This textbook was published by Springer on October 2, 2025. Dr. Pablo Gonzales and I Co-Edited this very first textbook dedicated to all things Majora. I wrote Chapter 2 on the History of Labia Majora Surgery. Below is the full unedited version. Enjoy. My Christmas gift to my loyal Cosmetic Gynecology Newsletter subscribers.
Historical Aspects of Labia Majoraplasty Surgery
A Personal Perspective by Red Alinsod, MD
Labia Majoraplasty has evolved significantly since its inception as a procedure for gynecologic malignancies to its current stage as a cosmetic procedure for beauty and a functional procedure for comfort. In this chapter I will trace the significant historical developments and focus on key contributions by pioneering surgeons. I will start and end with my personal story. You will notice that there is a common theme. The core is exposure to female genital cancer surgery.
My first introduction to labial surgery was in 1985 as a 3rd year medical student at Wilford Hall Medical Center in San Antonio, Texas. Kenneth Hancock, MD, gynecologic oncologist, was instrumental in helping me learn gynecologic anatomy and introduced me to vulvar surgeries. I was fascinated by radical vulvectomies I saw him teach his residents. Dr. Hancock was fresh out of his Gynecologic Oncology Fellowship at University of Texas MD Anderson Cancer and Tumor Institute (no MD Anderson Cancer Center). “Anderson” was well known for its aggressive and radical surgeries headed by Felix Rutledge, MD. He was known for Total Pelvic Exenterations (aka Exents) for advanced cervical and uterine cancer. Dr. Hancock became instrumental in writing a letter for me to obtain my residency at Loma Linda University Medical Center who had three Gynecologic Oncologists. Robert Wagner, MD, and Elden Keeney, MD, were graduates of MD Anderson. The Chairman of the department was Alan King, MD, also a Gynecologic Oncologist from Memorial Sloan Kettering Medical Center in New York. My path was set. I was going to be a Gynecologic Oncologist.
In my third year of residency at Loma Linda I heard about competitive Fellowships that were going to be started by the two biggies: The Rutledge Fellowship by MD Anderson and the Galloway Fellowship by Memorial Sloan Kettering. With great support and encouragement by my Loma Linda faculty I was accepted to both. I chose to be a Rutledge Fellow, the first one ever, and off I went to Houston. That was 1988, the year L.A. Dodger Kirk Gibson hit that walk off home run against the Oakland As. I was post call and watching it when it happened that evening. My month at MD Anderson was an eye opener. I had never seen any program work their residents harder and with full support and dedication. Their stated goal was to build the finest surgeons with the best hands to be the boss and run departments. A bit intimidating for sure. I met Dr. Rutledge who was retired and on his 3rd wife but who came to all the meetings and even showed up for the endless number of Exents done by the Fellows. I was completely overwhelmed being among legends like David Gershenson, MD, Taylor Wharton, MD, Michelle Follen, MD, Mitchell Morris, MD.
The Exenterations removed all the reproductive organs, bladder, anus, vulva, bowel, and we created pouches for urine and stool. There was an “Above Team” that took care of the abdominal hysterectomies and bowel and bladder surgery. There was a “Below Team” that did the complete vulvectomies and made neovaginas out of Gracilis muscle. I made sure I spent most of my time as part of the Below Team. I loved that they let this 3rd year resident do the Fellows work to recreate labias and vaginas from the inner thigh tissue. I was in my element. The staff was very encouraging and pushed me to pursue pelvic surgery. There was no urogynecology Fellowship at that time, so the next logical step was to see if infertility surgery was for me. So, I went to Yale to do a one-month elective in Reproductive Endocrinology in my senior year of residency. I was completely unimpressive. The Chairman at the time was the famous Alan DeCherney, MD. I worked exceptionally hard with the Fellows doing inseminations and IVF. I was in meetings almost every day doing Case Planning with the team headed by Dr. DeCherney. At the end of my rotation, I went up to Dr. DeCherney and thanked him for his mentorship and he said, “and who are you again?” I realized REI was not for me.
As disappointed as I was for my lackluster performance at Yale’s REI division, I was blessed to meet one of the most modest and brilliant man I had ever encountered. E. Albert Reece, MD. He was a Maternal Fetal Medicine attending along with John Hobbins, MD. They are the giants who deciphered the causes and treatments for Gestational Diabetes. Dr. Reece was a devout Seventh Day Adventist Christian and taught me the ropes of Academia counseling me to ALWAYS make sure to thank the Attending Staff personally and with letters, so they do not forget me. He encouraged me not to be narrow minded and just automatically go to MD Anderson for my GYN ONC Fellowship, so he introduced me to Peter Schwartz, MD, and Setsuko Chambers, MD, who later offered me the one Fellowship position that was to start on July 1990. I accepted. Then disaster struck. The 1st Gulf War was about to heat up, so the Air Force told me I had to be on active duty and that my deferral for starting my Gynecologic Oncology Fellowship at Yale was rescinded. I was heartbroken notifying Dr. Schwartz that I was not able to be his 1990 Fellow. This disappointment turned into excitement as I served for four years at George and Nellis Air Force Base.
