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Bilateral Triangular & Inverted Horizontal V-Shaped Resection — Liu Classification Hoodoplasty

The Liu 2022 classification system (Aesthet Plast Surg) classifies clitoral hood hypertrophy by anatomical zone. Two techniques within the system, bilateral triangular skin resection (for the wide central hood) and inverted horizontal V-shaped resection (for the long central hood), cover Zone C central hypertrophy. In the Liu series (level IV), 1,135 patients were classified and 789 received classification-based surgery. Overall satisfaction was 95.7%, complications 4.3% and revision 1.9%, with no paresthesia at 6 months.[1] For positioning versus other female cosmetic options see Cosmetic Genital Surgery — Female.

Society positioning. ACOG Committee Opinion No. 795 (2020) states that procedures to alter sexual appearance or function, other than those done for clinical indications, are not medically indicated, pose substantial risk, and have no established safety or effectiveness. It notes the lack of high-quality effectiveness data and advises BDD assessment when indicated.[2] A 2023 German, Austrian and Swiss S2k guideline recommends deferring aesthetic genital surgery when BDD is suspected and referring for specific evaluation (expert consensus, +++).[11] The FIGO 2025 statement defines cosmetic genital surgery as aesthetic alteration in women without structural or functional abnormalities and calls it ethically inappropriate for obstetrician-gynecologists to recommend, perform or refer patients for those procedures.[10] The hoodoplasty literature consists largely of single-surgeon case series.

The Liu zone-based classification​

The clitoral-hood region is divided into two anatomical zones:[1]

  • Central zone (Zone C). The midline prepuce overlying the clitoral glans.
  • Lateral zone (Zone L). The lateral folds of the hood that blend into the labia minora.

Liu describes five anatomic patterns with corresponding operative options.[1] Evaluate the patient's concerns and goals, normal variation, and psychological concerns before considering an operation in light of the society guidance above.[2][10]

TypeDescriptionLiu series’ proposed approach
Type 1 — StandardNormal anatomy, no hypertrophyNo intervention
Type 2 — Central hypertrophy (Zone C)Excess overlying the glans onlyBilateral triangular resection (wide hood) OR inverted horizontal V-shaped resection (long hood) [1]
Type 3 — Lateral hypertrophy (Zone L)Excess in the lateral folds onlyVertically oriented lateral excision
Type 4 — Composite hypertrophyExcess in both Zone C and Zone LCombination of central + lateral techniques
Type 5 — Special variantsUnusual anatomyIndividualized approach

Type 2 central hypertrophy is subdivided into a wide pattern and a long pattern, each with a different excision geometry.[1] Before marking, assess the vulva standing and in lithotomy; with the labia separated and hood gently elevated, assess glans coverage and the lateral hood–labia junction for fused anatomy.[15]

Bilateral triangular resection — for the wide central hood​

Indication: horizontal redundancy; the central hood is excessively wide, creating lateral fullness over the clitoral glans.[1]

Concept and geometry. Bilateral triangular wedges of skin are excised from each side of the central hood. The triangles are oriented to reduce the transverse width of the prepuce, narrowing the hood while preserving midline coverage of the clitoral glans. Bilateral, symmetric marking allows the planned width reduction to be compared side to side.

Step-by-step (after Liu 2022):

StepDetail
1. MarkingLithotomy. Two mirror-image triangular wedges marked on the lateral aspects of the central hood — apex of each triangle directed toward the midline (preserving midline coverage), base along the lateral free edge of the prepuce. Width of each triangle determines the degree of narrowing.
2. AnesthesiaLocal with epinephrine, ± sedation, or general.
3. ExcisionExcise both marked preputial triangles in a plane superficial to dartos and away from the glans and clitoral body to protect the dorsal clitoral neurovascular bundle. Avoid deep dissection into corporal tissue.[12]
4. HemostasisBipolar electrocautery; selective suture ligation.
5. ClosureSymmetric layered closure with fine absorbable suture. Bring the new lateral prepuce edges together without undue tension; preserve midline glans coverage.[12]

Inverted horizontal V-shaped resection — for the long central hood​

Anatomic pattern: vertical redundancy; the central hood extends inferiorly to overhang the clitoral glans.[1] Before excision, assess gentle preputial retraction to distinguish mobile redundancy from adhesions or phimosis; evaluate symptomatic adhesions or phimosis separately.[14]

Concept and geometry. A horizontally oriented inverted V (chevron) is excised across the hood. The apex of the inverted V points inferiorly (toward the clitoris) and the arms extend superiorly and laterally toward the mons. Excising this tissue shortens the vertical length of the hood, effectively "lifting" it to expose the clitoral glans appropriately. Triana and Robledo’s 2015 review describes inverted-V hoodoplasty; Triana’s 2024 cohort predominantly used longitudinal, with some horseshoe, excision rather than this pattern.[3][4]

Step-by-step (after Liu 2022):

