Labiaplasty: Indications and Predictors of Postoperative Sequelae in 451 Consecutive Cases

Labiaplasty: Indications and Predictors of Postoperative Sequelae in 451 Consecutive Cases Abstract Background The increasing demand for labiaplasty is well recognized; however, the procedure remains contentious. Objectives We aim to provide a large-scale, up-to-date analysis of labiaplasty outcomes and factors influencing postoperative sequelae (POS). Methods We analyzed a single-center, prospectively maintained database of females undergoing labiaplasty between 2002 and 2017. Demographic, procedural, and outcomes’ data were retrieved. Binary logistic regressions were used to evaluate the odds of developing POS (revisional surgery and complications); presented as odds ratios (OR) with 95% confidence intervals (CI). Results Data for 451 consecutive patients were retrieved, ten of whom were <18 years of age. Overall, 86% were Caucasian, mean age was 32.6 years, and 11.8% were smokers. Concomitant labia majora reduction was performed in 7.3%, and clitoral hood reduction in 5.8%. There were 32 cases of POS (7.1%), while the complication rate was 3.8%. Comparing those with POS to those without, there were no differences in age (32.8 vs 29.9 years, P = 0.210), operative time (78.5 vs 80.6 minutes, P = 0.246), or comorbidities (P > 0.05 for all). On univariable analysis, increased odds of POS occurred with sexual dysfunction as an indication for surgery (OR 3.778, CI 1.682-8.483). On subgroup analysis of those ≥18 years, both smoking (2.576, CI 1.044-6.357) and sexual dysfunction as an indication (OR 4.022, CI 1.772-9.131) increased the odds of POS. On multivariable analysis of the subgroup, sexual dysfunction as an indication persisted in significance (OR 3.850, CI 1.683-8.807). Conclusions Results compare favorably with previously reported complication and revisional surgery rates. Smoking and sexual dysfunction may increase the risk of complications. Level of Evidence: 2 The increasing demand for labiaplasty is well recognized. According to the American Society for Aesthetic Plastic Surgery, in the United States alone, 10,774 procedures were performed by board-certified plastic surgeons in 2016, an increase of 23% from the previous year.1 It has been suggested that increasing exposure to female nudity in the media may have propagated this trend, and recent literature has shown variation in the reasons for seeking labiaplasty.2,3 Hypertrophy of the labia minora (Figure 1) may cause significant psychological distress for women, in addition to functional concerns, such as irritation in certain clothing or tugging during sexual intercourse.3,4 Studies have found that women may experience psychological and functional improvements after labiaplasty, including greater confidence in sexual relationships, resolution of discomfort when exercising, and relief from feelings of self-consciousness.4,5 Moreover, previous research has demonstrated consistently low complication rates, between 2% and 13%.6-8 Figure 1. View largeDownload slide A 39-year-old woman presented for treatment of labia minora hypertrophy (wedge excision). (A, C) Preoperative and (B, D) three month postoperative photographs. Figure 1. View largeDownload slide A 39-year-old woman presented for treatment of labia minora hypertrophy (wedge excision). (A, C) Preoperative and (B, D) three month postoperative photographs. However, the procedure remains controversial, with critics suggesting there is an inadequate body of literature examining the postoperative satisfaction and risks after labiaplasty, including a lack of long-term follow up.8 Others believe the procedure to be particularly unnecessary in the adolescent population, suggesting that the labia majora are likely to continue growth in early adulthood, descending to a level where the labia minora do not appear as prominent.9 Given the need for further studies to confirm the safety of the procedure and the controversy surrounding the younger population, the aim of this study was to report complications and rates of revisional surgery after labiaplasty in a large, single-center series, encompassing adolescent and adult women. Our secondary aim is to identify preoperative characteristics that may be associated with the development of complications and revisional surgery. METHODS Patient Selection and Outcome Variables Analysis of a prospectively maintained database of consecutive females undergoing labiaplasty at a single center between May 2002 and May 2017 was performed. Institutional Review Board (IRB) approval for this study was granted by the Beth Israel Deaconess Medical Center IRB. Patient characteristics included age, race, body mass index (BMI, in kg/m2), comorbidities (diabetes, hypertension, high cholesterol, anxiety, depression, thyroid disease), history of sexual assault, history of female genital surgery, medications (use of blood thinners, oral contraceptive pill, or hormone replacement therapy), menopausal status, smoking status, previous vaginal delivery, and whether they were sexually active. Indication for surgery was listed as any combination of aesthetic or appearance-related, functional (nonsexual), functional (sexual, hereafter referred to as “sexual dysfunction,” which was patient-reported), discomfort, chronic urinary or vulvar infection, postmassive weight loss, or other. For the purposes of modeling the latter three were collapsed into a single category. Procedural details included laterality (unilateral or bilateral), additional procedures (labia majora reduction, clitoral hood reduction, labial fat grafting, radiofrequency treatment, vaginoplasty, other), length of surgery (minutes: time of entering operating room until time departing operating room), and anesthetic type (local or general). Postoperative details included the development of postoperative sequelae. This included need for revisional surgery, in addition to wound dehiscence, bleeding, hematoma, wound infection, other infection, numbness, pain, dyspareunia, need for readmission, need for antibiotics, and venous thromboembolism. We also included length of follow up (including last documented follow up and time since surgery), and length of stay in days. Statistical Analysis All statistical analyses were performed using IBM SPSS version 22.01 for Mac (IBM Corp., Armonk, NY). Fisher’s exact or chi-square tests were used to compare categorical variables between those developing complications and those not (with respect to number and percentage of cases), while the independent t test or Mann Whitney U test was used for continuous data (presented as mean and standard deviation). Binary logistic regression modeling was performed to adjust for confounding when analyzing factors affecting the odds of developing postoperative sequelae (complications and revisional surgery); variables that were significant on univariable analysis were included in the multivariable model. Results are presented with odds ratios (OR) with 95% confidence intervals (CI). Additional subgroup regression analysis was also performed on those aged 18 years or more, while characteristics of those under 18 are summarized. Statistical significance was determined when P < 0.05. Graphical features were developed using GraphPad PRISM Version 6.0e. RESULTS Over the study period, data for 451 consecutive cases were retrieved. The number of annual cases increased over time, from 1 in 2002 to 47 in 2016 (Figure 2). Most patients were Caucasian (74.7%), sexually active (59.9%), and premenopausal (79.2%). Mean age was 32.6 years (range, 14-68 years), including 31 teenagers and ten patients under the age of 18. The most prevalent comorbidities were depression (14.6%) and anxiety (5.8%), while 11.8% were smokers. The most common indication for labiaplasty cited was aesthetic (81.6%); other causes included discomfort (61.4%), nonsexual function (54.5%), sexual function (12.2%), chronic urogenital infection (1.1%), and weight loss (0.4%) or other, unspecified (0.4%). Four hundred and five patients underwent wedge excision, 38 edge trim, and 8 “other.” Seventy-eight per cent of cases were bilateral, and the most common concomitant procedure was labia majora reduction (7.3%). All were same-day outpatient procedures and a majority were performed under local anesthetic (76.3%). Patient and operative characteristics for the whole cohort are summarized in Table 1. When isolating those ten patients aged less than 18 years (range, 14-17 years) we found that all were Caucasian, 9/10 listed discomfort and appearance as their indications for surgery, while none indicated sexual dysfunction as a reason. No one in this group underwent concomitant procedures. Figure 2. View largeDownload slide Annual number of labiaplasties performed between May 2002 and May 2017. Figure 2. View largeDownload slide Annual number of labiaplasties performed between May 2002 and May 2017. Table 1. Comparison of Characteristics Between Those Developing Complications and Those Without (presented as number and percentage unless indicated by *) Patient characteristic Overall No complications Complications P value N % N % N % Age* 32.6 10.1 32.8 10.2 29.9 7.8 0.210 BMI* 22.2 3.2 22.1 2.9 24.2 5.7 0.091 Race 0.449  White 337 86.0 315 86.1 22 84.6 —  African American 8 2.0 7 1.9 1 3.8 —  Asian 12 3.1 12 3.3 0 0 —  Native American 1 0.3 1 .3 0 0 —  Other 34 8.7 31 8.5 3 11.5 —  Missing 59 13.1 84 20.0 9 28.1 — Smoking 53 11.8 46 11.0 7 21.9 0.083 Comorbidities  Diabetes 3 0.7 3 0.7 0 0 1.000  Hypertension 11 2.4 11 2.6 0 0 1.000  Cholesterol 4 0.9 4 1.0 0 0 1.000  Anxiety 26 5.8 25 6.0 1 3.1 1.000  Depression 66 14.6 60 14.3 6 18.8 0.444  Thyroid disease 16 3.5 15 3.6 1 6.3 1.000 Other relevant history  Sexual assault 2 0.4 1 0.2 1 3.1 0.137  FGM 12 2.7 11 2.6 1 3.1 0.591  Premenopause 357 79.2 331 79.0 26 81.3 1.000  Vaginal delivery 384 85.1 358 85.4 26 81.3 0.604  Sexually active 270 93.1 251 93.0 19 95.0 1.000 Drug history  Blood thinner 6 1.3 6 1.4 0 0 1.000  OCP 72 16.0 66 15.8 6 18.8 0.655  HRT 6 1.3 6 1.4 0 0 1.000 Indication  Aesthetic 368 81.6 343 81.9 25 78.1 0.599  Discomfort 277 61.4 256 61.1 21 65.6 0.612  Function (nonsexual) 246 54.5 229 54.7 17 53.1 1.000  Function (sexual) 55 12.2 45 10.7 10 31.3 0.002  Chronic urine infection 3 0.7 2 0.5 1 3.1 0.199  Chronic genital infection 2 0.4 1 0.2 1 0.2 0.137  Postmassive weight loss 2 0.4 2 0.5 0 0 1.000  Other 2 0.4 2 0.5 0 0 1.000 Anesthetic 0.212  Local 344 76.3 320 76.4 24 75.0 —  General 45 10.0 44 10.5 1 3.1 —  Missing 62 13.7 55 13.1 7 21.9 — Procedure side  Bilateral 351 92.4 330 92.7 21 87.5 0.413 Operative time (minutes)* 78.6 44.7 78.5 45.7 80.6 27.0 0.246 Concomitant procedures  Labia majora reduction 33 7.3 29 6.9 4 12.5 0.278  Clitoral hood reduction 26 5.8 24 5.7 2 6.3 0.706  Other 51 11.3 48 11.5 3 9.4 1.000 Patient characteristic Overall No complications Complications P value N % N % N % Age* 32.6 10.1 32.8 10.2 29.9 7.8 0.210 BMI* 22.2 3.2 22.1 2.9 24.2 5.7 0.091 Race 0.449  White 337 86.0 315 86.1 22 84.6 —  African American 8 2.0 7 1.9 1 3.8 —  Asian 12 3.1 12 3.3 0 0 —  Native American 1 0.3 1 .3 0 0 —  Other 34 8.7 31 8.5 3 11.5 —  Missing 59 13.1 84 20.0 9 28.1 — Smoking 53 11.8 46 11.0 7 21.9 0.083 Comorbidities  Diabetes 3 0.7 3 0.7 0 0 1.000  Hypertension 11 2.4 11 2.6 0 0 1.000  Cholesterol 4 0.9 4 1.0 0 0 1.000  Anxiety 26 5.8 25 6.0 1 3.1 1.000  Depression 66 14.6 60 14.3 6 18.8 0.444  Thyroid disease 16 3.5 15 3.6 1 6.3 1.000 Other relevant history  Sexual assault 2 0.4 1 0.2 1 3.1 0.137  FGM 12 2.7 11 2.6 1 3.1 