Download Results from a Labiaplasty Outcomes Survey

Results from a Labiaplasty Outcomes Survey: Patient Motivation
and Satisfaction
Usha Rajagopal, MD1*, Karen Vieira, PhD2, Amber Bauer, MS2
1
San Francisco Plastic Surgery & Laser Center
2
The Med Writers
* Corresponding Author: 490 Post Street Suite 430, San Francisco, CA 94102, 415-3923333 (office), 415-392-5327 (fax).
Funding source: San Francisco Plastic Surgery & Laser Center
Keywords: labiaplasty, survey, patient satisfaction, surgery outcomes
Abstract
Background: Cosmetic labiaplasty (or labial reduction surgery) remains a controversial
procedure despite helping thousands of women every year feel more comfortable and
confident about their bodies.
Objectives: An outcomes survey in a series of 52 cases was conducted to ascertain
patient’s motivations for seeking labiaplasty and their satisfaction with the results of the
procedure.
Methods: Patients scheduled to undergo cosmetic labiaplasty between November 2007
and October 2008 were asked to complete an anonymous survey on the day of surgery,
prior to the actual procedure, and another survey either at their one-month follow-up visit
or via the mail. Surgical technique was chosen on an individual basis, depending on the
desired outcome of the patient.
Results: Fifty-two patients took part in the study; however, 23 (44%) were lost to follow
up. On the pre-surgery questionnaire, 39 patients (75%) cited both functional and
cosmetic reasons for wanting to undergo labiaplasty, while seven (13%) indicated that
they desired surgery for purely functional reasons and six (12%) for purely cosmetic
reasons. Overall, all of the patients were satisfied with the results of their surgery,
ranking how well the surgery met their expectations as a 9 on a 10-point scale. Most
patients reported they were more comfortable and confident following their labiaplasty.
Conclusions: When the expectations of the patient are matched to the proper surgical
technique, labiaplasty can produce overwhelmingly satisfying results, successfully
improving the self-esteem and confidence of women who are uncomfortable with the
appearance of their labia.
Introduction
Labiaplasty and other vaginal cosmetic surgeries are highly controversial. The
American College of Obstetricians and Gynecologists has stated that there is a lack of
evidence supporting the effectiveness of vaginal cosmetic procedures and few studies
documenting the long-term risks.1 A recent literature review also reached a similar
conclusion—that “medically nonessential surgery to the labia minora is being promoted
as an effective treatment for women's complaints, but no data on clinical effectiveness
exist.”2
However, the “clinical effectiveness” of any cosmetic surgery procedure is
generally based on the perceptions of the patient. Thus, the aesthetic results of the
surgery, as well as improvements in self-esteem, have clinical merit. This is why
aesthetic appearance is one of the four end-result categories included in the Cambridge
Classification for Plastic Surgery Outcome Audits.3
Previous research has shown that patients are overwhelmingly pleased with the
results of labiaplasty procedures. One of these studies was conducted in a Chilean clinic
and surveyed 55 labiaplasty patients. Two months following surgery, 91% of the patients
said they were “very satisfied” with the results and none said they were dissatisfied. 4
Another study of 163 patients in France found that 89% were satisfied with the aesthetic
results of the procedure, and 93% were happy with the functional outcomes.5
Previous outcome surveys have focused on patient satisfaction with a single
technique.4-7 In this study, however, we wanted to see if this clinic’s practice of choosing
the surgical technique that best meets the outcome expectations of the patient would
produce similar or better satisfaction with the results and also lead to improvements in the
patients’ self-esteem.
Patients and Methods
Patient Selection
This study included 52 patients with labiaplasty procedures performed between
March 19, 2007 and October 19, 2008 that gave informed consent to participate (see
Table 1). All of the patients were in good health and attended one pre-operative
consultation prior to their surgery. During this consultation, the patients were examined
by the plastic surgeon who explained both vocally and visually, in detail, what would
happen during the labiaplasty procedure. Patients were also given the opportunity to look
at before and after photos of previous patients’ procedures to give them a better idea of
what they could expect following surgery. Patients were informed of the risks associated
with the procedure, as well as briefed on the recovery process.
Table 1. Patient Characteristics
Characteristic
Age
Relationship status, %
Single
Married
Divorced
Partnered
Sexually active, %
Yes
No
Did not respond
Have children, %
Mean or
Percentage
Range
30.8
17-50
44
33
-
15
6
-
73
23
4
-
Yes
No
40
60
-
Surgical Procedure
After signing an informed consent form and having their vital signs taken,
patients were given either Lorazapan 2mg by mouth or Diazepam 10mg by mouth. A
topical anesthetic mixture (Lidocaine 15% and Prilocaine 5%) was also applied to the
labia area. After a waiting time of approximately 45 minutes, patients were ambulated to
the operating room.
In the operating room, the topical anesthetic was completely wiped off, and
Lidocaine 1% and Epinephrine 1/100,000 (approximately 10-12cc) was infiltrated in the
tissues to be reduced. After a 15-minute wait for vasoconstriction, the surgical procedure
was initiated. At the end of the procedure, Bupivacaine 0.25% and Epinephrine
(approximately 3-5cc) was infiltrated into the tissue for post-operative analgesia. Topical
antibiotic ointment (Bacitracin) and a sanitary pad were applied, and the patient was
walked to the recovery room.
