Trial Confirms Lap Colectomy Extraction Location Affects Hernia Risk


A randomized controlled trial has shown that patients are less likely to develop an incisional hernia in the 2.5 years after a laparoscopic colectomy when they have a transverse instead of a midline specimen extraction site.

The findings confirm results from smaller retrospective studies, but offer the strongest evidence demonstrating that extraction site location significantly affects incisional hernia risk.

The study also highlights the need for careful selection of patients who undergo transverse incisions.

In an intent-to-treat analysis, investigators found no significant difference in incisional hernias between midline and transverse incisions one year after surgery. This may be explained by the high number of patients randomly assigned to a transverse incision who were switched to a midline, open or Pfannenstiel incision, indicating the transverse incision is best reserved for selected patients.

“These results suggest that while a transverse incision results in less internal hernias compared to midline, it is less versatile and may only be feasible in select patients,” wrote Lawrence Lee, MD, PhD, and his colleagues from the Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, in Montreal.

The study is published online in the Annals of Surgery (2017 Nov 21. [Epub ahead of print]).

Dr. Lee and his colleagues randomly assigned 165 adult patients to a transverse (n=79) or midline (n=86) specimen extraction site, of which 141 completed one-year follow-up. Eligible patients underwent an elective laparoscopic right hemicolectomy, left hemicolectomy or rectosigmoid resection for malignant or benign disease, and did not have inflammatory bowel disease, emergency surgery, mid to low-rectal resection, transverse colectomy, single-incision laparoscopic surgery, planned stoma, ASA class IV to V status or morbid obesity. They could not participate in another trial that would have influenced the results.

Twenty-three of the 79 patients allocated to transverse were converted to open (n=15), or received a midline (n=10) or Pfannenstiel (n=8) incision.

With one year of follow-up after surgery, 141 patients were included in the intent-to-treat analysis, including 68 in the transverse group and 73 in the midline group. The incidence of incisional hernias was similar between the transverse group at 2% and the midline group at 8% (P=0.065). With a mean follow-up of 29.9 months in the transverse group and 30.6 months in the midline group, the incidence of incisional hernias was 14% in the midline group and 6% in the transverse group. Of the four patients who developed incisional hernias in the transverse group, only one underwent a transverse incision and three were converted to midline laparotomy during the initial surgery.

The per-protocol analysis at one year included 117 patients—52 in the transverse group and 65 in the midline group—with incisional hernia rates of 2% and 9%, respectively. Mean follow-up time in the per-protocol analysis was 29.1 months in the transverse group and 29.9 months in the midline group. At that time, incisional hernia incidence was 2% after transverse and 15% after midline incisions (P=0.013).

Conor P. Delaney, MD, professor of surgery and chair of the Digestive Disease and Surgery Institute of the Cleveland Clinic, in Ohio, said the study brings a new level of evidence to an idea that surgeons believe intuitively.

In 2013, he and his colleagues published a retrospective review of 280 laparoscopic colorectal procedures over a six-year period (Am J Surg 2013;205:264-267). They reported that midline hernia rates, although lower than with traditional open surgery, were higher than non-midline rates.

Non-midline incisions are a “very simple way to help patients’ long-term outcomes become improved,” he said, adding that non-midline incisions also tend to cause less pain.

“This study is a really good reminder of the high level of evidence that, wherever possible, we’ve got to get incisions away from the midline.”

The investigators said the number of incisional hernias throughout the study period was lower than in previous studies, and may reflect the low rates of surgical site infections (SSIs), a known risk factor for the development of incisional hernias. During the five years when patients were being enrolled in this study, SSIs were the target for multiple quality improvement initiatives at the study institution.

The investigators noted that they did not use the small bites technique, which has been shown to result in fewer incisional hernias after primary midline fascial closure. “It is unknown whether application of the small bites technique would have altered the result,” they wrote.

Patients in the transverse group reported higher scores in body pain (denoting less pain) and social function domains on the Medical Outcomes Study 36-Item Short Form Health Survey. Patients with midline incisions reported better cosmesis scores, although body image scores did not differ.

“There is a trade-off between cosmesis and risk of incisional hernia that should be important elements of the informed consent process for patients undergoing laparoscopic colectomy,” they wrote.

In the midline group, the umbilical port site was sharply extended using electrosurgery through the linea alba to create a periumbilical midline extraction incision. In the transverse group, an incision was created lateral to the linea semilunaris and rectus sheath. The external oblique aponeurosis was divided parallel to its fibers, and the internal oblique and transversus abdominis split in the direction of their fibers.

An independent surgeon who was not involved in the clinical care of the patient performed the hernia assessment by physical examination, as neither patient nor health care providers could be blinded to group assignment.

Reduced rates of incisional hernia was a hoped-for benefit of the smaller incisions enabled by laparoscopic surgery. However, laparoscopic versus open colectomy randomized trials have not demonstrated a difference in the incidence of incisional hernias with long-term follow-up.