0.591  Premenopause 357 79.2 331 79.0 26 81.3 1.000  Vaginal delivery 384 85.1 358 85.4 26 81.3 0.604  Sexually active 270 93.1 251 93.0 19 95.0 1.000 Drug history  Blood thinner 6 1.3 6 1.4 0 0 1.000  OCP 72 16.0 66 15.8 6 18.8 0.655  HRT 6 1.3 6 1.4 0 0 1.000 Indication  Aesthetic 368 81.6 343 81.9 25 78.1 0.599  Discomfort 277 61.4 256 61.1 21 65.6 0.612  Function (nonsexual) 246 54.5 229 54.7 17 53.1 1.000  Function (sexual) 55 12.2 45 10.7 10 31.3 0.002  Chronic urine infection 3 0.7 2 0.5 1 3.1 0.199  Chronic genital infection 2 0.4 1 0.2 1 0.2 0.137  Postmassive weight loss 2 0.4 2 0.5 0 0 1.000  Other 2 0.4 2 0.5 0 0 1.000 Anesthetic 0.212  Local 344 76.3 320 76.4 24 75.0 —  General 45 10.0 44 10.5 1 3.1 —  Missing 62 13.7 55 13.1 7 21.9 — Procedure side  Bilateral 351 92.4 330 92.7 21 87.5 0.413 Operative time (minutes)* 78.6 44.7 78.5 45.7 80.6 27.0 0.246 Concomitant procedures  Labia majora reduction 33 7.3 29 6.9 4 12.5 0.278  Clitoral hood reduction 26 5.8 24 5.7 2 6.3 0.706  Other 51 11.3 48 11.5 3 9.4 1.000 *Mean and standard deviation presented. Of note, “operative time” is time from entering the operating room until time of departing from the operative room. Actual mean surgical time is approximately 45 to 50 minutes. FGM, female genital mutilation; HRT, hormone replacement therapy; OCP, oral contraceptive pill. View Large Table 1. Comparison of Characteristics Between Those Developing Complications and Those Without (presented as number and percentage unless indicated by *) Patient characteristic Overall No complications Complications P value N % N % N % Age* 32.6 10.1 32.8 10.2 29.9 7.8 0.210 BMI* 22.2 3.2 22.1 2.9 24.2 5.7 0.091 Race 0.449  White 337 86.0 315 86.1 22 84.6 —  African American 8 2.0 7 1.9 1 3.8 —  Asian 12 3.1 12 3.3 0 0 —  Native American 1 0.3 1 .3 0 0 —  Other 34 8.7 31 8.5 3 11.5 —  Missing 59 13.1 84 20.0 9 28.1 — Smoking 53 11.8 46 11.0 7 21.9 0.083 Comorbidities  Diabetes 3 0.7 3 0.7 0 0 1.000  Hypertension 11 2.4 11 2.6 0 0 1.000  Cholesterol 4 0.9 4 1.0 0 0 1.000  Anxiety 26 5.8 25 6.0 1 3.1 1.000  Depression 66 14.6 60 14.3 6 18.8 0.444  Thyroid disease 16 3.5 15 3.6 1 6.3 1.000 Other relevant history  Sexual assault 2 0.4 1 0.2 1 3.1 0.137  FGM 12 2.7 11 2.6 1 3.1 0.591  Premenopause 357 79.2 331 79.0 26 81.3 1.000  Vaginal delivery 384 85.1 358 85.4 26 81.3 0.604  Sexually active 270 93.1 251 93.0 19 95.0 1.000 Drug history  Blood thinner 6 1.3 6 1.4 0 0 1.000  OCP 72 16.0 66 15.8 6 18.8 0.655  HRT 6 1.3 6 1.4 0 0 1.000 Indication  Aesthetic 368 81.6 343 81.9 25 78.1 0.599  Discomfort 277 61.4 256 61.1 21 65.6 0.612  Function (nonsexual) 246 54.5 229 54.7 17 53.1 1.000  Function (sexual) 55 12.2 45 10.7 10 31.3 0.002  Chronic urine infection 3 0.7 2 0.5 1 3.1 0.199  Chronic genital infection 2 0.4 1 0.2 1 0.2 0.137  Postmassive weight loss 2 0.4 2 0.5 0 0 1.000  Other 2 0.4 2 0.5 0 0 1.000 Anesthetic 0.212  Local 344 76.3 320 76.4 24 75.0 —  General 45 10.0 44 10.5 1 3.1 —  Missing 62 13.7 55 13.1 7 21.9 — Procedure side  Bilateral 351 92.4 330 92.7 21 87.5 0.413 Operative time (minutes)* 78.6 44.7 78.5 45.7 80.6 27.0 0.246 Concomitant procedures  Labia majora reduction 33 7.3 29 6.9 4 12.5 0.278  Clitoral hood reduction 26 5.8 24 5.7 2 6.3 0.706  Other 51 11.3 48 11.5 3 9.4 1.000 Patient characteristic Overall No complications Complications P value N % N % N % Age* 32.6 10.1 32.8 10.2 29.9 7.8 0.210 BMI* 22.2 3.2 22.1 2.9 24.2 5.7 0.091 Race 0.449  White 337 86.0 315 86.1 22 84.6 —  African American 8 2.0 7 1.9 1 3.8 —  Asian 12 3.1 12 3.3 0 0 —  Native American 1 0.3 1 .3 0 0 —  Other 34 8.7 31 8.5 3 11.5 —  Missing 59 13.1 84 20.0 9 28.1 — Smoking 53 11.8 46 11.0 7 21.9 0.083 Comorbidities  Diabetes 3 0.7 3 0.7 0 0 1.000  Hypertension 11 2.4 11 2.6 0 0 1.000  Cholesterol 4 0.9 4 1.0 0 0 1.000  Anxiety 26 5.8 25 6.0 1 3.1 1.000  Depression 66 14.6 60 14.3 6 18.8 0.444  Thyroid disease 16 3.5 15 3.6 1 6.3 1.000 Other relevant history  Sexual assault 2 0.4 1 0.2 1 3.1 0.137  FGM 12 2.7 11 2.6 1 3.1 0.591  Premenopause 357 79.2 331 79.0 26 81.3 1.000  Vaginal delivery 384 85.1 358 85.4 26 81.3 0.604  Sexually active 270 93.1 251 93.0 19 95.0 1.000 Drug history  Blood thinner 6 1.3 6 1.4 0 0 1.000  OCP 72 16.0 66 15.8 6 18.8 0.655  HRT 6 1.3 6 1.4 0 0 1.000 Indication  Aesthetic 368 81.6 343 81.9 25 78.1 0.599  Discomfort 277 61.4 256 61.1 21 65.6 0.612  Function (nonsexual) 246 54.5 229 54.7 17 53.1 1.000  Function (sexual) 55 12.2 45 10.7 10 31.3 0.002  Chronic urine infection 3 0.7 2 0.5 1 3.1 0.199  Chronic genital infection 2 0.4 1 0.2 1 0.2 0.137  Postmassive weight loss 2 0.4 2 0.5 0 0 1.000  Other 2 0.4 2 0.5 0 0 1.000 Anesthetic 0.212  Local 344 76.3 320 76.4 24 75.0 —  General 45 10.0 44 10.5 1 3.1 —  Missing 62 13.7 55 13.1 7 21.9 — Procedure side  Bilateral 351 92.4 330 92.7 21 87.5 0.413 Operative time (minutes)* 78.6 44.7 78.5 45.7 80.6 27.0 0.246 Concomitant procedures  Labia majora reduction 33 7.3 29 6.9 4 12.5 0.278  Clitoral hood reduction 26 5.8 24 5.7 2 6.3 0.706  Other 51 11.3 48 11.5 3 9.4 1.000 *Mean and standard deviation presented. Of note, “operative time” is time from entering the operating room until time of departing from the operative room. Actual mean surgical time is approximately 45 to 50 minutes. FGM, female genital mutilation; HRT, hormone replacement therapy; OCP, oral contraceptive pill. View Large Follow up time was available for 352/451 (78%) patients. Mean documented length of follow up for the whole cohort was 4.1 months (range, 0-92 months), while mean time since surgery was 6.2 years (range, 0-15 years). During this time, 32 patients had postoperative sequelae, including revisional surgery (7.1%) (Table 2). Thirty of these occurred in those undergoing wedge excision and the rate of postoperative sequelae (POS) did not change over time. The most common cause for revisional surgery was wound dehiscence, which occurred in 16 patients. Of note, these most frequently occurred at the leading edge of the closure, creating a notch (Figure 3). Thirty-one patients required revisional surgery; removing those that had revisional surgery without medical complications, the true complication rate was 3.8% (n = 17). Two patients under the age of 18 underwent revisional surgery: one for wound dehiscence, one with no medical complications. When comparing those who with postoperative sequelae (including revisional surgery) to those who did not, there were no significant differences in age (29.9 ± 7.8 vs 32.8 ± 10.2, P = 0.210), BMI (24.2 vs 22.1 kg/m2, P = 0.091), race (a majority were white, 84.6% vs 86.1%, P = 0.582), or comorbidities (P > 0.05). There was a larger proportion of smokers vs non-smokers in the group with postoperative sequelae: 21.9% vs 11.0%, although this was not statistically significant (P = 0.083). Those with postoperative sequelae were more likely to indicate sexual dysfunction as a reason for surgery (31.3% vs 10.7%, P = 0.002). Table 2. Postoperative Sequela Rates Sequela N % Total postoperative sequelae 32 7.1 True complication rate* 17 3.8 Further surgery 31 6.9 Wound dehiscence 16 3.5 Bleeding 2 0.4 Pain 1 0.2 Readmission 1 0.2 Wound infection 0 0 Other infection 0 0 Hematoma 0 0 Numbness 0 0 Pain during sex 0 0 Antibiotics 0 0 Pulmonary embolus 0 0 Deep vein thrombosis 0 0 Sequela N % Total postoperative sequelae 32 7.1 True complication rate* 17 3.8 Further surgery 31 6.9 Wound dehiscence 16 3.5 Bleeding 2 0.4 Pain 1 0.2 Readmission 1 0.2 Wound infection 0 0 Other infection 0 0 Hematoma 0 0 Numbness 0 0 Pain during sex 0 0 Antibiotics 0 0 Pulmonary embolus 0 0 Deep vein thrombosis 0 0 *Excludes surgical revisions undertaken in the absence of complications. View Large Table 2. Postoperative Sequela Rates Sequela N % Total postoperative sequelae 32 7.1 True complication rate* 17 3.8 Further surgery 31 6.9 Wound dehiscence 16 3.5 Bleeding 2 0.4 Pain 1 0.2 Readmission 1 0.2 Wound infection 0 0 Other infection 0 0 Hematoma 0 0 Numbness 0 0 Pain during sex 0 0 Antibiotics 0 0 Pulmonary embolus 0 0 Deep vein thrombosis 0 0 Sequela N % Total postoperative sequelae 32 7.1 True complication rate* 17 3.8 Further surgery 31 6.9 Wound dehiscence 16 3.5 Bleeding 2 0.4 Pain 1 0.2 Readmission 1 0.2 Wound infection 0 0 Other infection 0 0 Hematoma 0 0 Numbness 0 0 Pain during sex 0 0 Antibiotics 0 0 Pulmonary embolus 0 0 Deep vein thrombosis 0 0 *Excludes surgical revisions undertaken in the absence of complications. View Large Figure 3. View largeDownload slide A 20-year-old woman presented with postoperative wound dehiscence. (A) Preoperative photograph and (B) postoperative photograph taken two months after wedge excision. Figure 3B reprinted with permission from Thieme (New York, NY). Figure 3. View largeDownload slide A 20-year-old woman presented with postoperative wound dehiscence. (A) Preoperative photograph and (B) postoperative photograph taken two months after wedge excision. Figure 3B reprinted with permission from Thieme (New York, NY). On univariable binary logistic regression, the only significant factor was sexual dysfunction as an indication for surgery, which increased the odds of postoperative sequelae, including revisional surgery (OR 3.778, CI 1.682-8.483). No other factors affected the odds of postoperative sequelae (Table 3). Table 3. Odds of Developing Postoperative Sequelae: Univariable Logistic Regression Results Presented as Odds Ratios (OR) With 95% Confidence Intervals (CI)—Whole Group Patient characteristics OR CI P value Age (mean ± SD)* 0.458 0.207-1.014 0.054 Race**  White (Ref.)  Other 1.123 0.372-3.393 0.837  Missing 1.621 0.628-4.185 0.318 Smoking 2.270 0.930-5.542 0.072 Comorbidities  Anxiety 0.508 0.067-3.878 0.514  Depression 1.381 0.545-3.495 0.496 Other relevant history  Premenopause 1.152 0.460-2.886 0.763  Vaginal delivery 0.738 0.292-1.868 0.522  Sexually active*** 1.438 0.183-11.333 0.730  OCP 1.234 0.489-3.115 0.656 Indication  Aesthetic 0.791 0.330-1.897 0.600  Discomfort 1.216 0.571-2.587 0.613  Function (non-sexual) 0.940 0.457-1.933 0.867  Function (sexual) 3.778 1.682-8.483 0.001  Other 1.899 0.226-15.926 0.555 Procedure side  Unilateral (Ref.) —  Bilateral 0.552 0.154-1.972 0.360  Missing 1.101 0.270-4.478 0.894 Concomitant procedures  Labia majora reduction 1.921 0.631-5.850 0.250  Clitoral hood reduction 1.097 0.247-4.866 0.903  Other 0.800 0.235-2.725 0.721 Patient characteristics OR CI P value Age (mean ± SD)* 0.458 0.207-1.014 0.054 Race**  White (Ref.)  Other 1.123 0.372-3.393 0.837  Missing 1.621 0.628-4.185 0.318 Smoking 2.270 0.930-5.542 0.072 Comorbidities  Anxiety 0.508 0.067-3.878 0.514  Depression 1.381 0.545-3.495 0.496 Other relevant history  Premenopause 1.152 0.460-2.886 0.763  Vaginal delivery 0.738 0.292-1.868 0.522  Sexually active*** 1.438 0.183-11.333 0.730  OCP 1.234 0.489-3.115 0.656 Indication  Aesthetic 0.791 0.330-1.897 0.600  Discomfort 1.216 0.571-2.587 0.613  Function (non-sexual) 0.940 0.457-1.933 0.867  Function (sexual) 3.778 1.682-8.483 0.001  Other 1.899 0.226-15.926 0.555 Procedure side  Unilateral (Ref.) —  Bilateral 0.552 0.154-1.972 0.360  Missing 1.101 0.270-4.478 0.894 Concomitant procedures  Labia majora reduction 1.921 0.631-5.850 0.250  Clitoral hood reduction 1.097 0.247-4.866 0.903  Other 0.800 0.235-2.725 0.721 *Mean and standard deviation presented. CI, confidence interval; OCP, oral contraceptive pill; OR, odds ratio. View Large Table 3. Odds of Developing Postoperative Sequelae: Univariable Logistic Regression Results Presented as Odds Ratios (OR) With 95% Confidence Intervals (CI)—Whole Group Patient characteristics OR CI P value Age (mean ± SD)* 0.458 0.207-1.014 0.054 Race**  White (Ref.)  