StepDetail
1. MarkingLithotomy. The horizontal inverted-V is marked across the hood with the apex pointing inferiorly and the two arms extending superolaterally. The vertical span of the V determines the amount of lift.
2. AnesthesiaLocal with epinephrine, ± sedation, or general.
3. ExcisionThe inverted-V wedge is excised through prepuce skin and subcutaneous tissue. Preserve the dorsal neurovascular bundle.
4. HemostasisBipolar electrocautery; selective suture ligation.
5. ClosureApproximate the superior and inferior cut edges in layers with fine absorbable suture to shorten the hood; before final closure, check that protective glans coverage remains and adjust if the hood retracts excessively.[13]

Outcomes across all Liu classification types (2022; n = 789 treated)​

EndpointResult
Patients classified1,135
Patients receiving classification-based surgery789
Overall satisfaction95.7% at 6 months across all treated types [1]
Complication rate4.3% (34 patients) [1]
Revision rate1.9% (15 patients) [1]
Paresthesia at 6 monthsNone reported

This is one of the largest reported hoodoplasty cohorts.[1] No paresthesia was reported at 6 months; follow-up beyond 6 months is not reported. Specific complication types (dehiscence, hematoma, infection) are not broken out.

Comparison with other hoodoplasty series​

These uncontrolled series include different operations, populations, outcome measures, and follow-up periods. Several combined hood and labia minora reduction.[1][5][7]

SeriesnSatisfactionComplicationsRevision
Liu 2022 classification-based[1]78995.7%4.3%1.9%
Eserdağ 2021 inverted-Y hoodoplasty with concomitant labiaplasty[5]6396.9% at 2 months (satisfaction denominator unspecified)No majorNot reported
Xia 2021 three-step excision[6]136 (ages 9–55; includes minors)95.5% (106/111 questionnaire respondents after 3 months)4.4%3.7%
Triana 2024 mixed labiaplasty and hoodplasty cohort[4]630 labiaplasties (303 with hood excess)98% reported improved self-esteem across the cohort; hoodoplasty-specific satisfaction not reportedNo majorNot reported
Shi 2026 modified wedge composite[7]738 (mean follow-up 1.9 mo)96.2% overall24/738 (3.3%) delayed wound healing; 10/738 (1.4%) perceived asymmetryNot reported
Duan 2026 two-part excision[8]68GAS improvement (p < 0.05)7.4%1.5%

Comparison with the Xia CLC classification​

The Xia 2022 CLC classification (Aesthet Surg J; 301 patients aged 9–55 years, including minors) takes a different approach, focusing on the clitoral hood–labia minora complex (CLC) rather than the hood alone, and divides patients into 3 types based on the relationship between the lateral hood and labia minora:[9]

Xia typeDescriptionFrequencyApproachSatisfaction
Type 1Isolated labia minora hypertrophy (1a) or isolated lateral hood redundancy (1b)158/602 sides (26.2%) Type 1a; 19/602 (3.2%) Type 1bIsolated reduction matched to the affected structureNot reported separately
Type 2Combined labia minora and lateral hood hypertrophy with a clear boundary285/602 sides (47.3%)Combined hood and labia reductionNot reported separately
Type 3Fused lateral clitoral hood and labia minora105/602 sides (17.5%), in 67/301 patientsSpecialized 4-step excision91.7% (33/36) after combined four-step versus 56.3% (9/16) after labial wedge excision alone (p = 0.01; 52/67 [77.6%] Type 3 patients answered at 3 months)

The Xia and Liu classifications address different zones. In Xia’s Type 3 four-step group, junction hematomas occurred on 2/80 treated sides (2.5%) and required surgical evacuation.[9] Liu subtypes the central zone (wide versus long). Xia subtypes the lateral-zone CLC and identifies the fused variant.[9] In a nonrandomized historical comparison, later combined labial-and-hood four-step cases reported higher 3-month satisfaction than earlier labial wedge-only cases (33/36 versus 9/16 respondents).[9]

Advantages of the Liu approach​

  • Anatomy-driven selection. The classification matches the pattern of excess (horizontal or vertical, central or lateral) to an excision design.[1]
  • Series size. 1,135 patients were classified and 789 treated.[1]
  • Structure. The classification gives a framework for planning.
  • Combinability. For Type 4 composite hypertrophy, central and lateral techniques are combined in the same operation.[1]
  • Sensation. No paresthesia was reported at 6 months in the treated cohort.[1]

Limitations​

  • The Liu series is a level IV case series without a control group.[1]
  • Follow-up beyond 6 months is not reported.
  • Specific complication types (dehiscence, hematoma, infection) are not individually reported.
  • ACOG 2020 notes the lack of high-quality data supporting the effectiveness of genital cosmetic procedures.[2]

Critical safety considerations​

Across all hoodoplasty techniques, including bilateral triangular and inverted-V resection[1][2]:

  • Preserve the dorsal neurovascular bundle of the clitoris.
  • Avoid over-resection. Excessive removal can produce clitoral exposure with hypersensitivity or chronic pain, or paradoxical loss of sensation.
  • Symmetric tissue removal to prevent postoperative asymmetry; the bilateral triangular design helps enforce symmetry by construction, but intraoperative comparison is still required.
  • Document neurologic baseline preoperatively and counsel before surgery about possible pain, altered sensation, dyspareunia, adhesions, and scarring.[2]

Postoperative management​

  • Activity restriction. Avoid intercourse, tampon use, and strenuous exercise for 4–6 weeks.
  • Wound care. Use a cold pack over a protective layer, 20 minutes on and 20 minutes off; avoid prolonged hot baths during the first week. Topical antibiotic ointment and a pad may be used for oozing.[12] Follow local protocol for the duration of cooling and the start of brief sitz baths; wear loose-fitting clothing.
  • Follow-up. When hood reduction is combined with labiaplasty, assess early bleeding or hematoma within 24 hours, as in Xia's composite series.[6] Review at 1 week (wound check), 6 weeks (clearance), and 3–6 months (outcome assessment). Consider follow-up to 12 months given limited long-term published data.
  • PRO assessment. FSFI and FGSIS at baseline and ≥ 6 months postoperatively.

See Also​

References​

1. Liu M, Li Q, Li S, et al. Preliminary exploration of a new clitoral hood classification system and treatment strategy. Aesthet Plast Surg. 2022;46(6):3080–3093. doi:10.1007/s00266-022-02874-y

2. Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. Elective female genital cosmetic surgery: ACOG Committee Opinion No. 795. Obstet Gynecol. 2020;135(1):e36–e42. doi:10.1097/AOG.0000000000003616

3. Triana L, Robledo AM. Aesthetic surgery of female external genitalia. Aesthet Surg J. 2015;35(2):165–177. doi:10.1093/asj/sju020

4. Triana L, Harini BS, Liscano E. Hoodplasty: individualized approach for labiaplasties. Aesthet Plast Surg. 2024;48(11):2197–2203. doi:10.1007/s00266-023-03777-2

5. Eserdağ S, Anğın AD. Surgical technique and outcomes of inverted-Y plasty procedure in clitoral hoodoplasty operations. J Minim Invasive Gynecol. 2021;28(9):1595–1602. doi:10.1016/j.jmig.2021.01.015

6. Xia Z, Liu CY, Yu N, et al. Three-step excision: an easy way for composite labia minora and lateral clitoral hood reduction. Plast Reconstr Surg. 2021;148(6):928e–935e. doi:10.1097/PRS.0000000000008589

7. Shi Y, Sun Y, Chen L, Gao Y, Li Q. Clinical observations of the modified wedge resection in composite labia minora and clitoral hood reduction surgery. Aesthet Plast Surg. 2026;50(4):1621–1627. doi:10.1007/s00266-025-05593-2

8. Duan L, Li Z, Zhang H, Zhang B. Composite labia minora and clitoral hood reduction: an optional surgical method. Aesthet Plast Surg. 2026;50(8):3035–3042. doi:10.1007/s00266-025-05075-5

9. Xia Z, Liu CY, Zhang M, et al. Fused lateral clitoral hood and labia minora: new classification based on anatomic variation of the clitoral hood-labia minora complex and simple surgical management. Aesthet Surg J. 2022;42(8):907–917. doi:10.1093/asj/sjac039

10. Capito L, Antsaklis A, Gupte S; FIGO Committee on Ethical Aspects of Human Reproduction and Women's Health. FIGO statement: cosmetic genital surgery. Int J Gynaecol Obstet. 2025;170(1):11–14. doi:10.1002/ijgo.70203

11. Beckmann MW, Borkenhagen A, Fahlbusch C, et al. "Reconstructive and Aesthetic Surgeries on the Female Genitalia. Guideline of the DGGG, DGPRÄC, OEGGG and SGGG (S2k-Level, AWMF Registry No. 009/019, May 2022)." Geburtshilfe Frauenheilkd. 2023;83(7):802–826. doi:10.1055/a-2065-4458

12. Furnas HJ, Canales FL, Pedreira RA, Comer C, Lin SJ, Banwell PE. "The Safe Practice of Female Genital Plastic Surgery." Plast Reconstr Surg Glob Open. 2021;9(7):e3660. doi:10.1097/GOX.0000000000003660

13. Pan RL, Tople TL, Morrison SD, Oppenheimer AJ. "Edge Labiaplasty with Clitoral Hood Reduction: Pitfalls and Pearls." Plast Reconstr Surg Glob Open. 2024;12(4):e5735. doi:10.1097/GOX.0000000000005735

14. Krapf JM, Pope R. "Approach to Diagnosis and Management of Clitorodynia." O&G Open. 2025;2(1):e062. doi:10.1097/og9.0000000000000062

15. Kang Y, Xia Z, Wang S, et al. "Standardized Photography of Female Genitalia and Anatomical Evaluations." Aesthet Surg J. 2023;43(11):1334–1344. doi:10.1093/asj/sjad127