After surgery, all patients were sent home with prescription pain medications and
instructions to apply ice to the local area immediately to avoid swelling and bruising.
Patients were allowed to shower the same day and return to most of their normal
activities.
Patient Outcomes Study
Labiaplasty patients scheduled for surgery at the author's clinic between
November 2007 and October 2008 (12 months) were given survey questionnaires and
asked to participate in the study. The pre-surgery questionnaire was completed on the day
of surgery, prior to the actual surgical procedure, and the post-surgery questionnaire was
either completed at the one-month follow-up appointment or mailed out to patients at
their home addresses if they did not come in for their one-month follow up.
The pre-surgery questionnaire focused mainly on the patient’s reasons for seeking
surgery. Patients were asked:
Age
Marital Status
-
Single
-
Married
-
Divorced
-
Widowed
-
Partnered
Sexually active (yes/no)
Number of pregnancies
Number of children
Reason for having labiaplasty surgery (please circle all that apply):
-
Cosmetic (i.e. appearance)
-
Functional (i.e. discomfort wearing clothing, discomfort riding bikes, painful
intercourse, frequent rash, yeast infections, hygiene)
How does the appearance of the labia make you feel? Does it affect your body
image/self-esteem?
How has the media (i.e. magazines, Internet, television, movies) affected your
decision to have surgery?
(Not at all) 1 2 3 4 5 6 7 8 9 10 (Tremendously)
The post-surgery questionnaire focused mainly on patient satisfaction. Questions
included:
How was your surgical experience?
How many weeks did it take to feel back to normal?
How well did the procedure meet your expectations?
(Poor) 1 2 3 4 5 6 7 8 9 10 (Excellent)
How well did the recovery process meet your expectations?
(Poor) 1 2 3 4 5 6 7 8 9 10 (Excellent)
How does the appearance of the labia make you feel? Does it affect your body
image/self-esteem?
Would you do this procedure again? Yes/No
Would you recommend this procedure to your friends? Yes / No
Results
Fifty-two patients agreed to take part in this study by completing the pre-surgery
questionnaire. These patients had an average age of 30.8 (range 17-50); however, 43%
were in their twenties. Forty-four percent of the patients were single, 33% were married,
15% were divorced and 6% were partnered. Nearly three-fourths of the participants
(73%) were sexually active at the time of completing the questionnaire (see Table 1).
Despite initial high response rates, only 29 patients (56%) completed both the preand post-surgery questionnaires (see Figure 1). Twenty-three patients were lost to follow
up.
Figure 1. Patient Response Rates
Typical surgical results of labial reduction are shown in pictures of six
consecutive patient cases in Figure 2.
Figure 2. Column 1: Pre-operative labial view of 6 consecutive patients A (age 24), B (age 27), C (age
21), D (age 28), E (age 38) and F (age 22) prior to labiaplasty surgery. Column 2: Post-operative labial
view of patients A, B, C, D, E and F one month following labial reduction surgery and of patient F two
months following surgery.
Complications
Of the fifty-two patients treated, four patients (7.7%) underwent office procedures to
improve symmetry. There were no other complications such as hematoma, infections, or
wound dehiscence.
Motivations for Seeking Surgery
Of the 52 patients who completed the pre-surgery questionnaire, 39 patients
(75%) cited both cosmetic and functional reasons for pursuing surgery, while only six
patients said they were undergoing labiaplasty for purely cosmetic reasons. The
remaining seven patients stated that they were having surgery for purely functional
reasons (e.g. discomfort wearing clothing, discomfort riding bikes, painful intercourse,
frequent rash, yeast infections, hygiene); however, six out of these patients later wrote
that the appearance of their labia negatively affected their body image and/or self-esteem
to some degree.
A total of 12 patients elaborated on their functional reason for wanting to have
labiaplasty surgery. All but two circled “discomfort wearing clothes.” Yeast infections
were an issue for five patients, while discomfort riding bikes was a problem for four.
Hygiene and painful intercourse were also mentioned. Among the cosmetic issues
patients faced were being “embarrassed,” “uncomfortable,” "insecure" or “inhibited”
during sex because of the appearance of their labia. One patient said that she found the
appearance of her labia "horrible, disgusting," while another wrote: "I always thought
something was wrong with my body when I was a young girl."
Based on the reported scores, the media (e.g. magazines, Internet, television,
movies) had little to no effect on patients’ desire to undergo labiaplasty. The average
ranking for the media’s influence on their decision was 3 (range 1-9) on a 10-point scale.
Patient Satisfaction
Overall, most patients were extremely satisfied with both their labiaplasty
procedure and their recovery. When asked to rank how well the procedure met their
expectations on a 10-point scale, patients responded with a mean ranking of 9 (range 610, see Figure 3). However, two patients did not respond to this question because it was
“too soon to answer” after surgery. Patients found their recovery met their expectations
slightly less, with a mean ranking of 8.25 on a 10-point scale (range 5-10, see Figure 4).