Other 1.123 0.372-3.393 0.837  Missing 1.621 0.628-4.185 0.318 Smoking 2.270 0.930-5.542 0.072 Comorbidities  Anxiety 0.508 0.067-3.878 0.514  Depression 1.381 0.545-3.495 0.496 Other relevant history  Premenopause 1.152 0.460-2.886 0.763  Vaginal delivery 0.738 0.292-1.868 0.522  Sexually active*** 1.438 0.183-11.333 0.730  OCP 1.234 0.489-3.115 0.656 Indication  Aesthetic 0.791 0.330-1.897 0.600  Discomfort 1.216 0.571-2.587 0.613  Function (non-sexual) 0.940 0.457-1.933 0.867  Function (sexual) 3.778 1.682-8.483 0.001  Other 1.899 0.226-15.926 0.555 Procedure side  Unilateral (Ref.) —  Bilateral 0.552 0.154-1.972 0.360  Missing 1.101 0.270-4.478 0.894 Concomitant procedures  Labia majora reduction 1.921 0.631-5.850 0.250  Clitoral hood reduction 1.097 0.247-4.866 0.903  Other 0.800 0.235-2.725 0.721 Patient characteristics OR CI P value Age (mean ± SD)* 0.458 0.207-1.014 0.054 Race**  White (Ref.)  Other 1.123 0.372-3.393 0.837  Missing 1.621 0.628-4.185 0.318 Smoking 2.270 0.930-5.542 0.072 Comorbidities  Anxiety 0.508 0.067-3.878 0.514  Depression 1.381 0.545-3.495 0.496 Other relevant history  Premenopause 1.152 0.460-2.886 0.763  Vaginal delivery 0.738 0.292-1.868 0.522  Sexually active*** 1.438 0.183-11.333 0.730  OCP 1.234 0.489-3.115 0.656 Indication  Aesthetic 0.791 0.330-1.897 0.600  Discomfort 1.216 0.571-2.587 0.613  Function (non-sexual) 0.940 0.457-1.933 0.867  Function (sexual) 3.778 1.682-8.483 0.001  Other 1.899 0.226-15.926 0.555 Procedure side  Unilateral (Ref.) —  Bilateral 0.552 0.154-1.972 0.360  Missing 1.101 0.270-4.478 0.894 Concomitant procedures  Labia majora reduction 1.921 0.631-5.850 0.250  Clitoral hood reduction 1.097 0.247-4.866 0.903  Other 0.800 0.235-2.725 0.721 *Mean and standard deviation presented. CI, confidence interval; OCP, oral contraceptive pill; OR, odds ratio. View Large When performing a subgroup analysis of the adult population (n = 441), univariable analysis revealed an increased chance of postoperative sequelae with smokers (OR 2.576, CI 1.044-6.357) and sexual dysfunction as an indication for surgery (OR 4.022, CI 1.772-9.131) (Table 4). On multivariable analysis, smoking did not persist in significance (OR 2.376, CI 0.942-5.993); however, sexual dysfunction increased the odds of postoperative sequelae (OR 3.850, CI 1.683-8.807) (Table 5). Table 4. Odds of Developing Postoperative Sequelae: Univariable Logistic Regression Results Presented as Odds Ratios (OR) With 95% Confidence Intervals (CI)—Adults Only Patient characteristics OR CI P value Age (mean ± SD)* 0.540 0.242-1.209 0.540 Race**  White (ref.) — —  Other 1.192 0.391-3.631 0.757  Missing 1.754 0.673-4.574 0.251 Smoking 2.576 1.044-6.357 0.040 Comorbidities Anxiety 0.550 0.072-4.214 0.565 Depression 1.203 0.443-3.270 0.717 Other relevant history  Pre-menopause 1.087 0.431-2.744 0.859  Vaginal delivery 0.692 0.271-1.763 0.440  Sexually active*** NR — 0.998  OCP 1.418 0.557-3.612 0.464 Indication  Aesthetic 0.718 0.297-1.737 0.462  Discomfort 0.825 0.393-1.733 0.612  Function (non-sexual) 0.825 0.393-1.733 0.612  Function (sexual) 4.022 1.772-9.131 0.001  Other Procedure side  Unilateral (ref.) — —  Bilateral 1.337 0.295-6.064 0.706  Missing Concomitant procedures  Labia majora reduction 2.005 0.655-6.136 0.223  Clitoral hood reduction 1.140 0.256-5.071 0.864  Other Patient characteristics OR CI P value Age (mean ± SD)* 0.540 0.242-1.209 0.540 Race**  White (ref.) — —  Other 1.192 0.391-3.631 0.757  Missing 1.754 0.673-4.574 0.251 Smoking 2.576 1.044-6.357 0.040 Comorbidities Anxiety 0.550 0.072-4.214 0.565 Depression 1.203 0.443-3.270 0.717 Other relevant history  Pre-menopause 1.087 0.431-2.744 0.859  Vaginal delivery 0.692 0.271-1.763 0.440  Sexually active*** NR — 0.998  OCP 1.418 0.557-3.612 0.464 Indication  Aesthetic 0.718 0.297-1.737 0.462  Discomfort 0.825 0.393-1.733 0.612  Function (non-sexual) 0.825 0.393-1.733 0.612  Function (sexual) 4.022 1.772-9.131 0.001  Other Procedure side  Unilateral (ref.) — —  Bilateral 1.337 0.295-6.064 0.706  Missing Concomitant procedures  Labia majora reduction 2.005 0.655-6.136 0.223  Clitoral hood reduction 1.140 0.256-5.071 0.864  Other CI, confidence interval; OCP, oral contraceptive pill; OR, odds ratio. View Large Table 4. Odds of Developing Postoperative Sequelae: Univariable Logistic Regression Results Presented as Odds Ratios (OR) With 95% Confidence Intervals (CI)—Adults Only Patient characteristics OR CI P value Age (mean ± SD)* 0.540 0.242-1.209 0.540 Race**  White (ref.) — —  Other 1.192 0.391-3.631 0.757  Missing 1.754 0.673-4.574 0.251 Smoking 2.576 1.044-6.357 0.040 Comorbidities Anxiety 0.550 0.072-4.214 0.565 Depression 1.203 0.443-3.270 0.717 Other relevant history  Pre-menopause 1.087 0.431-2.744 0.859  Vaginal delivery 0.692 0.271-1.763 0.440  Sexually active*** NR — 0.998  OCP 1.418 0.557-3.612 0.464 Indication  Aesthetic 0.718 0.297-1.737 0.462  Discomfort 0.825 0.393-1.733 0.612  Function (non-sexual) 0.825 0.393-1.733 0.612  Function (sexual) 4.022 1.772-9.131 0.001  Other Procedure side  Unilateral (ref.) — —  Bilateral 1.337 0.295-6.064 0.706  Missing Concomitant procedures  Labia majora reduction 2.005 0.655-6.136 0.223  Clitoral hood reduction 1.140 0.256-5.071 0.864  Other Patient characteristics OR CI P value Age (mean ± SD)* 0.540 0.242-1.209 0.540 Race**  White (ref.) — —  Other 1.192 0.391-3.631 0.757  Missing 1.754 0.673-4.574 0.251 Smoking 2.576 1.044-6.357 0.040 Comorbidities Anxiety 0.550 0.072-4.214 0.565 Depression 1.203 0.443-3.270 0.717 Other relevant history  Pre-menopause 1.087 0.431-2.744 0.859  Vaginal delivery 0.692 0.271-1.763 0.440  Sexually active*** NR — 0.998  OCP 1.418 0.557-3.612 0.464 Indication  Aesthetic 0.718 0.297-1.737 0.462  Discomfort 0.825 0.393-1.733 0.612  Function (non-sexual) 0.825 0.393-1.733 0.612  Function (sexual) 4.022 1.772-9.131 0.001  Other Procedure side  Unilateral (ref.) — —  Bilateral 1.337 0.295-6.064 0.706  Missing Concomitant procedures  Labia majora reduction 2.005 0.655-6.136 0.223  Clitoral hood reduction 1.140 0.256-5.071 0.864  Other CI, confidence interval; OCP, oral contraceptive pill; OR, odds ratio. View Large Table 5. Odds of Developing Postoperative Sequelae: Multivariable Logistic Regression Presented as Odds Ratios (OR) With 95% Confidence Intervals (CI)—Adults Only Variable OR CI P value Smoking 2.376 0.942-5.993 0.067 Function (sexual) 3.850 1.683-8.807 0.001 Variable OR CI P value Smoking 2.376 0.942-5.993 0.067 Function (sexual) 3.850 1.683-8.807 0.001 CI, confidence interval; OR, odds ratio. View Large Table 5. Odds of Developing Postoperative Sequelae: Multivariable Logistic Regression Presented as Odds Ratios (OR) With 95% Confidence Intervals (CI)—Adults Only Variable OR CI P value Smoking 2.376 0.942-5.993 0.067 Function (sexual) 3.850 1.683-8.807 0.001 Variable OR CI P value Smoking 2.376 0.942-5.993 0.067 Function (sexual) 3.850 1.683-8.807 0.001 CI, confidence interval; OR, odds ratio. View Large DISCUSSION The increasing demand for labiaplasty, particularly in a younger population, warrants careful review of the postoperative outcomes and assessment of factors that may contribute to complications and revisional surgery. In this single-center consecutive evaluation of outcomes we found low complication rates, with an absence of major complications. We also identified that smoking and sexual dysfunction as an indication for surgery may increase the risk of complications and revisional surgery. In the senior author’s (C.H.) practice, patients are routinely invited back at two weeks, two months, and one year postoperatively; however, many who live far from the practice or have no postoperative concerns decline further follow up. We identified a postoperative sequela rate of 7.1%, and a true complication rate of 3.8%. Although average documented follow-up time in the present study was approximately four months, the mean time since surgery was just over six years. Therefore, we might assume that those who do not seek formal follow up have no issues and as such, we believe our results suggest a long-term, low complication rate. Lista et al published a retrospective review of 113 cases of labiaplasty performed using the edge excision technique between 2007 and 2014.6 Results showed that while 13.3% of patients reported transient symptoms of “swelling, bruising and pain,” only one patient developed a medical complication (bleeding) and four patients required revisional surgery to excise further redundant tissue or correct asymmetry. Results of a small series by Gonzalez et al showed that among the 50 consecutive cases of “custom flask labiaplasty” performed between 2007 and 2010, only one minor complication (wound dehiscence, 2%) was observed.8 Indeed, a cadaveric study performed by Kelishadi et al revealed the heterogeneity of the labia minora nerve supply, concluding that labiaplasty was unlikely to cause loss of sensation.10 Moreover, although concerns have been reported by the Royal College of Obstetricians and Gynecologists about the ethics and safety of the procedure, previous authors have suggested that lack of cosmetic surgery training within obstetrics and gynecology may be what leads to poorer outcomes, and we believe that in the hands of a qualified, experienced plastic surgeon, excellent outcomes with low complication rates can be achieved.11 The same logic has been applied elsewhere in plastic surgery: statements from the American Society of Plastic Surgeons (ASPS) have highlighted the need to educate patients on the importance of approaching board-certified plastic surgeons for consultation on plastic and reconstructive procedures, rather than nonboard certified physicians. Moreover, when considering labiaplasty in the broader context of outpatient plastic surgery, our complication rates are comparable, or superior to, that of other index procedures, including breast reduction12,13 and abdominoplasty.14 While there are those who may oppose these forms of plastic surgery, these procedures can have both functional and aesthetic benefits, and it is evident that labiaplasty is also performed for the same indications.3 Although complication and revision rates are low, it is important to evaluate factors that may increase the chances of postoperative sequelae. Results of the present study implicate sexual dysfunction as an associative factor in increased odds of postoperative sequelae after labiaplasty. There could be a variety of reasons for this finding. Patients who feel their labia impact negatively on their sex life may be more inclined to resume sexual activity postoperatively, potentially earlier than recommended by their surgeon. Their eagerness to prove their surgery has positively changed their situation may lead to early sexual activity and a potential for wound disruption. Another reason may be the psychological impact that their perceived labial abnormality has had: because of the deeply personal, sexual nature of the issue, the individual may have higher expectations of the postoperative outcomes than others, and a subsequent increased desire for revisional surgery if the results are not as anticipated. Previous research has suggested that there is a higher prevalence of body dysmorphic disorder (BDD) in those seeking cosmetic plastic surgery, and that these patients are likely to experience poorer outcomes postoperatively, with an increased rate of revisional surgery.15,16 A study by Sharp et al postulated that their cohort of patients