A Cochrane Review of randomized trials comparing midline with transverse incisions concluded that transverse incisions were less painful, had less effect on pulmonary function, and were associated with a decreased incidence of incisional hernia compared with midline incisions, but these data involved open surgery only (Cochrane Database Syst Rev 2005;[4]:CD005199).

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Antibiotic-Only Approach to Appendicitis Risky for Certain Patients


Elderly, Medically Complex Patients Have Lower Risk For Death With Surgery

 

Currently in the United States, about twice as many adults with appendicitis are treated without an operation as 20 years ago, but nonoperative management of an infected appendix is linked to a higher death rate in the hospital, according to the first large U.S. study to look at long-term trends in appendicitis.

Studies in Europe over the past two decades have shown that some patients with uncomplicated appendicitis can be treated successfully with antibiotics alone. These results appear to be driving the change in surgical practice for appendicitis in the United States.

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But this new study raises questions about whether a nonoperative approach is a safe option for older or medically complex patients.

After matching the cases in both treatment groups on age, sex and comorbidity index, the investigators reported a nearly sixfold increased death rate in the nonoperative care group. Compared with 0.08% of surgically treated patients with appendicitis, 0.47% of the nonoperatively managed patients died in the hospital.

“I am concerned that surgeons may be overextrapolating the European data and applying nonoperative management of appendicitis to patients for whom it is inappropriate,” said the study’s principal investigator Isaiah R. Turnbull, MD, PhD, assistant professor of acute and critical care surgery, Washington University School of Medicine, in St. Louis. “We as a community of surgeons need to consider whether nonoperative management of uncomplicated appendicitis, such as an antibiotics-first approach, is appropriate for these high-risk patients.”

Dr. Turnbull presented the findings at the 2017 Clinical Congress of the American College of Surgeons. The study was published last month in the Journal of Surgical Research (pii: S0022-4804[17]30661-3).

  • Researchers analyzed 477,680 adults with a primary diagnosis of appendicitis between 1998 and 2014.
  • According to their findings, the proportion of patients treated with early operations decreased from 94.6% to 92.1%, while nonoperative management increased from 2.3% to 4.9%.
  • Researchers also observed a sixfold increase in mortality for nonoperative patients.
  • There are approximately 250,000 cases of appendicitis in the U.S. annually.

The researchers analyzed the type of treatment for 477,680 adults with a primary diagnosis of appendicitis between 1998 and 2014 included in the National Inpatient Sample, a database of hospitalized patients representing more than 96% of the U.S. population.

Although the database did not specify whether the appendix had ruptured, investigators excluded patients who had a peritoneal abscess, as well as patients younger than 18 years of age and those who had elective admission.

Over the study period, the proportion of patients treated with an early operation decreased from 94.6% to 92.1%. Use of nonoperative management increased twofold, from 2.3% of patients with appendicitis in 1998 to 4.9% in 2014. Most of the remaining patients had an operation later than the second day in the hospital.

Additionally, in 135,856 patients with appendicitis from 2010 to 2014, the investigators compared patient characteristics and outcomes. A total of 131,162 patients underwent an early operation, primarily an appendectomy on the day of hospital admission or the next day. Another 4,694 patients received nonoperative management, defined as no operation or placement of an abdominal drain. It is not clear from this data set whether these patients received antibiotic therapy.

In this subgroup of patients from the most recent five-year period, those receiving nonoperative management were, on average, eight years older than patients in the early operation group—49 versus 41 years. They also had a significantly higher comorbidity index, with a score of 1.35 compared with 0.78.

The odds of dying of any cause during the hospitalization was 2.4 times higher in patients who had no operation compared with those who underwent an early operation.

“Our findings suggest that U.S. surgeons are selecting elderly, sicker patients for nonoperative management, possibly because they believe these patients are not good candidates for an operation,” Dr. Turnbull said. “However, these patients are at increased risk of a poor outcome if nonoperative management fails because they lack the physiologic reserve or ability to tolerate illness.” Many of the European studies of antibiotic treatment for appendicitis excluded elderly patients and had a patient age that was much younger than in this U.S. database, he said.

This is the first known study to show an association between nonoperative management of appendicitis and death. Mortality is rare in appendicitis, so tracking it requires a large data set.

Dr. Turnbull said he was cautious about making clinical recommendations based on this study alone, saying the primary conclusion from these data is that more information is needed. “That said, for me, I would counsel my colleagues that these data suggest that nonoperative management may not be appropriate for elderly patients or patients with significant medical comorbidities.”

The ongoing CODA trial is expected to provide some answers on how to best treat elderly patients as it is open to adults of all ages. It explicitly excludes several populations of medically complicated patients, such as those who have liver failure, immunologic deficiency, or second infectious conditions such as pneumonia.

Lead investigators in the CODA trial said the study presented at the ACS is interesting, but caution should be applied when interpreting the results. Giana H. Davidson, MD, MPH, assistant professor at the University of Washington, said early results from CODA show that surgeons have significant bias in giving treatment recommendations and patients have preferences that drive treatment decisions, which will not be accounted for using administrative data. “These preferences may also be associated with worse outcomes.”

