Aesth Plast Surg
DOI 10.1007/s00266-017-0831-1
REVIEW
Anatomy and Aesthetics of the Labia Minora: The Ideal Vulva?
C. Clerico1 • A. Larry1 • A. Mojallal1 • F. Boucher1
Received: 23 September 2016 / Accepted: 5 November 2017
Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2017
Abstract Female genital cosmetic surgery is becoming
more and more widespread both in the field of plastic and
gynaecological surgery. The increased demand for vulvar
surgery is spurred by the belief that the vulva is abnormal
in appearance. What is normal in terms of labial anatomy?
Labia minora enlargement or hypertrophy remains a clin-
ical diagnosis which is poorly defined as it could be con-
sidered a variation of the normal anatomy. Enlarged labia
minora can cause functional, aesthetic and psychosocial
problems. In reality, given the wide variety of vulvar
morphology among people, it is a very subjective issue to
define the ‘‘normal’’ vulva. The spread of nudity in the
general media plays a major role in creating an artificial
image and standards with regard to the ideal form. Physi-
cians should be aware that the patient’s self-perception of
the normal or ideal vulva is highly influenced by the
arguably distorted image related to our socio-psychological
environment, as presented to us by the general media and
internet. As physicians, we have to educate our patients on
the variation of vulvar anatomy and the potential risks of
these surgeries.
Level of Evidence V This journal requires that authors
assign a level of evidence to each article. For a full
description of these evidence-based medicine ratings,
please refer to Table of Contents or the online Instructions
to Authors www.springer.com/00266.
& C. Clerico
cyril.clerico@gmail.com
1 strong scientific basis, its surgery is expanding. The goal of
Department of Plastic and Reconstructive Surgery, Croix-
Rousse Hospital, University of 103 Grande Rue de la Croix-
Rousse, 69004 Lyon, France
BODY CONTOURING
Keywords Labial hypertrophy
Labia minora
Labia
minora reduction
Vaginal rejuvenation
Cosmetic
vaginoplasty
Aesthetic genitalia surgery
Vulva
Vulvar
perception
Labia minora anatomy
Labiaplasty
Introduction
Female genital cosmetic surgery is becoming more and
more widespread both in the field of plastic and gynaeco-
logical surgery. The term female genital surgery encom-
passes various techniques aiming to ameliorate the female
vulvar area both aesthetically and functionally. These
various interventions of the female vulva can include
surgeries of the labia minora and majora, the clitoris and
even the vagina where indicated. Among the proposed
techniques, labiaplasty or the reduction in labia minora
hypertrophy is regarded as one of the most common female
genital surgeries performed today, but the anatomical cri-
teria behind this intervention and the pathological bases of
labial hypertrophy are still widely discussed subjects
among the scientific community. The increased demand for
vulvar surgery by patients is driven by the belief that their
vulva is abnormal in appearance. But the question is, what
is to be considered the norm in terms of labial morphology?
For instance, the term ‘‘labia minora’’ itself raises this
question: Are they really supposed to be small? And if so,
what is considered large?
Labia minora enlargement or hypertrophy remains a
clinical diagnosis which is poorly defined as it could be
considered a variation of the normal anatomy. Even though
the anatomical description of the ‘‘ideal vulva’’ has no
this article is to provide the scientific literature a descrip-
tion of the anatomical criteria constituting the ideal vulva,
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thus leading to better clinical assessment and clarifying the
indications for interventions such as labiaplasty or labial fat
injections.
Materials and Methods
A literature review concerning the labia minora was carried
out. A literature search was conducted using PUBMED
with the following keywords: labia minora, labial hyper-
trophy, labia minora reduction, labiaplasty, labia anatomy,
vaginal rejuvenation, cosmetic vaginoplasty, aesthetic
genital surgery, and vulva.
All articles concerning the anatomy of the labia minora
were studied along with any articles describing surgical