undergoing labiaplasty may have had a higher rate of BDD, as although not formally examined, they had a high proportion of cases who had undergone previous cosmetic surgery.5 We did not examine this potential association; however, if those with sexual dysfunction were more likely to have an undiagnosed BDD, this might account for the increase in postoperative sequelae. The other potential risk factor identified in this study was smoking. Smoking is a well-known risk factor for poor healing, yet the influence of smoking on postoperative outcomes after labiaplasty has previously been poorly characterized. Although not significant on multivariable analysis, within the adult subgroup of the present study, smoking trended towards increasing the odds of postoperative sequelae. Goltsman et al analyzed the American College of Surgeons National Surgical Quality Improvement Program, evaluating the impact of smoking on plastic surgery outcomes in 40,465 cases.17 Smoking was found to significantly increase the odds of complications, including wound dehiscence; however, although the authors subcategorized by anatomic location, labiaplasty was not specifically noted, nor even the urogenital region. Wound dehiscence was the majority cause of revisional surgery within the present study and it may be that smoking increases the risk of developing wound dehiscence in the female genital region, as it is a risk factor for delayed wound healing in other anatomic locations.17 The senior author’s policy is to routinely provide smoking cessation advice and strongly recommend not smoking for four weeks preoperatively and postoperatively. In patients who do not stop smoking preoperatively, the technique is modified to an edge resection instead of a wedge resection. The edge trim technique has been shown to maintain more of the segmental vasculature to the edge of the labia minora.18 However, it is important to note that our analysis also included revisional surgery without medical complications, and so we extend our discussion to hypothesize what the association between smoking and revision for causes other than a medical complication could be. Smoking was associated with reduced scar redness in a series of 49 patients undergoing reduction mammaplasty; the authors suggested that a poorer blood supply to the area might dampen the inflammatory response and result in superior scar cosmesis.19 It is difficult to understand why a smoking population may have a tendency toward increasing revisions in the absence of complications. It may be that there are personality traits more commonly associated with smoking, which lead to these outcomes. A recent prospective psychological study evaluated the relationships between five particular personality traits, including neuroticism and conscientiousness, and nicotine dependence.20 The study compared outcomes in 2474 smokers and 2566 nonsmokers. Results showed that smokers had significantly higher levels of neuroticism and lower conscientiousness than nonsmokers. These findings have been corroborated by others studies, and, if true, could underpin our findings.21 Neuroticism (a greater tendency to experience negative emotions) could lead to increased dissatisfaction with results and a heightened desire for revisional surgery, while lower conscientiousness (including self-discipline) could lead to a lack of compliance with postoperative instructions and higher wound dehiscence rates. Further research is needed to truly understand the role that smoking has in postoperative sequelae after labiaplasty. There is a younger, nonadult population who undergo labiaplasty. Recent American Society of Aesthetic Plastic Surgery statistics show that 5.2% of labiaplasties in 2016 were in those aged 18 years or under.1 Our study included ten patients under the age of 18. Only one of these developed a medical complication postoperatively. A review of cosmetic and reconstructive breast surgery in the adolescent population by Crerand and Magee considered the psychology, ethics, and legalities of such surgery.15 They suggest that the adolescent population is particularly vulnerable to psychological difficulties, recommending careful assessment of the individual’s cognitive maturity and understanding of the procedure. Although sparse, previous research has demonstrated that adolescents may derive significant psychological and functional benefits from certain procedures, such as breast reduction surgery.22,23 Moreover, in our cohort, while nine of the ten cited appearance-related indications for surgery, the same number also cited discomfort as a reason. When consulting with adolescent patients, the senior author routinely speaks to both the patient and the parents initially. Parents frequently do not understand their child’s concern with the appearance of the genitalia. Education with the aid of diagrams and photographs helps both the patient and the parent understand the variation of anatomy in the area. The issue in adolescent patients is frequently asymmetry, where one side of the labia minora (the larger side) developed normally and the other failed to develop past a prepubertal size. Labiaplasty may be appropriate in adolescents with significant asymmetry or hyperplasia if the presence of excess labia affects the physical or emotional wellbeing of the patient. We believe that with careful preoperative discussion and counseling, and careful patient selection, labiaplasty can be safely undertaken in the adolescent population. The findings of this study should be interpreted within the context of the limitations. While providing analysis of complications and revisions, we did not evaluate postoperative patient-reported outcomes, which would have added further depth to our study. However, this large series of adolescent and adult patients undergoing labiaplasty benefits from the analysis of data extracted from a prospectively maintained database. Moreover, all surgery was performed by a single surgeon, eliminating the potential for bias arising from varying surgical technique. CONCLUSION Labiaplasty may be important in alleviating a spectrum of physical and appearance-related symptoms in women, ranging from adolescence to adulthood. We believe that evidence supporting the safety and efficacy of the procedure is growing, and that results of the present series support this trend. Sexual dysfunction as an indication for surgery and smoking may impact postoperative sequelae; however, in experienced hands, excellent outcomes with consistently low complication rates can still be achieved. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Cosmetic surgery national data bank statistics . Aesthet Surg J . 2017 ; 37 ( Suppl 2 ): 1 - 29 . 2. Sharp G , Mattiske J , Vale KI . Motivations, expectations, and experiences of labiaplasty: a qualitative study . Aesthet Surg J . 2016 ; 36 ( 8 ): 920 - 928 . Google Scholar CrossRef Search ADS PubMed 3. Sorice SC , Li AY , Canales FL , Furnas HJ . Why women request labiaplasty . Plast Reconstr Surg . 2017 ; 139 ( 4 ): 856 - 863 . Google Scholar CrossRef Search ADS PubMed 4. Sharp G , Tiggemann M , Mattiske J . Psychological outcomes of labiaplasty: a prospective study . Plast Reconstr Surg . 2016 ; 138 ( 6 ): 1202 - 1209 . Google Scholar CrossRef Search ADS PubMed 5. Sharp G , Tiggemann M , Mattiske J . A retrospective study of the psychological outcomes of labiaplasty . Aesthet Surg J . 2017 ; 37 ( 3 ): 324 - 331 . Google Scholar PubMed 6. Lista F , Mistry BD , Singh Y , Ahmad J . The safety of aesthetic labiaplasty: a plastic surgery experience . Aesthet Surg J . 2015 ; 35 ( 6 ): 689 - 695 . Google Scholar CrossRef Search ADS PubMed 7. Ouar N , Guillier D , Moris V , Revol M , Francois C , Cristofari S . Complications postopératoires des nymphoplasties de réduction. Étude comparative rétrospective entre résections longitudinale et cunéiforme . Ann Chir Plast Esthet . 2017 ; 62 ( 3 ): 219 - 223 . Google Scholar CrossRef Search ADS PubMed 8. Gonzalez F , Dass D , Almeida B . Custom flask labiaplasty . Ann Plast Surg . 2015 ; 75 ( 3 ): 266 - 271 . Google Scholar CrossRef Search ADS PubMed 9. Gulia C , Zangari A , Briganti V , Bateni ZH, Porrello A, Piergentili R . Labia minora hypertrophy: causes, impact on women’s health, and treatment options . Int Urogynecol J . 2017;28(10):1453-1461 . 10. Kelishadi SS , Omar R , Herring N et al. The safe labiaplasty: a study of nerve density in labia minora and its implications . Aesthet Surg J . 2016 ; 36 ( 6 ): 705 - 709 . Google Scholar CrossRef Search ADS PubMed 11. Goodman MP . Commentary on: A retrospective study of the psychological outcomes of labiaplasty . Aesthet Surg J . 2017 ; 37 ( 3 ): 332 - 336 . Google Scholar PubMed 12. Carpelan A , Kauhanen S , Mattila K , Jahkola T , Tukiainen E . Reduction mammaplasty as an outpatient procedure: a retrospective analysis of outcome and success rate . Scand J Surg . 2015 ; 104 ( 2 ): 96 - 102 . Google Scholar CrossRef Search ADS PubMed 13. Fischer JP , Cleveland EC , Shang EK , Nelson JA , Serletti JM . Complications following reduction mammaplasty: a review of 3538 cases from the 2005-2010 NSQIP data sets . Aesthet Surg J . 2014 ; 34 ( 1 ): 66 - 73 . Google Scholar CrossRef Search ADS PubMed 14. Swanson E . Prospective clinical study of 551 cases of liposuction and abdominoplasty performed individually and in combination . Plast Reconstr Surg Glob Open . 2013 ; 1 ( 5 ): e32 . Google Scholar CrossRef Search ADS PubMed 15. Crerand CE , Magee L . Cosmetic and reconstructive breast surgery in adolescents: psychological, ethical, and legal considerations . Semin Plast Surg . 2013 ; 27 ( 1 ): 72 - 78 . Google Scholar CrossRef Search ADS PubMed 16. Guan Jeremy GC , Stephen L . Prevalence of body dysmorphic disorder and impact on subjective outcome amongst Singaporean rhinoplasty patients . Anaplastology . 2015 ; 4:140 . 17. Goltsman D , Munabi NC , Ascherman JA . The association between smoking and plastic surgery outcomes in 40,465 patients: an analysis of the American College of Surgeons National Surgical Quality Improvement Program Data Sets . Plast Reconstr Surg . 2017 ; 139 ( 2 ): 503 - 511 . Google Scholar CrossRef Search ADS PubMed 18. Georgiou CA , Benatar M , Dumas P et al. A cadaveric study of the arterial blood supply of the labia minora . Plast Reconstr Surg . 2015 ; 136 ( 1 ): 167 - 178 . Google Scholar CrossRef Search ADS PubMed 19. Deliaert AE , Van den Kerckhove E , Tuinder S , Noordzij SM , Dormaar TS , van der Hulst RR . Smoking and its effect on scar healing . Eur J Plast Surg . 2012 ; 35 ( 6 ): 421 - 424 . Google Scholar CrossRef Search ADS PubMed 20. Choi JS , Payne TJ , Ma JZ , Li MD . Relationship between personality traits and nicotine dependence in male and female smokers of African-American and European-American samples . Front Psychiatry . 2017 ; 8 : 122 . Google Scholar CrossRef Search ADS PubMed 21. Zvolensky MJ , Taha F , Bono A , Goodwin RD . Big five personality factors and cigarette smoking: a 10-year study among US adults . J Psychiatr Res . 2015 ; 63 : 91 - 96 . Google Scholar CrossRef Search ADS PubMed 22. Evans GR , Ryan JJ . Reduction mammaplasty for the teenage patient: a critical analysis . Aesthetic Plast Surg . 1994 ; 18 ( 3 ): 291 - 297 . Google Scholar CrossRef Search ADS PubMed 23. Lee MC , Lehman JA Jr , Tantri MD , Parker MG , Wagner DS . Bilateral reduction mammoplasty in an adolescent population: adolescent bilateral reduction mammoplasty . J Craniofac Surg . 2003 ; 14 ( 5 ): 691 - 695 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

