Sir:

I congratulate Dr. Munhoz and colleagues¹ on their modification of the central wedge technique, which I reported in 1998.² I applaud them for emphasizing the importance of preserving the natural labial borders to maintain a normal appearance and to prevent a possibly painful scar.

The authors used inferior wedge resection and superior pedicle flap reconstruction to perform a labia minora reduction. Although I agree that a wedge technique is preferable, I do not believe the inferior wedge gives a better result, for several important reasons. Women seeking this operation desire removal of the most bulky and protruding tissue. Removal of an inferior wedge leaves the bulky superior tissue as the labial edge. Often the inferior edge of the labium is the thinnest and least protuberant portion, as illustrated in their Figures 1 and 5. Removal of this area, therefore, is counterproductive. In contrast, a central wedge can be placed to remove the most objectionable portion of each labium. Perhaps the authors chose the superior pedicle as a solution to the difficulty in approximating the thicker upper labium, which is attached to a thick, convoluted, lateral clitoral hood to the thinner inferior labial edge. Approximating the inferior flap to the frenulum extension of the clitoris as it ends at the upper labial edge will solve this alignment quandary. Also, the outer wedge excision should then be curved laterally and anteriorly (“hockey stick”) to excise this redundant lateral labium and excess lateral clitoral hood (if desired by the patient).³ Therefore, the internal and external V excisions are shaped differently, with the intervening subcutaneous tissue preserved while the leading labial edge is precisely re-approximated. Only enough subcutaneous tissue is excised to produce a good cosmetic result. This allows for better subcutaneous closure, which is necessary to prevent wound dehiscence and fistula formation.

The hockey stick lateral wedge excision allows for elimination of much of the unsightly lateral hood, which is a major aesthetic and often functional concern for these women; this issue is not addressed by these authors. In addition, the central wedge flaps are extremely healthy, with wide vascular bases that eliminate the tip necrosis problems seen with the superior flap technique. Therefore, a more predictable and better aesthetic outcome results with a central wedge excision combined with a lateral hockey stick V excision. A more detailed description of my technique and results will be forthcoming shortly.

Gary J. Alter, M.D.

Department of Plastic Surgery

UCLA School of Medicine

416 North Bedford Drive, Suite 400

Beverly Hills, Calif. 90210

[email protected]

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