techniques applied to them. The articles studied were from
reference journals in the field such as: Plastic and Recon-
structive Surgery, Aesthetic Surgery Journal, J Pediatr
Adolesc Gynecol, Annales de Chirurgie Plastique et
Esthetique.
Regarding the inclusion criteria for the articles included
in this review, we selected those principally dealing with
the anatomical, psychological and sociological aspect of
the subject. Articles dealing only with the surgical man-
agement of labial hypertrophy were excluded.
With concern to the descriptive anatomy, the appearance
and perception of the vulva from an aesthetic point of view,
the available literature can be described as lacking. Only
seven articles were identified that directly covered the
abovementioned subject.
There was an evident lack of prospective randomized
trials on the subject. Though, weak evidence articles rais-
ing a question on the subject existed.
Results
Embryology and Histology
The labia minora are formed from the urogenital folds
appearing around the third week of development. They are
formed by a double sheet of stratified squamous epithe-
lium, non-keratinized and contained within a connective
tissue that is fat free, rich in vascular and nerve plexus. The
labial skin contains sebaceous and sweat glands.
Anatomy
The labia minora can be described as a pair of muco-cu-
taneous skin folds, hairless and containing sebaceous
glands. They have two upper expansions, one covering the
upper part of the clitoris, known as the clitoral hood or
prepuce, and a lower one called the clitoral frenulum.
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Aesth Plast Surg
Although the classic anatomy of the external genitalia is
well known, it was not until 1899 that Waldeyer made the
first recordings of labial measurements. According to his
point of view a normal size labia may vary between 2.5 and
3.5 cm in size. More recent studies further identified the
average labia minora size as 2 cm knowing that they have a
wide variation which can range between 7 mm up to 5 cm
in size [1].
The vulva is the external part of the female genitalia. It
includes several structures whose main function is to pro-
tect the vaginal introitus and the urethral opening. It
includes the labia majora, which are two skin folds lined
with hair on their outer surface that join together forming
the anterior and posterior labial commissures and superi-
orly being a part of the mons pubis. The labia minora form
two anterior folds of which the medial part goes up to form
the clitoral frenulum and its lateral part ascends to form the
clitoral hood [2]. The role of the labia minora is to prevent
vaginal dryness and guide the urinary flow [3]. To maintain
its role, the size of the labia minora has to be at least 1 cm
in size. The vascularization of the vulvar area is supplied
by the internal pudendal artery, a branch of the internal
iliac artery that passes through the greater sciatic foramen
and gives off the lower rectal arteries, posterior perineal
and labial branches, bulbar artery and the deep and dorsal
clitoral arteries. The venous return is via the internal
pudendal vein and vaginal venous plexus, which itself is
anastomosed with the uterine venous plexus [4]. The pos-
terior innervation is mainly provided by the internal
pudendal nerve (S2-4), the anterior region receives its
innervation from branches of the ilio-inguinal (T12-L1)
and the genito-femoral (L1-2) nerves.
Aetiology of the Labia Minora Hypertrophy
Most often the cause of labial hypertrophy is idiopathic,
and less frequently it can be congenital in nature [5]. Often
patients are born with an enlarged labium that remains
undetected until puberty. Other sources of labial hyper-
trophy are: androgenic hormone use [6], chronic irritation
[7], in some cases hypertrophy has been seen to worsen
after pregnancy and increasing age. Certain ‘‘myths’’ and
allegations exsist linking hypertrophy with masturbation
and excessive sexual activity, but these have never been
proven [8].
The Definition of Labial Hypertrophy
A normal size labium has a length of 20–30 mm, a width of
15 mm and a thickness of 4 mm [9]. The definition of
labial hypertrophy unfortunately remains poorly defined.
Conventionally labial hypertrophy is defined as maximal
Aesth Plast Surg