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Abstract

Abstract Background The increasing demand for labiaplasty is well recognized; however, the procedure remains contentious. Objectives We aim to provide a large-scale, up-to-date analysis of labiaplasty outcomes and factors influencing postoperative sequelae (POS). Methods We analyzed a single-center, prospectively maintained database of females undergoing labiaplasty between 2002 and 2017. Demographic, procedural, and outcomes’ data were retrieved. Binary logistic regressions were used to evaluate the odds of developing POS (revisional surgery and complications); presented as odds ratios (OR) with 95% confidence intervals (CI). Results Data for 451 consecutive patients were retrieved, ten of whom were <18 years of age. Overall, 86% were Caucasian, mean age was 32.6 years, and 11.8% were smokers. Concomitant labia majora reduction was performed in 7.3%, and clitoral hood reduction in 5.8%. There were 32 cases of POS (7.1%), while the complication rate was 3.8%. Comparing those with POS to those without, there were no differences in age (32.8 vs 29.9 years, P = 0.210), operative time (78.5 vs 80.6 minutes, P = 0.246), or comorbidities (P > 0.05 for all). On univariable analysis, increased odds of POS occurred with sexual dysfunction as an indication for surgery (OR 3.778, CI 1.682-8.483). On subgroup analysis of those ≥18 years, both smoking (2.576, CI 1.044-6.357) and sexual dysfunction as an indication (OR 4.022, CI 1.772-9.131) increased the odds of POS. On multivariable analysis of the subgroup, sexual dysfunction as an indication persisted in significance (OR 3.850, CI 1.683-8.807). Conclusions Results compare favorably with previously reported complication and revisional surgery rates. Smoking and sexual dysfunction may increase the risk of complications. Level of Evidence: 2 The increasing demand for labiaplasty is well recognized. According to the American Society for Aesthetic Plastic Surgery, in the United States alone, 10,774 procedures were performed by board-certified plastic surgeons in 2016, an increase of 23% from the previous year.1 It has been suggested that increasing exposure to female nudity in the media may have propagated this trend, and recent literature has shown variation in the reasons for seeking labiaplasty.2,3 Hypertrophy of the labia minora (Figure 1) may cause significant psychological distress for women, in addition to functional concerns, such as irritation in certain clothing or tugging during sexual intercourse.3,4 Studies have found that women may experience psychological and functional improvements after labiaplasty, including greater confidence in sexual relationships, resolution of discomfort when exercising, and relief from feelings of self-consciousness.4,5 Moreover, previous research has demonstrated consistently low complication rates, between 2% and 13%.6-8 Figure 1. View largeDownload slide A 39-year-old woman presented for treatment of labia minora hypertrophy (wedge excision). (A, C) Preoperative and (B, D) three month postoperative photographs. Figure 1. View largeDownload slide A 39-year-old woman presented for treatment of labia minora hypertrophy (wedge excision). (A, C) Preoperative and (B, D) three month postoperative photographs. However, the procedure remains controversial, with critics suggesting there is an inadequate body of literature examining the postoperative satisfaction and risks after labiaplasty, including a lack of long-term follow up.8 Others believe the procedure to be particularly unnecessary in the adolescent population, suggesting that the labia majora are likely to continue growth in early adulthood, descending to a level where the labia minora do not appear as prominent.9 Given the need for further studies to confirm the safety of the procedure and the controversy surrounding the younger population, the aim of this study was to report complications and rates of revisional surgery after labiaplasty in a large, single-center series, encompassing adolescent and adult women. Our secondary aim is to identify preoperative characteristics that may be associated with the development of complications and revisional surgery. METHODS Patient Selection and Outcome Variables Analysis of a prospectively maintained database of consecutive females undergoing labiaplasty at a single center between May 2002 and May 2017 was performed. Institutional Review Board (IRB) approval for this study was granted by the Beth Israel Deaconess Medical Center IRB. Patient characteristics included age, race, body mass index (BMI, in kg/m2), comorbidities (diabetes, hypertension, high cholesterol, anxiety, depression, thyroid disease), history of sexual assault, history of female genital surgery, medications (use of blood thinners, oral contraceptive pill, or hormone replacement therapy), menopausal status, smoking status, previous vaginal delivery, and whether they were sexually active. Indication for surgery was listed as any combination of aesthetic or appearance-related, functional (nonsexual), functional (sexual, hereafter referred to as “sexual dysfunction,” which was patient-reported), discomfort, chronic urinary or vulvar infection, postmassive weight loss, or other. For the purposes of modeling the latter three were collapsed into a single category. Procedural details included laterality (unilateral or bilateral), additional procedures (labia majora reduction, clitoral hood reduction, labial fat grafting, radiofrequency treatment, vaginoplasty, other), length of surgery (minutes: time of entering operating room until time departing operating room), and anesthetic type (local or general). Postoperative details included the development of postoperative sequelae. This included need for revisional surgery, in addition to wound dehiscence, bleeding, hematoma, wound infection, other infection, numbness, pain, dyspareunia, need for readmission, need for antibiotics, and venous thromboembolism. We also included length of follow up (including last documented follow up and time since surgery), and length of stay in days. Statistical Analysis All statistical analyses were performed using IBM SPSS version 22.01 for Mac (IBM Corp., Armonk, NY). Fisher’s exact or chi-square tests were used to compare categorical variables between those developing complications and those not (with respect to number and percentage of cases), while the independent t test or Mann Whitney U test was used for continuous data (presented as mean and standard deviation). Binary logistic regression modeling was performed to adjust for confounding when analyzing factors affecting the odds of developing postoperative sequelae (complications and revisional surgery); variables that were significant on univariable analysis were included in the multivariable model. Results are presented with odds ratios (OR) with 95% confidence intervals (CI). Additional subgroup regression analysis was also performed on those aged 18 years or more, while characteristics of those under 18 are summarized. Statistical significance was determined when P < 0.05. Graphical features were developed using GraphPad PRISM Version 6.0e. RESULTS Over the study period, data for 451 consecutive cases were retrieved. The number of annual cases increased over time, from 1 in 2002 to 47 in 2016 (Figure 2). Most patients were Caucasian (74.7%), sexually active (59.9%), and premenopausal (79.2%). Mean age was 32.6 years (range, 14-68 years), including 31 teenagers and ten patients under the age of 18. The most prevalent comorbidities were depression (14.6%) and anxiety (5.8%), while 11.8% were smokers. The most common indication for labiaplasty cited was aesthetic (81.6%); other causes included discomfort (61.4%), nonsexual function (54.5%), sexual function (12.2%), chronic urogenital infection (1.1%), and weight loss (0.4%) or other, unspecified (0.4%). Four hundred and five patients underwent wedge excision, 38 edge trim, and 8 “other.” Seventy-eight per cent of cases were bilateral, and the most common concomitant procedure was labia majora reduction (7.3%). All were same-day outpatient procedures and a majority were performed under local anesthetic (76.3%). Patient and operative characteristics for the whole cohort are summarized in Table 1. When isolating those ten patients aged less than 18 years (range, 14-17 years) we found that all were Caucasian, 9/10 listed discomfort and appearance as their indications for surgery, while none indicated sexual dysfunction as a reason. No one in this group underwent concomitant procedures. Figure 2. View largeDownload slide Annual number of labiaplasties performed between May 2002 and May 2017. Figure 2. View largeDownload slide Annual number of labiaplasties performed between May 2002 and May 2017. Table 1. Comparison of Characteristics Between Those Developing Complications and Those Without (presented as number and percentage unless indicated by *) Patient characteristic Overall No complications Complications P value N % N % N % Age* 32.6 10.1 32.8 10.2 29.9 7.8 0.210 BMI* 22.2 3.2 22.1 2.9 24.2 5.7 0.091 Race 0.449  White 337 86.0 315 86.1 22 84.6 —  African American 8 2.0 7 1.9 1 3.8 —  Asian 12 3.1 12 3.3 0 0 —  Native American 1 0.3 1 .3 0 0 —  Other 34 8.7 31 8.5 3 11.5 —  Missing 59 13.1 84 20.0 9 28.1 — Smoking 53 11.8 46 11.0 7 21.9 0.083 Comorbidities  Diabetes 3 0.7 3 0.7 0 0 1.000  Hypertension 11 2.4 11 2.6 0 0 1.000  Cholesterol 4 0.9 4 1.0 0 0 1.000  Anxiety 26 5.8 25 6.0 1 3.1 1.000  Depression 66 14.6 60 14.3 6 18.8 0.444  Thyroid disease 16 3.5 15 3.6 1 6.3 1.000 Other relevant history  Sexual assault 2 0.4 1 0.2 1 3.1 0.137  FGM 12 2.7 11 2.6 1 3.1 0.591  Premenopause 357 79.2 331 79.0 26 81.3 1.000  Vaginal delivery 384 85.1 358 85.4 26 81.3 0.604  Sexually active 270 93.1 251 93.0 19 95.0 1.000 Drug history  Blood thinner 6 1.3 6 1.4 0 0 1.000  OCP 72 16.0 66 15.8 6 18.8 0.655  HRT 6 1.3 6 1.4 0 0 1.000 Indication  Aesthetic 368 81.6 343 81.9 25 78.1 0.599  Discomfort 277 61.4 256 61.1 21 65.6 0.612  Function (nonsexual) 246 54.5 229 54.7 17 53.1 1.000  Function (sexual) 55 12.2 45 10.7 10 31.3 0.002  Chronic urine infection 3 0.7 2 0.5 1 3.1 0.199  Chronic genital infection 2 0.4 1 0.2 1 0.2 0.137  Postmassive weight loss 2 0.4 2 0.5 0 0 1.000  Other 2 0.4 2 0.5 0 0 1.000 Anesthetic 0.212  Local 344 76.3 320 76.4 24 75.0 —  General 45 10.0 44 10.5 1 3.1 —  Missing 62 13.7 55 13.1 7 21.9 — Procedure side  Bilateral 351 92.4 330 92.7 21 87.5 0.413 Operative time (minutes)* 78.6 44.7 78.5 45.7 80.6 27.0 0.246 Concomitant procedures  Labia majora reduction 33 7.3 29 6.9 4 12.5 0.278  Clitoral hood reduction 26 5.8 24 5.7 2 6.3 0.706  Other 51 11.3 48 11.5 3 9.4 1.000 Patient characteristic Overall No complications Complications P value N % N % N % Age* 32.6 10.1 32.8 10.2 29.9 7.8 0.210 BMI* 22.2 3.2 22.1 2.9 24.2 5.7 0.091 Race 0.449  White 337 86.0 315 86.1 22 84.6 —  African American 8 2.0 7 1.9 1 3.8 —  Asian 12 3.1 12 3.3 0 0 —  Native American 1 0.3 1 .3 0 0 —  Other 34 8.7 31 8.5 3 11.5 —  Missing 59 13.1 84 20.0 9 28.1 — Smoking 53 11.8 46 11.0 7 21.9 0.083 Comorbidities  Diabetes 3 0.7 3 0.7 0 0 1.000  Hypertension 11 2.4 11 2.6 0 0 1.000  Cholesterol 4 0.9 4 1.0 0 0 1.000  Anxiety 26 5.8 25 6.0 1 3.1 1.000  Depression 66 14.6 60 14.3 6 18.8 0.444  Thyroid disease 16 3.5 15 3.6 1 6.3 1.000 Other relevant history  Sexual assault 2 0.4 1 0.2 1 3.1 0.137  FGM 12 2.7 11 2.6 1 3.1 0.591  Premenopause 357 79.2 331 79.0 26 81.3 1.000  Vaginal delivery 384 85.1 358 85.4 26 81.3 0.604  Sexually active 