Long considered a minor aspect of cosmetic surgery, the demand for alterations to the female genitalia is rising. Women seeking cosmetic surgery of their external genitals generally desire to alter the shape or appearance of one of four aspects of their genitalia: the labia minora, labia majora, clitoral hood, or mons pubis. Labia minora reduction is the most common of the four to be requested, constituting the majority of cases. This is reflected in the literature as well, with most publications pertaining to this structure.
The degree of prominence of the mons pubis is determined by the amount of fibro-fatty tissue present below the dermis and anterior to the pubic symphysis. Extending inferiorly and posteriorly from the mons are the labia majora, which form the lateral boundaries of the vaginal region. Each labium has an outer, pigmented surface that is invested with hair follicles and an inner, nonpigmented, smooth surface with large sebaceous follicles. Anteriorly, the two labia converge to form the anterior labial commissure, while posteriorly, they run parallel to each other and appear to dissipate in the neighboring integument approximately 3 cm from the anus in the perineum. Below the anterior commissure lies the clitoris, which is partially covered by the clitoral hood. This sheath of skin comprises the anterior extent of the labia minora. The clitoris is an erectile structure formed by the two corpora cavernosa muscles, which are connected by a fibrous septum. It has a highly sensitive, spongy erectile tip, the glans. The labia minora are folds of skin that are situated medial to the labia majora (Figure 19–1). Anteriorly, they divide into two portions, the upper division meeting in the midline above the clitoris to form the clitoral hood, or preputium clitoridis, and the lower division terminating in the undersurface of the clitoris as the frenulum of the clitoris or anterior fourchette. Posteriorly, the two sides meet at the bottom aspect of the vaginal orifice to form the frenulum of the labia or posterior fourchette. As with the labia majora, the lateral surface of the labia minora is usually more darkly pigmented than the medial surface, which has a mucosa-like appearance.
Anatomy of the female external genitalia.
The principal arterial supply to the perineum is via the internal pudendal artery. This vessel enters the perineum via the lesser sciatic foramen and divides into several branches as it approaches the medial margin of the inferior pubic rami: the perineal artery to the perineum, the posterior labial branches to the labia, and multiple branches to the clitoris and corpus cavernosum. Anteriorly, the labia are supplied by the superficial external pudendal artery. Accompanying this vessel from the main external pudendal is the deep external branch. These two arteries form a rich anastamotic plexus with the internal pudendal blood supply.