically, their labias and mons. Before, people never really talked about surgery “down there,” either because it was embarrassing or we did not know there were options for these areas. But before we can delve into the new trends and surgeries for these areas, let’s familiarize ourselves with the female anatomy (in a very straightforward, non-weird way, of course).

The female anatomy

Although board certified plastic surgeons are trained to reconstruct every part of the body from head to toe, I have really focused my cosmetic practice on the areas external to the vagina. So we will begin with the labia minora. These are the two flaps of skin begin at the clitoral hood and continue downward along the opening of the vagina. The labia minora are composed of erectile tissue and elastic fibers, not fat. This tissue has many sebaceous glands, but does not have any hair follicles or sweat glands. What most women do not realize is that labia minora come in all shapes and sizes. They can be small and short; they can be very long or very asymmetrical, meaning the left does not match the right side. Some of them can be very long in just one area. Many labia minora are smooth in appearance while others are more wrinkled. Many women are born this way. I have had teenage patients who have never had intercourse, who had severely long labia minora. In childbirth, there is a possibility that the labia minora grow, either due to the swelling in this area and/or the actual trauma of a baby barreling through the birth canal and stretching this tissue permanently. Lastly, the appearance of this tissue tends to be hyperpigmented in comparison to the adjacent labia majora.

The labia majora are the outer folds that are on the outside of the labia minora. They protect the opening of the urethra (where we urinate from) and the vagina. These large, fleshy folds of tissue contain sweat and sebaceous glands that produce lubricating secretions. These are the hair-bearing areas that we begin to recognize during puberty. The labia majora itself can look wrinkled or so full that they completely cover and hide the labia minora. I have had several patients who get these areas injected with dermal fillers to give a fuller and smoother appearance.

Our last anatomical area to discuss is the mons pubis, or as women now call it the “F.U.P.A.” FUPA is an acronym with a less-than-elegant origin; so in an effort to keep things classy, we will call it the fat upper pubic area instead. This is the area of skin, subcutaneous and deep fat located above the clitoris, but below the abdominal wall. Its upper border is typically where obstetricians place the C-section, or Pfannestiel, scars. Again, these areas come in all shapes and sizes. Many of my patients seeking rejuvenation often report that they have always “had a large area here since [they] were teenagers.” Oftentimes, women who have had C-sections notice that this area becomes very prominent and protrude out. This makes sense because the scar plane that extends from the skin towards the uterus is relatively firm compared to the adjacent native, unoperated tissue. This deep scar traverses many layers of the body and tethers the skin in one spot. As a woman’s body changes, the tissue and skin above and below this area eventually hangs over the scar like a shelf.

Rejuvenating the “Lady Bits”

Women in the United States are now seeking rejuvenation of their privates for several reasons. 1. The most important is to improve their quality of life. Feeling pain or embarrassment from enlarged, elongated or bulky anatomy down there is the number one reason to pursue surgical improvement. 2. Women seek to enjoy intimacy with their partner more. An elongated labia minora can experience trauma during intercourse that is unusual and painful. 3. Women seek to improve their hygiene. Having excess tissue and folds in the groin and private areas certainly create more heat, moisture, and odors. Going restroom multiple times a day should not be an unpleasant experience, but can be for women who struggle with these issues. This is the primary reason why we created our Twinberry breathable panties with Coolcore fabric. Yes, insert shameless, but necessary plug here! (Get your panties at www.LiveTwinberry.com now and experience the difference!) 4. Lastly, women want to feel their best and most confident not just for themselves, but also for their partners. Not having that mental block of feeling the need to turn off the lights or hide during intimacy is fabulous to truly enjoy those special moments.

The absolute NUMBER ONE most common cosmetic surgical procedure that I perform below the abdominal wall is a monsplasty, or what I call a “FUPA-ectomy.” The name is relatable and accurately describes how I get rid of the appearance of a FUPA. I include a FUPAectomy with each and every tummy tuck that I perform. I like to keep my tummy tuck incisions low; therefore, I am already in the general region of the mons. It makes sense to try to improve this area for our patients while we are there for the best, optimal results.

When evaluating this area, it is important to determine what is causing it, what type of tissue is in excess, and planning for how the recovery is going to be. FUPAs are often caused and accentuated by C-section scars, but a majority of FUPAs are actually created by the pregnancy itself. In the last trimester of pregnancy, the uterus and abdomen have expanded considerably and the baby begins to descend. Women cannot peer over their abdomens to visualize the changes occurring this time and fail to see that there is actually extra skin that grows in this area as a result of their pregnancy as well. When reducing this area, it is important to recognize that it is not just adipose that is causing the appearance of a FUPA, but typically, there is a lot of extra skin that needs to be removed as well. Even if the lady is small in stature, there is almost always extra skin that needs to be tailored. Lastly, if I anticipate a large residual empty space after reducing the FUPA, I may leave a drainage tube in for a week. Failure to do so can guarantee a postoperative fluid collection that will then need to be aspirated and drained in the clinic. Another technique I may use is closing this space with sutures, provided that the risk of injury to deeper structures is low. I emphasize to my patients the importance of wearing supportive underwear and placing an ice pack in this area for the first week to decrease the postoperative edema. Since it is a gravity-dependent area, all the edema gathers here; I call it the Grand Central Station of the body. It unfortunately cannot be elevated to decrease the swelling, so cool compresses are the best therapy during this time. Gentle massages towards the incision (never away) can help as well.

The second most common cosmetic surgical procedure I perform for female is labiaplasty. This entails reducing the size of the labia minora. Several techniques and incision patterns have been described. Out of all the techniques I have used, my favorite is removing the excess tissue in a longitudinal (ie. Up and down, vertical) orientation. The blood supply to the incision is reliable, meaning that the scar will heal well with a decreased risk for delayed healing or wounds. I have more control over aesthetic outcomes with this method. Also, each lip of the labia minora divides into 2 or 3 segments around the clitoral hood. The longitudinal excision pattern allows me to “blend” in my incision around the clitoral hood to make it proportional to the rest of the area. I recommend that patients wait 6 weeks minimum before allowing any trauma to the area. At 6-8 weeks is when any incision will be as strong as it is ever going to be. These scars then mature and soften for the rest of the year.

Labia majora reduction is not as commonly performed in my practice as not too many people ask for this. However, the results of this procedure are very pleasing to those who desire a significant reduction. The incisions/scars are placed and hidden in the relatively hyperpigmented areas adjacent to the labia minora to decrease any sensitivity from clothing and for aesthetic purposes. Eight weeks of recovery is recommended prior to any potential trauma to the area.

Concluding Thoughts

We are blessed with only one body and getting to love every part is a great feeling. Plastic or reconstructive surgery may not be for everyone. For those where surgery can help improve their mental health or quality of life, it may be worth gathering more information on their options. Select your plastic surgeon carefully and use them as your resource to guide you through your surgical journey.