270 93.1 251 93.0 19 95.0 1.000 Drug history  Blood thinner 6 1.3 6 1.4 0 0 1.000  OCP 72 16.0 66 15.8 6 18.8 0.655  HRT 6 1.3 6 1.4 0 0 1.000 Indication  Aesthetic 368 81.6 343 81.9 25 78.1 0.599  Discomfort 277 61.4 256 61.1 21 65.6 0.612  Function (nonsexual) 246 54.5 229 54.7 17 53.1 1.000  Function (sexual) 55 12.2 45 10.7 10 31.3 0.002  Chronic urine infection 3 0.7 2 0.5 1 3.1 0.199  Chronic genital infection 2 0.4 1 0.2 1 0.2 0.137  Postmassive weight loss 2 0.4 2 0.5 0 0 1.000  Other 2 0.4 2 0.5 0 0 1.000 Anesthetic 0.212  Local 344 76.3 320 76.4 24 75.0 —  General 45 10.0 44 10.5 1 3.1 —  Missing 62 13.7 55 13.1 7 21.9 — Procedure side  Bilateral 351 92.4 330 92.7 21 87.5 0.413 Operative time (minutes)* 78.6 44.7 78.5 45.7 80.6 27.0 0.246 Concomitant procedures  Labia majora reduction 33 7.3 29 6.9 4 12.5 0.278  Clitoral hood reduction 26 5.8 24 5.7 2 6.3 0.706  Other 51 11.3 48 11.5 3 9.4 1.000 *Mean and standard deviation presented. Of note, “operative time” is time from entering the operating room until time of departing from the operative room. Actual mean surgical time is approximately 45 to 50 minutes. FGM, female genital mutilation; HRT, hormone replacement therapy; OCP, oral contraceptive pill. View Large Table 1. Comparison of Characteristics Between Those Developing Complications and Those Without (presented as number and percentage unless indicated by *) Patient characteristic Overall No complications Complications P value N % N % N % Age* 32.6 10.1 32.8 10.2 29.9 7.8 0.210 BMI* 22.2 3.2 22.1 2.9 24.2 5.7 0.091 Race 0.449  White 337 86.0 315 86.1 22 84.6 —  African American 8 2.0 7 1.9 1 3.8 —  Asian 12 3.1 12 3.3 0 0 —  Native American 1 0.3 1 .3 0 0 —  Other 34 8.7 31 8.5 3 11.5 —  Missing 59 13.1 84 20.0 9 28.1 — Smoking 53 11.8 46 11.0 7 21.9 0.083 Comorbidities  Diabetes 3 0.7 3 0.7 0 0 1.000  Hypertension 11 2.4 11 2.6 0 0 1.000  Cholesterol 4 0.9 4 1.0 0 0 1.000  Anxiety 26 5.8 25 6.0 1 3.1 1.000  Depression 66 14.6 60 14.3 6 18.8 0.444  Thyroid disease 16 3.5 15 3.6 1 6.3 1.000 Other relevant history  Sexual assault 2 0.4 1 0.2 1 3.1 0.137  FGM 12 2.7 11 2.6 1 3.1 0.591  Premenopause 357 79.2 331 79.0 26 81.3 1.000  Vaginal delivery 384 85.1 358 85.4 26 81.3 0.604  Sexually active 270 93.1 251 93.0 19 95.0 1.000 Drug history  Blood thinner 6 1.3 6 1.4 0 0 1.000  OCP 72 16.0 66 15.8 6 18.8 0.655  HRT 6 1.3 6 1.4 0 0 1.000 Indication  Aesthetic 368 81.6 343 81.9 25 78.1 0.599  Discomfort 277 61.4 256 61.1 21 65.6 0.612  Function (nonsexual) 246 54.5 229 54.7 17 53.1 1.000  Function (sexual) 55 12.2 45 10.7 10 31.3 0.002  Chronic urine infection 3 0.7 2 0.5 1 3.1 0.199  Chronic genital infection 2 0.4 1 0.2 1 0.2 0.137  Postmassive weight loss 2 0.4 2 0.5 0 0 1.000  Other 2 0.4 2 0.5 0 0 1.000 Anesthetic 0.212  Local 344 76.3 320 76.4 24 75.0 —  General 45 10.0 44 10.5 1 3.1 —  Missing 62 13.7 55 13.1 7 21.9 — Procedure side  Bilateral 351 92.4 330 92.7 21 87.5 0.413 Operative time (minutes)* 78.6 44.7 78.5 45.7 80.6 27.0 0.246 Concomitant procedures  Labia majora reduction 33 7.3 29 6.9 4 12.5 0.278  Clitoral hood reduction 26 5.8 24 5.7 2 6.3 0.706  Other 51 11.3 48 11.5 3 9.4 1.000 Patient characteristic Overall No complications Complications P value N % N % N % Age* 32.6 10.1 32.8 10.2 29.9 7.8 0.210 BMI* 22.2 3.2 22.1 2.9 24.2 5.7 0.091 Race 0.449  White 337 86.0 315 86.1 22 84.6 —  African American 8 2.0 7 1.9 1 3.8 —  Asian 12 3.1 12 3.3 0 0 —  Native American 1 0.3 1 .3 0 0 —  Other 34 8.7 31 8.5 3 11.5 —  Missing 59 13.1 84 20.0 9 28.1 — Smoking 53 11.8 46 11.0 7 21.9 0.083 Comorbidities  Diabetes 3 0.7 3 0.7 0 0 1.000  Hypertension 11 2.4 11 2.6 0 0 1.000  Cholesterol 4 0.9 4 1.0 0 0 1.000  Anxiety 26 5.8 25 6.0 1 3.1 1.000  Depression 66 14.6 60 14.3 6 18.8 0.444  Thyroid disease 16 3.5 15 3.6 1 6.3 1.000 Other relevant history  Sexual assault 2 0.4 1 0.2 1 3.1 0.137  FGM 12 2.7 11 2.6 1 3.1 0.591  Premenopause 357 79.2 331 79.0 26 81.3 1.000  Vaginal delivery 384 85.1 358 85.4 26 81.3 0.604  Sexually active 270 93.1 251 93.0 19 95.0 1.000 Drug history  Blood thinner 6 1.3 6 1.4 0 0 1.000  OCP 72 16.0 66 15.8 6 18.8 0.655  HRT 6 1.3 6 1.4 0 0 1.000 Indication  Aesthetic 368 81.6 343 81.9 25 78.1 0.599  Discomfort 277 61.4 256 61.1 21 65.6 0.612  Function (nonsexual) 246 54.5 229 54.7 17 53.1 1.000  Function (sexual) 55 12.2 45 10.7 10 31.3 0.002  Chronic urine infection 3 0.7 2 0.5 1 3.1 0.199  Chronic genital infection 2 0.4 1 0.2 1 0.2 0.137  Postmassive weight loss 2 0.4 2 0.5 0 0 1.000  Other 2 0.4 2 0.5 0 0 1.000 Anesthetic 0.212  Local 344 76.3 320 76.4 24 75.0 —  General 45 10.0 44 10.5 1 3.1 —  Missing 62 13.7 55 13.1 7 21.9 — Procedure side  Bilateral 351 92.4 330 92.7 21 87.5 0.413 Operative time (minutes)* 78.6 44.7 78.5 45.7 80.6 27.0 0.246 Concomitant procedures  Labia majora reduction 33 7.3 29 6.9 4 12.5 0.278  Clitoral hood reduction 26 5.8 24 5.7 2 6.3 0.706  Other 51 11.3 48 11.5 3 9.4 1.000 *Mean and standard deviation presented. Of note, “operative time” is time from entering the operating room until time of departing from the operative room. Actual mean surgical time is approximately 45 to 50 minutes. FGM, female genital mutilation; HRT, hormone replacement therapy; OCP, oral contraceptive pill. View Large Follow up time was available for 352/451 (78%) patients. Mean documented length of follow up for the whole cohort was 4.1 months (range, 0-92 months), while mean time since surgery was 6.2 years (range, 0-15 years). During this time, 32 patients had postoperative sequelae, including revisional surgery (7.1%) (Table 2). Thirty of these occurred in those undergoing wedge excision and the rate of postoperative sequelae (POS) did not change over time. The most common cause for revisional surgery was wound dehiscence, which occurred in 16 patients. Of note, these most frequently occurred at the leading edge of the closure, creating a notch (Figure 3). Thirty-one patients required revisional surgery; removing those that had revisional surgery without medical complications, the true complication rate was 3.8% (n = 17). Two patients under the age of 18 underwent revisional surgery: one for wound dehiscence, one with no medical complications. When comparing those who with postoperative sequelae (including revisional surgery) to those who did not, there were no significant differences in age (29.9 ± 7.8 vs 32.8 ± 10.2, P = 0.210), BMI (24.2 vs 22.1 kg/m2, P = 0.091), race (a majority were white, 84.6% vs 86.1%, P = 0.582), or comorbidities (P > 0.05). There was a larger proportion of smokers vs non-smokers in the group with postoperative sequelae: 21.9% vs 11.0%, although this was not statistically significant (P = 0.083). Those with postoperative sequelae were more likely to indicate sexual dysfunction as a reason for surgery (31.3% vs 10.7%, P = 0.002). Table 2. Postoperative Sequela Rates Sequela N % Total postoperative sequelae 32 7.1 True complication rate* 17 3.8 Further surgery 31 6.9 Wound dehiscence 16 3.5 Bleeding 2 0.4 Pain 1 0.2 Readmission 1 0.2 Wound infection 0 0 Other infection 0 0 Hematoma 0 0 Numbness 0 0 Pain during sex 0 0 Antibiotics 0 0 Pulmonary embolus 0 0 Deep vein thrombosis 0 0 Sequela N % Total postoperative sequelae 32 7.1 True complication rate* 17 3.8 Further surgery 31 6.9 Wound dehiscence 16 3.5 Bleeding 2 0.4 Pain 1 0.2 Readmission 1 0.2 Wound infection 0 0 Other infection 0 0 Hematoma 0 0 Numbness 0 0 Pain during sex 0 0 Antibiotics 0 0 Pulmonary embolus 0 0 Deep vein thrombosis 0 0 *Excludes surgical revisions undertaken in the absence of complications. View Large Table 2. Postoperative Sequela Rates Sequela N % Total postoperative sequelae 32 7.1 True complication rate* 17 3.8 Further surgery 31 6.9 Wound dehiscence 16 3.5 Bleeding 2 0.4 Pain 1 0.2 Readmission 1 0.2 Wound infection 0 0 Other infection 0 0 Hematoma 0 0 Numbness 0 0 Pain during sex 0 0 Antibiotics 0 0 Pulmonary embolus 0 0 Deep vein thrombosis 0 0 Sequela N % Total postoperative sequelae 32 7.1 True complication rate* 17 3.8 Further surgery 31 6.9 Wound dehiscence 16 3.5 Bleeding 2 0.4 Pain 1 0.2 Readmission 1 0.2 Wound infection 0 0 Other infection 0 0 Hematoma 0 0 Numbness 0 0 Pain during sex 0 0 Antibiotics 0 0 Pulmonary embolus 0 0 Deep vein thrombosis 0 0 *Excludes surgical revisions undertaken in the absence of complications. View Large Figure 3. View largeDownload slide A 20-year-old woman presented with postoperative wound dehiscence. (A) Preoperative photograph and (B) postoperative photograph taken two months after wedge excision. Figure 3B reprinted with permission from Thieme (New York, NY). Figure 3. View largeDownload slide A 20-year-old woman presented with postoperative wound dehiscence. (A) Preoperative photograph and (B) postoperative photograph taken two months after wedge excision. Figure 3B reprinted with permission from Thieme (New York, NY). On univariable binary logistic regression, the only significant factor was sexual dysfunction as an indication for surgery, which increased the odds of postoperative sequelae, including revisional surgery (OR 3.778, CI 1.682-8.483). No other factors affected the odds of postoperative sequelae (Table 3). Table 3. Odds of Developing Postoperative Sequelae: Univariable Logistic Regression Results Presented as Odds Ratios (OR) With 95% Confidence Intervals (CI)—Whole Group Patient characteristics OR CI P value Age (mean ± SD)* 0.458 0.207-1.014 0.054 Race**  White (Ref.)  Other 1.123 0.372-3.393 0.837  Missing 1.621 0.628-4.185 0.318 Smoking 2.270 0.930-5.542 0.072 Comorbidities  Anxiety 0.508 0.067-3.878 0.514  Depression 1.381 0.545-3.495 0.496 Other relevant history  Premenopause 1.152 0.460-2.886 0.763  Vaginal delivery 0.738 0.292-1.868 0.522  Sexually active*** 1.438 0.183-11.333 0.730  OCP 1.234 0.489-3.115 0.656 Indication  Aesthetic 0.791 0.330-1.897 0.600  Discomfort 1.216 0.571-2.587 0.613  Function (non-sexual) 0.940 0.457-1.933 0.867  Function (sexual) 3.778 1.682-8.483 0.001  Other 1.899 0.226-15.926 0.555 Procedure side  Unilateral (Ref.) —  Bilateral 0.552 0.154-1.972 0.360  Missing 1.101 0.270-4.478 0.894 Concomitant procedures  Labia majora reduction 1.921 0.631-5.850 0.250  Clitoral hood reduction 1.097 0.247-4.866 0.903  Other 0.800 0.235-2.725 0.721 Patient characteristics OR CI P value Age (mean ± SD)* 0.458 0.207-1.014 0.054 Race**  White (Ref.)  Other 1.123 0.372-3.393 0.837  Missing 1.621 0.628-4.185 0.318 Smoking 2.270 0.930-5.542 0.072 Comorbidities  Anxiety 0.508 0.067-3.878 0.514  Depression 1.381 0.545-3.495 0.496 Other relevant history  Premenopause 1.152 0.460-2.886 0.763  Vaginal delivery 0.738 0.292-1.868 0.522  Sexually active*** 1.438 0.183-11.333 0.730  OCP 1.234 0.489-3.115 0.656 Indication  Aesthetic 0.791 0.330-1.897 0.600  Discomfort 1.216 0.571-2.587 0.613  Function (non-sexual) 0.940 0.457-1.933 0.867  Function (sexual) 3.778 1.682-8.483 0.001  Other 1.899 0.226-15.926 0.555 Procedure side  Unilateral (Ref.) —  Bilateral 0.552 0.154-1.972 0.360  Missing 1.101 0.270-4.478 0.894 Concomitant procedures  Labia majora reduction 1.921 0.631-5.850 0.250  Clitoral hood reduction 1.097 0.247-4.866 0.903  Other 0.800 0.235-2.725 0.721 *Mean and standard deviation presented. CI, confidence interval; OCP, oral contraceptive pill; OR, odds ratio. View Large Table 3. Odds of Developing Postoperative Sequelae: Univariable Logistic Regression Results Presented as Odds Ratios (OR) With 95% Confidence Intervals (CI)—Whole Group Patient characteristics OR CI P value Age (mean ± SD)* 0.458 0.207-1.014 0.054 Race**  White (Ref.)  