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Is labioplasty the best option in adolescence?

CHICAGO -- Labioplasty resulted in high rates of satisfaction and few complications in what is being described as the largest series of pediatric and adolescent females undergoing labioplasty for symptomatic labial hypertrophy.

The study in 37 girls, aged 7-17 years, evoked strong responses when presented at the meeting.

One audience member said she was disturbed by the age range of the participants, and questioned why labioplasty was even performed in a 7-year-old.

Principal investigator Dr. Xiomara M. Santos replied that the child had extensive labial hypertrophy due to chronic masturbation and experienced no complications as a result of surgery The girl also had been diagnosed with precocious adrenarche. Dr. Santos stressed that in no case was a procedure performed for cosmetic reasons, and that patients and their mothers received extensive counseling on the risks and benefits prior to surgery.

Senior author Dr. Jennifer Dietrich, chief of gynecology at Texas Children's Hospital in Houston, said in an interview that labioplasty in adolescents is safe and effective for symptomatic labial hypertrophy, but that counseling and education cannot be emphasized enough. She noted that only two girls in the series were prepubertal: the 7-year-old and an 8-year-old with precocious puberty who developed symptomatic labial hypertrophy after vulvar trauma. Both girls had failed conservative management and underwent surgery because of considerable hygiene difficulties and chronic discomfort.

"Ultimately these are procedures for patients who are symptomatic enough that it affects their daily life," she said. "Patients and parents who consent regardless of conservative measures attempted are making a very private choice in this matter based on quality of life issues."

The 37 girls underwent either bilateral or unilateral labioplasty with or without clitoral hood revision under general anesthesia between July 2007 and June 2010. Symptomatic labial hypertrophy was defined as labia minora of more than 4 cm, with 60% of patients having labia of 7-8 cm. The mean age was 12.6 years.

The straight surgical technique was used bilaterally in 17 patients and unilaterally in 5, the wedge excision technique bilaterally in 1 and unilaterally in 3, the elliptical technique in only 3 patients bilaterally and the contoured technique bilaterally in only 1 patient. Clitoral hood revision for clitoral hood hypertrophy was performed in six patients. One patient underwent surgery after trauma.

Postoperative perineal care included conjugated estrogen cream and bacitracin in 34 patients and Silvadene cream in 3 patients, with sitz baths twice daily.

No intraoperative or major postoperative complications were reported among the 37 patients, with 10 (27%) experiencing minor postoperative complications, said Dr. Santos a clinical fellow at Texas Children's Hospital. The complications included three wound infections, two cases of wound dehiscence, two wound hematomas, reaction to the prescribed cream in two patients, and severe postoperative pain requiring admission in one patient. All complications resolved with minor interventions by 6 weeks post procedure, with 70% resolving by 3 weeks.

Noncompliance with postoperative perineal care occurred in 27% of patients and was significantly correlated with having a minor postoperative complication, Dr. Santos said. No statistically significant correlation was identified with complication rates and surgical technique, suture type, type of procedure, body mass index (BMI), age, and age at menarche. Two patients were not satisfied with the surgery, resulting in an overall satisfaction rate of 94%.

Among 34 patients with long-term follow-up available, 3 patients (9%) experienced a recurrence, Dr. Santos reported. However, Dr. Dietrich told this news agency that her fellow misspoke and that only two patients (5.8%) experienced a recurrence, one 2 months after surgery and one 2 years later. Only one patient underwent a repeat procedure, both women said.

"Labial hypertrophy can cause significant physical and social discomfort," Dr. Santos concluded. "Providers should perform the technique which he or she is comfortable with and best suits the patient's anatomy."

When asked by the audience how satisfaction was measured, Dr. Santos replied that they asked the patient if she was happy with the result. The audience also asked how compliance with postoperative care was measured, to which Dr. Santos replied that they assumed the patients were following instructions. Her responses failed to satisfy the audience, with an attendee suggesting that resolution of symptoms would have been a more rigorous clinical end point than overall satisfaction and cautioning the authors about making assumptions that can change clinical practice. Dr. Santos agreed that satisfaction is a complex construct to measure, and said they did ask patients whether their symptoms resolved.

In a separate interview, Dr. Julie Strickland, immediate past-president of the North American Society for Pediatric and Adolescent Gynecology (NASPAG), also questioned the vigor of the study's methodology, and said part of the controversy lies in the use of plastic surgery in girls prior to menarche when they are neither physically or psychologically mature.

"There aren't rigid criteria of what is normal and abnormal, so we get this request a lot," she said. "During adolescence it is really normal [for girls] to question their body composition and to worry about normalcy They go to gym and they look slightly different from someone else, and that can really become a psychological issue that they grow out of. "So it's controversial if it should be done at all, except in extreme cases, and particularly below the age of 18 because it is a plastic procedure."

Dr. Dietrich said that for every patient who presents with symptomatic hypertrophy, there are probably two patients who are concerned about appearance, but with counseling and education do not undergo a procedure.

The age of menarche for the group overall was about 11.5 years, but as early as 10 years, Dr. Dietrich said. Although BMI was not associated with complications, she noted that 60% of adolescents falling in the early adolescent category (10-14 years) were overweight or obese, which is a risk factor for earlier puberty and in line with girls developing earlier in the last few decades.

Recurrence in such young patients is also a critical issue, said Dr. Strickland of the University of Missouri-Kansas City. This can be particularly troublesome if a unilateral labioplasty is performed and repeat surgery is needed for the contralateral side. She observed that most recommendations and textbooks discuss labioplasty in cases of extreme symptomatic labial hypertrophy, but that it is segregated after growth is complete. Dr. Strickland defined extreme as labia that have undergone marked anatomic changes; are typically at least 8-9 cm in size; and can be pinched, difficult to clean, and eroded or irritated because of exposure to clothing.

In an interview, Dr. Santos reiterated that all of the patients were symptomatic, that they and their parents were told about the risks and benefits of surgery and that labial hypertrophy can be managed without surgery.


Major Finding: There were no intraoperative or major postoperative complications, and 10 patients (27%) experienced minor postoperative complications.

Data source: Retrospective analysis of 37 girls with symptomatic labial hypertrophy who underwent bilateral or unilateral labioplasty with or without clitoral hood revision.

Disclosures: Dr. Santos and Dr. Dietrich reported no relevant financial disclosures


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Title Annotation:GYNECOLOGY
Author:Wendling, Patrice
Publication:OB GYN News
Date:Jun 1, 2011
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