I had the privilege to care for the women of the military and retirees. I ran the Gynecology Department and did hundreds of pelvic reconstruction cases. I was surprised to see a demand for labial reduction surgery even then in the early 1990s. So, I did them with both electrocautery and my CO2 laser. I lasered so many venereal wart lesions then. I started using the laser on the labia minora and majora not just for venereal warts. Air Force salaried soldiers and their wives, retirees, dependents, could not afford seeing a plastic surgeon in town so I was more than happy to do their surgeries labial surgeries and prolapse and tightening surgeries. In my eyes it was an easy surgery when compared to the exenterations I had been doing with the teams at MD Anderson.
After my Air Force career, I entered private practice in Los Angeles and for a medium sized multi-specialty group. The field of urogynecology was starting to grow rapidly and this really was what I wanted to pursue. From 1994 to 2004 I worked with industry and designed slings and mesh repair kits and surgical tools. I did a few labiaplasty surgeries because it was not a thing back then. Urogynecology was starting to be “The Thing” that gave birth to unofficial Fellowship programs like Ostergaard’s at UC Irvine. Laparoscopy was booming with the rise of Marco Pelosi II and III, Harry Reich, John Miklos, C.Y. Liu, David Redwine. I saw gynecology change slowly from being a specialty for vaginal surgery to laparoscopic surgery. It made me more determined to try and retain and expand vaginal surgery and ensure it was not a lost art. I active taught for Caldera Medical, AMS, BARD, Ethicon. I taught the UCLA residents and eventually became the mesh repair clinical instructor for Harbor UCLA’s Urogynecology Fellowship from 1997 to 2005. I focused strictly on labial and vaginal surgeries.
In 2000 I heard about David Matlock and reached out to him right after he completed his MBA at UC Irvine. He had just finished his MBA Group Project of launching the Laser Vaginal Rejuvenation Institute of America. His group aced it. The project became his outline for successfully launching LVRIA. He graduated his first LVRIA class soon after his MBA graduation. I heard about it and was in awe that people would pay so much money for such a course. I saw him take labiaplasty surgery and vaginoplasty surgery into the mainstream with lots of headwinds and naysayers. To this day!
I recently asked David why he even went back to school to get his MBA. He said
“One thing I learned about an MD, MBA, is that people look at you differently in the business world. A very good friend of mine asked “Why do you need this? You’re already a good businessman,” and I told him I felt that I was holding myself back. That’s why I did it. In my interview with one of the professors, she was called away for a short period of time she had my essay in front of her and what I noticed was that she had highlighted, and I stated I seek knowledge. When I saw that I knew I was in. I have a whole lot of stories, my friend.”
“Obviously, with any business, they’re going to be critics. You had to have a thick skin and push through it. The criticism was weird, was the lack of research. There was plenty of research there because of what some of these procedures were drawing from. I knew 100% that the research would come! Therefore, I pushed forward. I was able to grow this nationally in internationally. The media came to me, and I really understood that sex sells. I’ve been on everything. Television shows nationally and internationally, magazines, Vogue, Harper Bazar, Cosmopolitan, Nationally, Internationally, etc., etc. So, look where we are today! I knew that’s what would happen. Now it’s accepted and it’s International. F*** all those nay sayers in the beginning!”
David ran the first Cosmetic Gynecology courses in history in Beverly Hills starting in 2000 and said this:
“As you may or may not know I entered it as a business venture and first secured intellectual property with a patent attorney. I trained I’ve 436 surgeons in over 46 countries. I would train up to 10 at a time. I did world, European, and Asian, organized by the marking company. Get this we were able to charge $60k per doctor. Crazy money. But I liked at it as a business deal.”
“Run those numbers serious money was made. Some people may have rejected for me commercializing it but that’s what I learned in my MBA program. That’s what the professors told us to do. Just like many grad students coming out and launching businesses.”
“I only trained gynecologist, plastic surgeons, and urologist. That’s it. The doctor spent three days with me. One day of didactics, one day seeing me in surgery, performing the cases, and one day in the lab working on inanimate objects to simulate all the procedures. The support group putting all this together was a marketing company. A laser marketing company. It was a well-oiled machine.”
“I started a movement, and I was right. Let alone that I publicized it nationally in internationally with free marketing for everyone. Actually, that’s why we are where we are, and I understood, and I told the media I need them, and they need me.”