labial width exceeding 5 cm [10, 11]. Rouzier proposed

4 cm [12] and Munhoz defined it at 3 cm [13].
More recently, the excess of skin of the clitoral hood is
also included in the labial hypertrophy definition, and
Cunha proposed 3 types of hypertrophy depending on the
degree of coverage of the clitoris [14] (Fig. 1).
Franco proposed in 1993 [15] dividing the hypertrophy
into 4 categories according to size:
Type 1 No hypertrophy, labia \ 2 cm
Type 2 Labia size between 2 and 4 cm
Type 3 Labia size between 4 and 6 cm
Type 4 Labia size [ 6 cm
However, it is very often seen that patients present for
labial reduction with a labial size below 2 or 3 cm. The act
of shaving and hair removal in the vulvar area has been
shown to accentuate the difference in size between the
labia minora and labia majora, which is considered not
very desirable by many patients [16]. It therefore appears
that because the criteria of the ‘‘ideal vulva’’ are very
subjective, its surgical indication remains at the discretion
of the surgeons [17].
Aside from these aesthetic concerns that are the most
frequent motives for a consultation, some functional
complaints are also frequently reported by some patients.
Some patients might complain about pain or discomfort
during sexual activities and in particular during penetra-
tion. Certain patients complain of a burning sensation
during intercourse. A majority of patients also complain
from irritation during certain sport activities such as
cycling, jogging and horseback riding. Finally, many
patients also showed reluctance to wear tight clothing such
as bathing suits in public, what was interesting to note also,
is that hygiene problems are uncommon.

Discussion

It is unsurprising to see in our current time, with all that is

presented to us by the general media and female models
portraying images of what is claimed to be the perfect
beauty to the general public, that many people have
become more aware of their self-body image and that
perception of beauty has changed. While aesthetic surg-
eries involving breast, face and the body contour are
widely accepted, those involving the genitals were con-
Fig. 1 Labial hypertrophy classification according to Cuna [14]: Type
sidered taboo. Yet over the past 10 years we are witnessing 1: Hypertrophy limited to the labia minora. Type 2: Hypertrophy that
a rapid change in the demand for these operations and start involving the clitoral hood and frenulum. Type 3: Hypertrophy
subsequently, an equally large interest by surgeons. The with total involvement of the labia minora, clitoral hood and frenulum
majority of these demands are made concerning the mor-
phology of the labia minora, but in reality, given the wide of nudity in the general media plays a major role in cre-
variety of vulvar morphology among people, it is a very ating an artificial image and standards with regard to the
subjective issue to define the ‘‘normal’’ vulva. The spread ideal form. This is reflected by patients with issues