Other 1.123 0.372-3.393 0.837  Missing 1.621 0.628-4.185 0.318 Smoking 2.270 0.930-5.542 0.072 Comorbidities  Anxiety 0.508 0.067-3.878 0.514  Depression 1.381 0.545-3.495 0.496 Other relevant history  Premenopause 1.152 0.460-2.886 0.763  Vaginal delivery 0.738 0.292-1.868 0.522  Sexually active*** 1.438 0.183-11.333 0.730  OCP 1.234 0.489-3.115 0.656 Indication  Aesthetic 0.791 0.330-1.897 0.600  Discomfort 1.216 0.571-2.587 0.613  Function (non-sexual) 0.940 0.457-1.933 0.867  Function (sexual) 3.778 1.682-8.483 0.001  Other 1.899 0.226-15.926 0.555 Procedure side  Unilateral (Ref.) —  Bilateral 0.552 0.154-1.972 0.360  Missing 1.101 0.270-4.478 0.894 Concomitant procedures  Labia majora reduction 1.921 0.631-5.850 0.250  Clitoral hood reduction 1.097 0.247-4.866 0.903  Other 0.800 0.235-2.725 0.721 Patient characteristics OR CI P value Age (mean ± SD)* 0.458 0.207-1.014 0.054 Race**  White (Ref.)  Other 1.123 0.372-3.393 0.837  Missing 1.621 0.628-4.185 0.318 Smoking 2.270 0.930-5.542 0.072 Comorbidities  Anxiety 0.508 0.067-3.878 0.514  Depression 1.381 0.545-3.495 0.496 Other relevant history  Premenopause 1.152 0.460-2.886 0.763  Vaginal delivery 0.738 0.292-1.868 0.522  Sexually active*** 1.438 0.183-11.333 0.730  OCP 1.234 0.489-3.115 0.656 Indication  Aesthetic 0.791 0.330-1.897 0.600  Discomfort 1.216 0.571-2.587 0.613  Function (non-sexual) 0.940 0.457-1.933 0.867  Function (sexual) 3.778 1.682-8.483 0.001  Other 1.899 0.226-15.926 0.555 Procedure side  Unilateral (Ref.) —  Bilateral 0.552 0.154-1.972 0.360  Missing 1.101 0.270-4.478 0.894 Concomitant procedures  Labia majora reduction 1.921 0.631-5.850 0.250  Clitoral hood reduction 1.097 0.247-4.866 0.903  Other 0.800 0.235-2.725 0.721 *Mean and standard deviation presented. CI, confidence interval; OCP, oral contraceptive pill; OR, odds ratio. View Large When performing a subgroup analysis of the adult population (n = 441), univariable analysis revealed an increased chance of postoperative sequelae with smokers (OR 2.576, CI 1.044-6.357) and sexual dysfunction as an indication for surgery (OR 4.022, CI 1.772-9.131) (Table 4). On multivariable analysis, smoking did not persist in significance (OR 2.376, CI 0.942-5.993); however, sexual dysfunction increased the odds of postoperative sequelae (OR 3.850, CI 1.683-8.807) (Table 5). Table 4. Odds of Developing Postoperative Sequelae: Univariable Logistic Regression Results Presented as Odds Ratios (OR) With 95% Confidence Intervals (CI)—Adults Only Patient characteristics OR CI P value Age (mean ± SD)* 0.540 0.242-1.209 0.540 Race**  White (ref.) — —  Other 1.192 0.391-3.631 0.757  Missing 1.754 0.673-4.574 0.251 Smoking 2.576 1.044-6.357 0.040 Comorbidities Anxiety 0.550 0.072-4.214 0.565 Depression 1.203 0.443-3.270 0.717 Other relevant history  Pre-menopause 1.087 0.431-2.744 0.859  Vaginal delivery 0.692 0.271-1.763 0.440  Sexually active*** NR — 0.998  OCP 1.418 0.557-3.612 0.464 Indication  Aesthetic 0.718 0.297-1.737 0.462  Discomfort 0.825 0.393-1.733 0.612  Function (non-sexual) 0.825 0.393-1.733 0.612  Function (sexual) 4.022 1.772-9.131 0.001  Other Procedure side  Unilateral (ref.) — —  Bilateral 1.337 0.295-6.064 0.706  Missing Concomitant procedures  Labia majora reduction 2.005 0.655-6.136 0.223  Clitoral hood reduction 1.140 0.256-5.071 0.864  Other Patient characteristics OR CI P value Age (mean ± SD)* 0.540 0.242-1.209 0.540 Race**  White (ref.) — —  Other 1.192 0.391-3.631 0.757  Missing 1.754 0.673-4.574 0.251 Smoking 2.576 1.044-6.357 0.040 Comorbidities Anxiety 0.550 0.072-4.214 0.565 Depression 1.203 0.443-3.270 0.717 Other relevant history  Pre-menopause 1.087 0.431-2.744 0.859  Vaginal delivery 0.692 0.271-1.763 0.440  Sexually active*** NR — 0.998  OCP 1.418 0.557-3.612 0.464 Indication  Aesthetic 0.718 0.297-1.737 0.462  Discomfort 0.825 0.393-1.733 0.612  Function (non-sexual) 0.825 0.393-1.733 0.612  Function (sexual) 4.022 1.772-9.131 0.001  Other Procedure side  Unilateral (ref.) — —  Bilateral 1.337 0.295-6.064 0.706  Missing Concomitant procedures  Labia majora reduction 2.005 0.655-6.136 0.223  Clitoral hood reduction 1.140 0.256-5.071 0.864  Other CI, confidence interval; OCP, oral contraceptive pill; OR, odds ratio. View Large Table 4. Odds of Developing Postoperative Sequelae: Univariable Logistic Regression Results Presented as Odds Ratios (OR) With 95% Confidence Intervals (CI)—Adults Only Patient characteristics OR CI P value Age (mean ± SD)* 0.540 0.242-1.209 0.540 Race**  White (ref.) — —  Other 1.192 0.391-3.631 0.757  Missing 1.754 0.673-4.574 0.251 Smoking 2.576 1.044-6.357 0.040 Comorbidities Anxiety 0.550 0.072-4.214 0.565 Depression 1.203 0.443-3.270 0.717 Other relevant history  Pre-menopause 1.087 0.431-2.744 0.859  Vaginal delivery 0.692 0.271-1.763 0.440  Sexually active*** NR — 0.998  OCP 1.418 0.557-3.612 0.464 Indication  Aesthetic 0.718 0.297-1.737 0.462  Discomfort 0.825 0.393-1.733 0.612  Function (non-sexual) 0.825 0.393-1.733 0.612  Function (sexual) 4.022 1.772-9.131 0.001  Other Procedure side  Unilateral (ref.) — —  Bilateral 1.337 0.295-6.064 0.706  Missing Concomitant procedures  Labia majora reduction 2.005 0.655-6.136 0.223  Clitoral hood reduction 1.140 0.256-5.071 0.864  Other Patient characteristics OR CI P value Age (mean ± SD)* 0.540 0.242-1.209 0.540 Race**  White (ref.) — —  Other 1.192 0.391-3.631 0.757  Missing 1.754 0.673-4.574 0.251 Smoking 2.576 1.044-6.357 0.040 Comorbidities Anxiety 0.550 0.072-4.214 0.565 Depression 1.203 0.443-3.270 0.717 Other relevant history  Pre-menopause 1.087 0.431-2.744 0.859  Vaginal delivery 0.692 0.271-1.763 0.440  Sexually active*** NR — 0.998  OCP 1.418 0.557-3.612 0.464 Indication  Aesthetic 0.718 0.297-1.737 0.462  Discomfort 0.825 0.393-1.733 0.612  Function (non-sexual) 0.825 0.393-1.733 0.612  Function (sexual) 4.022 1.772-9.131 0.001  Other Procedure side  Unilateral (ref.) — —  Bilateral 1.337 0.295-6.064 0.706  Missing Concomitant procedures  Labia majora reduction 2.005 0.655-6.136 0.223  Clitoral hood reduction 1.140 0.256-5.071 0.864  Other CI, confidence interval; OCP, oral contraceptive pill; OR, odds ratio. View Large Table 5. Odds of Developing Postoperative Sequelae: Multivariable Logistic Regression Presented as Odds Ratios (OR) With 95% Confidence Intervals (CI)—Adults Only Variable OR CI P value Smoking 2.376 0.942-5.993 0.067 Function (sexual) 3.850 1.683-8.807 0.001 Variable OR CI P value Smoking 2.376 0.942-5.993 0.067 Function (sexual) 3.850 1.683-8.807 0.001 CI, confidence interval; OR, odds ratio. View Large Table 5. Odds of Developing Postoperative Sequelae: Multivariable Logistic Regression Presented as Odds Ratios (OR) With 95% Confidence Intervals (CI)—Adults Only Variable OR CI P value Smoking 2.376 0.942-5.993 0.067 Function (sexual) 3.850 1.683-8.807 0.001 Variable OR CI P value Smoking 2.376 0.942-5.993 0.067 Function (sexual) 3.850 1.683-8.807 0.001 CI, confidence interval; OR, odds ratio. View Large DISCUSSION The increasing demand for labiaplasty, particularly in a younger population, warrants careful review of the postoperative outcomes and assessment of factors that may contribute to complications and revisional surgery. In this single-center consecutive evaluation of outcomes we found low complication rates, with an absence of major complications. We also identified that smoking and sexual dysfunction as an indication for surgery may increase the risk of complications and revisional surgery. In the senior author’s (C.H.) practice, patients are routinely invited back at two weeks, two months, and one year postoperatively; however, many who live far from the practice or have no postoperative concerns decline further follow up. We identified a postoperative sequela rate of 7.1%, and a true complication rate of 3.8%. Although average documented follow-up time in the present study was approximately four months, the mean time since surgery was just over six years. Therefore, we might assume that those who do not seek formal follow up have no issues and as such, we believe our results suggest a long-term, low complication rate. Lista et al published a retrospective review of 113 cases of labiaplasty performed using the edge excision technique between 2007 and 2014.6 Results showed that while 13.3% of patients reported transient symptoms of “swelling, bruising and pain,” only one patient developed a medical complication (bleeding) and four patients required revisional surgery to excise further redundant tissue or correct asymmetry. Results of a small series by Gonzalez et al showed that among the 50 consecutive cases of “custom flask labiaplasty” performed between 2007 and 2010, only one minor complication (wound dehiscence, 2%) was observed.8 Indeed, a cadaveric study performed by Kelishadi et al revealed the heterogeneity of the labia minora nerve supply, concluding that labiaplasty was unlikely to cause loss of sensation.10 Moreover, although concerns have been reported by the Royal College of Obstetricians and Gynecologists about the ethics and safety of the procedure, previous authors have suggested that lack of cosmetic surgery training within obstetrics and gynecology may be what leads to poorer outcomes, and we believe that in the hands of a qualified, experienced plastic surgeon, excellent outcomes with low complication rates can be achieved.11 The same logic has been applied elsewhere in plastic surgery: statements from the American Society of Plastic Surgeons (ASPS) have highlighted the need to educate patients on the importance of approaching board-certified plastic surgeons for consultation on plastic and reconstructive procedures, rather than nonboard certified physicians. Moreover, when considering labiaplasty in the broader context of outpatient plastic surgery, our complication rates are comparable, or superior to, that of other index procedures, including breast reduction12,13 and abdominoplasty.14 While there are those who may oppose these forms of plastic surgery, these procedures can have both functional and aesthetic benefits, and it is evident that labiaplasty is also performed for the same indications.3 Although complication and revision rates are low, it is important to evaluate factors that may increase the chances of postoperative sequelae. Results of the present study implicate sexual dysfunction as an associative factor in increased odds of postoperative sequelae after labiaplasty. There could be a variety of reasons for this finding. Patients who feel their labia impact negatively on their sex life may be more inclined to resume sexual activity postoperatively, potentially earlier than recommended by their surgeon. Their eagerness to prove their surgery has positively changed their situation may lead to early sexual activity and a potential for wound disruption. Another reason may be the psychological impact that their perceived labial abnormality has had: because of the deeply personal, sexual nature of the issue, the individual may have higher expectations of the postoperative outcomes than others, and a subsequent increased desire for revisional surgery if the results are not as anticipated. Previous research has suggested that there is a higher prevalence of body dysmorphic disorder (BDD) in those seeking cosmetic plastic surgery, and that these patients are likely to experience poorer outcomes postoperatively, with an increased rate of revisional surgery.15,16 A study by Sharp et al postulated that their cohort of patients undergoing labiaplasty may have had a higher rate of BDD, as although not formally examined, they had a high proportion