In the beginning, David taught Designer Laser Vaginal Rejuvenation (Labiaplasty Surgery) and Laser Vaginal Rejuvenation (Vaginoplasty, Perineoplasty). For the saggy labia majora, he initially used a wide perineoplasty technique to pull the labia majora downward to reduce the sag and draping effects but ultimately found this to be unsatisfactory. The problem of a tight introitis and potential for dyspareunia were present with this method. I asked him if his perineoplasty was his initial approach to a saggy labia majora and he said “that was one of the ways that I used to help reduce the majora. Ultimately, I didn’t get the results that I wanted, and I’ve stopped that approach. I’m sure I showed them (his Fellows) both. The best approach is the vertical elliptical/reduction.”
“For the majora, I found that the best approach would be a midline vertical elliptical excision. You can do anything to reduce the length, thickness, decrease thickness with that incision. With a medial approach you can’t get that and then that has the potential to fish-mouth labia minora.”
Jack Pardo, MD, from Chile, one of Dr. Matlock’s earliest graduates, remembers learning the midline vertical elliptical excision from Dr. Matlock. Jack’s grandfather and father were tailors and his exposure to gynecologic oncology made him secure about female genital anatomy. He did not do many vulvectomy surgeries early in his career but had the exposure to become confident in knowing where the vessels and nerves were located. To his recollection he did his own first solo “U.S. Football” shaped labia majora excision in 2009. Here are photos from Dr. Pardo’s landmark publication showing the medial incision going close to the labia minora and the pale white scar at the top of the labia majora ridge. Shown with permission (Fig. 1, 2):
Marco Pelosi III gained valuable experience working with pelvic surgeons and gynecologic oncologists and plastic surgeons early on after residency. Again, the common thread seems to be the work with the Gynecologic Oncology specialists. Macro Pelosi III also remembers the Midline Vertical Elliptical excisions that removed a football shaped area of labia majora tissue on each side (Fig. 3). However, in Dr. Pardo’s recollection, the elliptical excision was horizontal going across the middle of the labia majora and when sutured “pinched” the majora to reduce the sagging. This technique morphed into a more aesthetically pleasing vertical elliptical excision (“more banana shaped and not symmetrical” per Pardo) and changed the horizontal scar across the labia minora to a vertical scar on each majora.
An American shaped football excision of labia majora was developed by Pelosi and Pardo. The only problem was that now there was a railroad track scars on the middle of the labia majora. This was not a big problem in the days when women were not shaving everything off. However, when the days of the Brazilian waxing and laser hair removal became more prevalent Dr. Pardo, and his colleagues, modified their techniques further and placed the medial incision closer to the labia minora to hide the scar once healed. Doctors Jack Pardo, Vicente Sola, and Paolo Ricci submitted their landmark research on 60 Labia Majora Lifting patients on September 18, 2011, and it was published in The American Journal of Cosmetic Surgery in 2012. Patients were collected from May 2004 through June 2011. At that point in history, David held the surgical secrets close to the vest like the Chamberlains did with their obstetrics delivery forceps. I was much the same as David and did not publish any of my cosmetic gynecology techniques. Jack remembers telling David Matlock and John Miklos about an earlier publication regarding colpoperineoplasty on Acta Scandinavia that initially drew David Matlock’s and John Miklos’ disapproval of revealing secrets, but this turned out to be a positive attraction towards David’s LVRIA program.
As comfort and experience grew with labiaplasty surgery (Minora and Majora and Clitoral Hood) Dr. Jack Pardo brought his surgeries into the office in Latin America and began teaching his surgery under local anesthesia. Dr. Michael Goodman had the same experience as he taught local anesthesia techniques worldwide for labial and vaginal cosmetic surgeries in 2010.
Listen and watch my in-depth interviews of these GIANTS on my Cosmetic Gynecology Newsletter:
Jan 3, 2025: Walking Down Memory Lane with Marco Pelosi III: The Birth of ISCG:
Jan 27, 2025: Jack Pardo, MD, and the Genesis of Cosmetic Gynecology in Latin America
As David Matlock’s LVRIA empire was rapidly expanding in stature and influence in the early 2000s and my pelvic surgical world focused on design of products for use in pelvic reconstructive surgery. Many of these products would ultimately be instrumental in allowing for in-office awake No IV surgeries for cosmetic gynecology. My patented Alinsod Stand Surgical Table allowed still and calm hands for delicate labial surgery. My Alinsod Scissors and pickups and clams allowed for deep pelvic reach and placement of sutures. The Lone Star Retractor allowed for vision deep into the vagina. The slings and ultralightweight mesh and dermal allografts we brought out to market helped transform urogynecology. I was in Los Angeles at this time in my career (1994-2004) and watching how successfully David and his Fellows were changing the gynecology landscape. I was recruited as a urogynecologist to Laguna Beach, California, by South Coast Medical Center, who envisioned capturing the pelvic floor surgery business in the South Orange County region where the average age of women was in the mid 40s. My vision was to combine urogynecology with cosmetic gynecology and integrate the two. So, I moved and opened shop on January 5, 2005. I did the large majority of my labiaplasty and vaginoplasty surgeries in my office and started teaching and giving courses in both urogynecologic surgery and cosmetic gynecology. My big secret was the pudendal-levator block and labial blocks with microtumescent anesthesia I had developed that allowed deep pelvic floor dissections in the office. I kept all my labiaplasty and vaginoplasty secrets as well as my anesthesia techniques very private and only for my Alinsod Fellows. I chose not to publish at the time but to collect and share my thousands of Before and After pictures to those in search of surgical results. I had non-disclosures signed as did Dr. Matlock.