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Fig. 2 «The great wall of
vagina» (http://www.greatwall
ofvagina.co.uk/home) A work
of art displaying the vulvar casts
of various female volunteers.
This piece is one of many being
displayed at the exhibition. A
large variability in the appear-
ance of vulvas can be appreci-
ated by looking at this
impressive work. Image from
the official website of artist
Jamie McCartney (http://www.
greatwallofvagina.co.uk/home)
concerning their vulvar appearance who are constantly
comparing their vulvar morphology with what they per-
ceive as being normal and attractive. These concepts are
therefore important to explain to the patients who are
psychologically affected by this dysmorphia.
Ethics and Legislation: The Ideal Vulva!
The cosmetic surgery of the genital area has had its fair
share of criticism in the literature [18]. Colson considered
it to be a trend, with no validated standards, no good
practice guide or sufficiently measurable results [17]. For
Daniels, female cosmetic genitoplasty differs only slightly
from female genital mutilation, which is being practiced in
some countries in Africa, even though ritual amputation is
known to be banned in Europe [20]. According to the
World Health Organization (WHO), the definition of
female genital mutilation is the resection of any part of the
external genitalia for non-medical reasons [21]. It is also
known that European law protects woman from genital
mutilation and according to this law surgeons can face up
to 14 years in prison. To date, there has only been one case
of conviction in France and in Switzerland [22].
Many feminist movements rallied against the trend of
cosmetic genital surgery, where many women wanted to
modify the appearance of their genitalia to more closely
match their vision of an ideal vulva. This perception of an
ideal vulva is unfortunately the product of the images being
shown in the general media and internet. A surgeon in the
USA is even showing his patients images from ‘‘Playboy
magazine’’ to help them choose the look that suits them
[17]. Yet the ideal vulva does not exist [23] and on the
contrary it has to be understood that the appearance of the
123
Aesth Plast Surg
external genitalia has a wide variability that must be
accepted in the majority of cases. Unfortunately, many
women, especially adolescents, are obsessed with its
appearance and refuse to accept this normal variability
[24]. A great demonstration of this variability is shown in
this work of art by an English sculptor. He created casts of
the genitals of over 500 women and showed it in an
exhibition called ‘‘The great wall of vagina’’ (Fig. 2).
What was interesting though is that this visit to the
exhibition had an impressive impact on the attending
woman. This experience had completely changed their
opinion regarding their self-body image. Before having
visited the museum, some women confessed that they had
difficulty with the form of their external genitalia. And
after having seen the great variability presented in this
exhibition, they felt better and less worried. In conclusion,
cosmetic vulvar surgery should not be offered to all
patients who raise a concern over the appearance of their
vulvas. It must be offered specifically when good indica-
tions exist. The most important of these indication is true
labial hypertrophy with a functional or psychological
impact (knowing that the definition of labial hypertrophy is
also vague). We should explain to the patients the existence
of such variability that is normal, and that we should not
base our total decision solely on what is presented to us by
the media, internet or magazines [25].
Female genital mutilation (FGM), regardless of the type,
has been recognized as a harmful practice and a violation
of the human rights of women. FGM can be divided into
four categories. Type 1: Partial or total removal of the
clitoris and/or prepuce. Type 2: partial or total removal of
the clitoris and the labia minora, with or without excision
of the labia majora. Type 3: narrowing of the vaginal
Aesth Plast Surg
Fig. 3 Female genital
mutilation: World Health
Organization classifications
2007
orifice with creation of a covering seal by cutting and
appositioning the labia minora and/or labia majora, with or
without excision of the clitoris. Type 4: all other harmful
procedures to the female genitalia for non-medical purpose
[26].
Hereby, if one refers to this WHO classification of
female genital mutilation, a labiaplasty would be consid-
ered a type 2a FGM, whether it is a partial excision
(commonly known as a ‘‘reduction’’) or total excision.
Thus, the term female genital mutilation (or excision)
encompasses all procedures that involve partial or total
removal of a part of the external genitalia of women and/or
any other injury done to the female genital organs for non-
medical purposes (WHO 2008) [27] (Fig. 3).
Interestingly, labiaplasty is not the only medical
practice exempted from legal prosecution knowing that it
corresponds to a sub-type of female genital mutilation
listed by the WHO: genital piercings are among the
exceptions. However, genital piercing could imply cli-
toral piercings which could correspond to a Type 1, or a
Type 4 FGM, which involves all other unspecified
practices on the female genital organs for non-medical
purposes, such as piercings and punctures (WHO 2008)
[27].
123

Conclusion
There has been a substantial increase in demands to modify the
vulvar morphology. This current ‘‘vision’’ of the ‘‘ideal’’ vulva
is becoming the aesthetic norm that many patients desire.
Part of our work should be focused on examining the
various aesthetic and functional complaints encountered by
patients who have enlarged labia minora. It allows us to
better define the criteria behind the management of such
pathology including the resulting and important psycho-
logical consequence which should not be neglected.
In conclusion, the desires of patients presenting for
vulvar cosmetic surgery should be approached systemati-
cally. Physicians should be aware that the patient’s self-
perception of the normal or ideal vulva is highly influenced
by the arguably distorted images related to our socio-psy-
chological environment, as presented to us by the general
media and internet. As physicians, we have to educate our
patients about variations in vulvar anatomy and the
potential risks of these surgeries.
Acknowledgements None of the authors has a financial interest in
any of the products or devices mentioned in this article. Funding was
provided by CLERICO Cyril (Grant No. 06 66 82 68 63).
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