Once again, one patient did not respond as it was too soon after her surgery to tell.
Figure 3. Patient Satisfaction: Surgery Results. Distribution of patient responses to the question: "How
well did the procedure meet your expectations?" Poor =1, Excellent = 10.
Figure 4. Patient Satisfaction: Recovery. Distribution of patient responses to the question: "How well did
the recovery process meet your expectations?" Poor =1, Excellent = 10.
Many patients reported that following surgery they felt more comfortable and
confident with the way they looked, often opening up opportunities they had avoided in
the past. One patient wrote, “It makes me feel more comfortable to be nude. I feel better
about how I look.” Another said, “[The surgery made] me feel more comfortable and
[will] allow me to go to the beach more.” A third reported that she felt “more comfortable
in clothes and with men.” Not all patients were 100% satisfied, though. One patient said,
“It’s a lot better but not exactly how I would like it.”
All 29 of the patients said they would recommend having the procedure to their
friends. In fact, one reported that she already had.
Discussion
With regards to the female genital region, many researchers have noted that even
a slight deviation from what is perceived as “normal” can cause significant emotional
distress that can negatively affect a woman’s self-esteem and quality of life.8 This was
mirrored in the responses from the 52 patients surveyed for this study. Ninety-eight
percent of patients said their self-esteem and/or body image was negatively affected by
the appearance of their labia.
A theme that was present in most pre-surgery responses was that of being
“uncomfortable.” However, the women who participated in this survey often failed to
distinguish between physical and emotional discomfort. For example, responses like “It
makes me uncomfortable during sex” are ambiguous as to whether this was a result of a
functional or aesthetic issue. As a result of this ambiguity, offering patients the option of
“discomfort wearing clothes” most likely gave patients a functional justification for their
desire to undergo labiaplasty. In a previous qualitative study of six women who
underwent labial reduction surgery, the researchers found that the patients often
emphasized physical discomfort rather than appearance as reasons for seeking surgery in
order to “legitimize” their surgery request.9 It is a possibility that the women who
participated in this study also rationalized their request for labiaplasty with the functional
reason of physical discomfort while wearing clothes, when actually they were focusing
on how emotionally “uncomfortable” they felt when wearing certain types of clothing.
Whatever the reasons for undergoing surgery, the results of the procedure were
overwhelmingly positive. Seventy-two percent of respondents who completed the postsurgery questionnaire ranked their surgery as "excellent" (9 or 10 on a 10-point scale)
when asked how well the procedure met their expectations. This was much lower when
patients were asked how well their recovery met their expectations, as only 41%
responded with "excellent" (9 or 10). However, this may have been because the patient
was not ready to face the after effects of surgery, despite being briefed about the recovery
process.
Labiaplasty was also shown to have a marked impact on self-esteem. Following
the procedure, 90% of respondents said that the surgery had improved their self-esteem to
some extent and had improved the way they viewed their bodies. Two patients were still
swollen when they completed the post-surgery questionnaire but were very optimistic
about how they would view their bodies and feel about themselves after they had fully
recovered. Only one patient expressed some dissatisfaction with the results, although she
did say that it was an improvement from before.
This study had a few limitations. In some cases the post-surgery questionnaires
were completed too soon after the surgery to get an accurate picture of the patient’s
satisfaction as they were still in the recovery stage. Also, just having the surgery a month
prior probably gave the patients a certain amount of satisfaction no matter what the
aesthetic result. For example, one patient wrote in her post-operative questionnaire: “I
have not been able to get a very good look at my labia after surgery but I already know it
makes me feel better.” Waiting 2 to 6 months following surgery to administer the second
questionnaire would have allowed for the patients’ initial post-surgery enthusiasm to fade
and for them to return to their normal lifestyle activities before they were asked to
evaluate their satisfaction levels. By then, they may have been fully healed and able to
more accurately rate their results. However, due to the low rate of responses when the
post-surgery questionnaire was sent via mail to their homes and due to the extremely low
rate of patients coming in for a longer-term post-surgical follow-up appointment,
administering the survey at the one-month follow-up visit was the best option for getting
a high response rate. Even using the current methodology, 44% of patients were lost to
follow up. This rate would have been much higher if the follow-up period were increased.
Another limitation was the fact that the questionnaires were administered by staff
at the cosmetic surgery clinic. Previous research has shown that women seeking
procedures like labiaplasty view medical staff as “gatekeepers” and adapt their reasons
for seeking surgery accordingly. As a result, even when they are assured their
participation is completely anonymous, patients’ qualitative answers and ratings of
satisfaction can by biased when collected by members of the clinical team.9 However,
while bringing in a third party to administer the surveys would have probably eliminated
this bias, it may have made the women skeptical or uncomfortable, significantly reducing
the response rate.
Conclusion
Although labiaplasty is a controversial procedure, there were no significant
adverse events associated with the surgery in these 52 cases, and practically all (97%) of
the patients were pleased with the results and cited improvements in their body image.
This shows that when the expectations of the patient are matched to the proper surgical
technique, labiaplasty can successfully improve the self-esteem and confidence of women
who are uncomfortable with the appearance of their labia.
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