I launched my Alinsod Institute for Aesthetic Vulvovaginal Surgery training program in 2006 and started the Congress of Aesthetic Vulvovaginal Surgery (CAVS) in 2006 in conjunction with the now defunct AAOCG (American Academy of Cosmetic Gynecology). The first lecture on labia majoraplasty was at that Congress in Las Vegas with the first live course in Laguna Beach in October 2007. Prominent surgeons I had the thrill to work with in those early years were Dr. Alexander Bader in 2008, Dr. Michael Goodman in 2010, Dr. Sejal Ajmera in 2012, Dr. Christine Hamori in 2013, Dr. Amr Seifeldin in 2015, Dr. Joao Jaenisch in 2015, Dr. John Miklos, and Dr. Robert Moore in 2017. They have taught, spoken, or have published on Labia Majoraplasty and have been the most influential surgeons in the field of labia majoraplasty. I thank them for their contributions. One significant publication of note is the May-June 2011 article written by Miklos and Moore titled Simultaneous Labia Minora and Majora Reduction: A Case Report, published in the Journal of Minimally Invasive Gynecology. Theirs is the first publication of a combination surgery involving the labia majora. I had taught this method in my Fellowship program and presented it in several Congresses showing dozens of videos I call the “Universal Approach.”
My first labia majoraplasty were done in the office in 2005. Looking back at all my photos and videos and reading all the available materials published shows that my first photographed labia majoraplasty using the Curvilinear Labia Majoraplasty technique was on March 1, 2007. There are no sets of labia majoraplasty photos I can find that predate these photo sets. I believe these to be the very first non-cancer labia majoraplasty photos ever taken. My technical modification was to hug the medial incision line to be as close to the labia minora as possible to hide the scar but not remove so much tissue that a gaping introitus appears. Going short of this junction and leaving the scar line lateral to the minora-majora junction risked a visible white pale scar being visible. Here is that labia majoraplasty case and the photos I used to teach my Alinsod Fellows (Fig 4 – 10):
The second set of labia majoraplasty pictures I took were 3 weeks later May 21, 2007, as I expanded my teaching sets as more and more surgeons were showing interest in my surgical preceptorship. Here is Case 2 that highlighted the tightening of the vagina, perineum, and labia majora (Fig. 11 – 17):
On August 29, 2007, I took pictures of Case 3 that would turn out to be the most influential teaching set of Labia Majoraplasty photos that I have used around the world and on my lectures and website (Fig 18 – 22):
Historically, only the skin of the labia majora is removed when doing a labia majoraplasty. When a large “Camel Toe” is present, liposuction has been tried to remove fat. It has not been very successful. In vulvar cancer surgery, the labia majora is often removed as well as the fat with dissection done all the way to the muscles beneath the pubic ramus. Lymph node dissection is performed in these cases. This surgery has been modified to be a cosmetic labia majora reduction that includes a great deal of normal but voluminous fat. The first case of Labia Majoraplasty with Fat Pad Reduction for cosmetic indications was performed in my Laguna Beach office on Feb 29, 2012 (Fig. 23 – 30):
These life changing and confidence building surgeries are now offered and performed worldwide as the training programs add these procedures to their agendas. My online teaching platform called Gynflix (www.gynflix.com) was developed during the pandemic and launched in September of 2022 to served dozens of countries and all 50 United States (Fig. 30, 31). Its mission is to train surgeons to safely perform labial and vaginal surgeries as well as nonsurgical procedures. With the growing international demand for Cosmetic Gynecology and availability of very few high quality and professional preceptorship programs worldwide, I decided to share my 20+ years of experience and digital collection to a hungry and growing audience. Gynflix is the first online educational platform with 4K and HD videos and exquisite photography of core procedures, to improve the surgical standard, and reduce botched cases for my global audience. It has a secondary goal of educating Providers and the Lay Public, giving access to solutions, and to connecting the two.
Red Alinsod, MD
Chapter written on January 31, 2025
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