of cases who had undergone previous cosmetic surgery.5 We did not examine this potential association; however, if those with sexual dysfunction were more likely to have an undiagnosed BDD, this might account for the increase in postoperative sequelae. The other potential risk factor identified in this study was smoking. Smoking is a well-known risk factor for poor healing, yet the influence of smoking on postoperative outcomes after labiaplasty has previously been poorly characterized. Although not significant on multivariable analysis, within the adult subgroup of the present study, smoking trended towards increasing the odds of postoperative sequelae. Goltsman et al analyzed the American College of Surgeons National Surgical Quality Improvement Program, evaluating the impact of smoking on plastic surgery outcomes in 40,465 cases.17 Smoking was found to significantly increase the odds of complications, including wound dehiscence; however, although the authors subcategorized by anatomic location, labiaplasty was not specifically noted, nor even the urogenital region. Wound dehiscence was the majority cause of revisional surgery within the present study and it may be that smoking increases the risk of developing wound dehiscence in the female genital region, as it is a risk factor for delayed wound healing in other anatomic locations.17 The senior author’s policy is to routinely provide smoking cessation advice and strongly recommend not smoking for four weeks preoperatively and postoperatively. In patients who do not stop smoking preoperatively, the technique is modified to an edge resection instead of a wedge resection. The edge trim technique has been shown to maintain more of the segmental vasculature to the edge of the labia minora.18 However, it is important to note that our analysis also included revisional surgery without medical complications, and so we extend our discussion to hypothesize what the association between smoking and revision for causes other than a medical complication could be. Smoking was associated with reduced scar redness in a series of 49 patients undergoing reduction mammaplasty; the authors suggested that a poorer blood supply to the area might dampen the inflammatory response and result in superior scar cosmesis.19 It is difficult to understand why a smoking population may have a tendency toward increasing revisions in the absence of complications. It may be that there are personality traits more commonly associated with smoking, which lead to these outcomes. A recent prospective psychological study evaluated the relationships between five particular personality traits, including neuroticism and conscientiousness, and nicotine dependence.20 The study compared outcomes in 2474 smokers and 2566 nonsmokers. Results showed that smokers had significantly higher levels of neuroticism and lower conscientiousness than nonsmokers. These findings have been corroborated by others studies, and, if true, could underpin our findings.21 Neuroticism (a greater tendency to experience negative emotions) could lead to increased dissatisfaction with results and a heightened desire for revisional surgery, while lower conscientiousness (including self-discipline) could lead to a lack of compliance with postoperative instructions and higher wound dehiscence rates. Further research is needed to truly understand the role that smoking has in postoperative sequelae after labiaplasty. There is a younger, nonadult population who undergo labiaplasty. Recent American Society of Aesthetic Plastic Surgery statistics show that 5.2% of labiaplasties in 2016 were in those aged 18 years or under.1 Our study included ten patients under the age of 18. Only one of these developed a medical complication postoperatively. A review of cosmetic and reconstructive breast surgery in the adolescent population by Crerand and Magee considered the psychology, ethics, and legalities of such surgery.15 They suggest that the adolescent population is particularly vulnerable to psychological difficulties, recommending careful assessment of the individual’s cognitive maturity and understanding of the procedure. Although sparse, previous research has demonstrated that adolescents may derive significant psychological and functional benefits from certain procedures, such as breast reduction surgery.22,23 Moreover, in our cohort, while nine of the ten cited appearance-related indications for surgery, the same number also cited discomfort as a reason. When consulting with adolescent patients, the senior author routinely speaks to both the patient and the parents initially. Parents frequently do not understand their child’s concern with the appearance of the genitalia. Education with the aid of diagrams and photographs helps both the patient and the parent understand the variation of anatomy in the area. The issue in adolescent patients is frequently asymmetry, where one side of the labia minora (the larger side) developed normally and the other failed to develop past a prepubertal size. Labiaplasty may be appropriate in adolescents with significant asymmetry or hyperplasia if the presence of excess labia affects the physical or emotional wellbeing of the patient. We believe that with careful preoperative discussion and counseling, and careful patient selection, labiaplasty can be safely undertaken in the adolescent population. The findings of this study should be interpreted within the context of the limitations. While providing analysis of complications and revisions, we did not evaluate postoperative patient-reported outcomes, which would have added further depth to our study. However, this large series of adolescent and adult patients undergoing labiaplasty benefits from the analysis of data extracted from a prospectively maintained database. Moreover, all surgery was performed by a single surgeon, eliminating the potential for bias arising from varying surgical technique. CONCLUSION Labiaplasty may be important in alleviating a spectrum of physical and appearance-related symptoms in women, ranging from adolescence to adulthood. We believe that evidence supporting the safety and efficacy of the procedure is growing, and that results of the present series support this trend. Sexual dysfunction as an indication for surgery and smoking may impact postoperative sequelae; however, in experienced hands, excellent outcomes with consistently low complication rates can still be achieved. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Cosmetic surgery national data bank statistics . Aesthet Surg J . 2017 ; 37 ( Suppl 2 ): 1 - 29 . 2. Sharp G , Mattiske J , Vale KI . Motivations, expectations, and experiences of labiaplasty: a qualitative study . Aesthet Surg J . 2016 ; 36 ( 8 ): 920 - 928 . Google Scholar CrossRef Search ADS PubMed 3. Sorice SC , Li AY , Canales FL , Furnas HJ . Why women request labiaplasty . Plast Reconstr Surg . 2017 ; 139 ( 4 ): 856 - 863 . Google Scholar CrossRef Search ADS PubMed 4. Sharp G , Tiggemann M , Mattiske J . Psychological outcomes of labiaplasty: a prospective study . Plast Reconstr Surg . 2016 ; 138 ( 6 ): 1202 - 1209 . Google Scholar CrossRef Search ADS PubMed 5. Sharp G , Tiggemann M , Mattiske J . A retrospective study of the psychological outcomes of labiaplasty . Aesthet Surg J . 2017 ; 37 ( 3 ): 324 - 331 . Google Scholar PubMed 6. Lista F , Mistry BD , Singh Y , Ahmad J . The safety of aesthetic labiaplasty: a plastic surgery experience . Aesthet Surg J . 2015 ; 35 ( 6 ): 689 - 695 . Google Scholar CrossRef Search ADS PubMed 7. Ouar N , Guillier D , Moris V , Revol M , Francois C , Cristofari S . Complications postopératoires des nymphoplasties de réduction. Étude comparative rétrospective entre résections longitudinale et cunéiforme . Ann Chir Plast Esthet . 2017 ; 62 ( 3 ): 219 - 223 . Google Scholar CrossRef Search ADS PubMed 8. Gonzalez F , Dass D , Almeida B . Custom flask labiaplasty . Ann Plast Surg . 2015 ; 75 ( 3 ): 266 - 271 . Google Scholar CrossRef Search ADS PubMed 9. Gulia C , Zangari A , Briganti V , Bateni ZH, Porrello A, Piergentili R . Labia minora hypertrophy: causes, impact on women’s health, and treatment options . Int Urogynecol J . 2017;28(10):1453-1461 . 10. Kelishadi SS , Omar R , Herring N et al. The safe labiaplasty: a study of nerve density in labia minora and its implications . Aesthet Surg J . 2016 ; 36 ( 6 ): 705 - 709 . Google Scholar CrossRef Search ADS PubMed 11. Goodman MP . Commentary on: A retrospective study of the psychological outcomes of labiaplasty . Aesthet Surg J . 2017 ; 37 ( 3 ): 332 - 336 . Google Scholar PubMed 12. Carpelan A , Kauhanen S , Mattila K , Jahkola T , Tukiainen E . Reduction mammaplasty as an outpatient procedure: a retrospective analysis of outcome and success rate . Scand J Surg . 2015 ; 104 ( 2 ): 96 - 102 . Google Scholar CrossRef Search ADS PubMed 13. Fischer JP , Cleveland EC , Shang EK , Nelson JA , Serletti JM . Complications following reduction mammaplasty: a review of 3538 cases from the 2005-2010 NSQIP data sets . Aesthet Surg J . 2014 ; 34 ( 1 ): 66 - 73 . Google Scholar CrossRef Search ADS PubMed 14. Swanson E . Prospective clinical study of 551 cases of liposuction and abdominoplasty performed individually and in combination . Plast Reconstr Surg Glob Open . 2013 ; 1 ( 5 ): e32 . Google Scholar CrossRef Search ADS PubMed 15. Crerand CE , Magee L . Cosmetic and reconstructive breast surgery in adolescents: psychological, ethical, and legal considerations . Semin Plast Surg . 2013 ; 27 ( 1 ): 72 - 78 . Google Scholar CrossRef Search ADS PubMed 16. Guan Jeremy GC , Stephen L . Prevalence of body dysmorphic disorder and impact on subjective outcome amongst Singaporean rhinoplasty patients . Anaplastology . 2015 ; 4:140 . 17. Goltsman D , Munabi NC , Ascherman JA . The association between smoking and plastic surgery outcomes in 40,465 patients: an analysis of the American College of Surgeons National Surgical Quality Improvement Program Data Sets . Plast Reconstr Surg . 2017 ; 139 ( 2 ): 503 - 511 . Google Scholar CrossRef Search ADS PubMed 18. Georgiou CA , Benatar M , Dumas P et al. A cadaveric study of the arterial blood supply of the labia minora . Plast Reconstr Surg . 2015 ; 136 ( 1 ): 167 - 178 . Google Scholar CrossRef Search ADS PubMed 19. Deliaert AE , Van den Kerckhove E , Tuinder S , Noordzij SM , Dormaar TS , van der Hulst RR . Smoking and its effect on scar healing . Eur J Plast Surg . 2012 ; 35 ( 6 ): 421 - 424 . Google Scholar CrossRef Search ADS PubMed 20. Choi JS , Payne TJ , Ma JZ , Li MD . Relationship between personality traits and nicotine dependence in male and female smokers of African-American and European-American samples . Front Psychiatry . 2017 ; 8 : 122 . Google Scholar CrossRef Search ADS PubMed 21. Zvolensky MJ , Taha F , Bono A , Goodwin RD . Big five personality factors and cigarette smoking: a 10-year study among US adults . J Psychiatr Res . 2015 ; 63 : 91 - 96 . Google Scholar CrossRef Search ADS PubMed 22. Evans GR , Ryan JJ . Reduction mammaplasty for the teenage patient: a critical analysis . Aesthetic Plast Surg . 1994 ; 18 ( 3 ): 291 - 297 . Google Scholar CrossRef Search ADS PubMed 23. Lee MC , Lehman JA Jr , Tantri MD , Parker MG , Wagner DS . Bilateral reduction mammoplasty in an adolescent population: adolescent bilateral reduction mammoplasty . J Craniofac Surg . 2003 ; 14 ( 5 ): 691 - 695 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Aesthetic Surgery JournalOxford University Press

Published: Jan 9, 2018

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