David R. Flum, MD, MPH, professor of surgery and director of the Surgical Outcomes Research Center at the University of Washington, in Seattle, said the CODA trial was developed to answer some of the questions raised by the new study. “There are real questions about actual rates of adverse outcomes with antibiotic management of appendicitis.” Dr. Flum is a member of the editorial board of General Surgery News.

“While it’s likely that claims-based studies like this may show higher rates of adverse events because of confounding, the finding of increased risk is worrisome. For antibiotics to be offered as an alternative to appendectomy in the United States, we need a rigorous [randomized controlled trial] to establish the comparative rate of adverse events. For this reason, we think antibiotics should remain in the research space until CODA is completed and the results are released in 2020.”

Both Dr. Davidson and Dr. Flum commented based on the study abstract.

Appendicitis is the most common intraabdominal surgical emergency in the United States, with more than 250,000 cases annually.

Excessive IV Fluids on Day of Surgery Ups Peri-op Mortality


Patients undergoing major abdominal procedures have an independent risk for mortality when at least 6 L of IV fluid are administered on the day of surgery.

The retrospective study, which used a large administrative database of roughly 36,000 patient discharges from 393 hospitals across the United States, found that patients receiving at least 6 L of IV fluid on the day of surgery had a 48-hour inpatient mortality rate that was 48% higher than expected (Figure).

Overall, 21% of patients received over 6 L of IV fluid on the day of surgery, with 2% of patients receiving at least 9 L. “To me, this finding is provocative,” said Thomas Hopkins, MD, of Duke University Health System, in Durham, N.C. “After rigorously adjusting for patient characteristics like age, comorbidity, acute organ dysfunction and diagnosis, as well as disease-specific factors like procedure, location, surgical approach and duration of procedure, we found that excessive fluid administration was an independent risk factor for perioperative mortality.” The study was presented at the 2017 annual meeting of the American Society of Anesthesiologists (abstract A4147).

Dr. Hopkins, who is director of quality improvement in the Department of Anesthesiology and associate medical director of care redesign at Duke, was inspired to conduct the study because of his long-standing interest in enhanced recovery after surgery and his work on enhanced recovery programs (ERPs).

“Our multidisciplinary team here at Duke University Health System found that there are aspects of our ERP that have a differential impact on patient outcomes,” he said. “One of these factors appears to be perioperative fluid administration. Our preliminary data suggest that the way we administer fluid in the operating room and the way that we administer fluid on the surgical wards following the operation can have an impact on perioperative morbidity, length of hospital stay and ultimately on patient survival.”

The current study took the hypothesis generated from these preliminary data and tested it on a much larger patient population to determine whether the trends established at Duke would be applicable across an extremely large data set.

The study’s patient mortality risk was based on hospital practice, with 22% of hospitals having only 5.8% of their cases in the high-risk fluid category, whereas 26% of hospitals had 40.5% of patients in that category. “Therefore, there is clearly significant variation in practice, depending on site of care,” Dr. Hopkins said.

Based on the study, Dr. Hopkins and his colleagues are uncertain as to the distinguishing factors that each of the two hospital groups possesses to cause such disparate results. “But our hypothesis is that the hospitals in the best-performance group have some type of algorithm or protocol or standard approach to fluid management on the day of surgery, whereas hospitals in the underperforming group most likely did not,” he said.

The reflex assumption after reading the results of the study is that less fluid should be administered on the day of surgery, according to Dr. Hopkins. “This idea is not new. We have seen a fair amount of academic work attempting to elucidate the answer to this question over the past five years,” he said. However, a number of large retrospective analyses have concluded that “if you simply restrict fluid on the day of surgery, you can do harm. In fact, there is probably a bimodal distribution of patient morbidity and mortality that is associated with either too little or too much fluid on the day of surgery,” he said.

Hence, based on the literature and the present study, “the best solution is to consider a dynamic approach to perioperative volume resuscitation that leverages a patient-specific and a patient-tailored strategy,” Dr. Hopkins said.

Dr. Hopkins emphasized it is extremely important to stress that one-fifth of the surgical patient population for major abdominal surgeries in the United States could be at increased risk for perioperative mortality “because our current approach to fluid resuscitation in this patient population is very unstructured. We know there is a significant amount of variability in our practice.”

Dr. Hopkins is optimistic that the study will spur a reassessment of the need to consider fluid as a primary end point in ERPs and to focus on leveraging a dynamic fluid assessment to guide perioperative fluid administration, not only in the operati ng room but postoperatively on the floor. “Hopefully, this will increase awareness about variability in practice, how that variability can impact perioperative outcomes, and ultimately how it can impact value delivery in the perioperative space,” he said.

Dr. Hopkins said we are living in a time where the definition of value, as it applies to perioperative medicine, is changing very rapidly. “In these times of rapid change, ERPs have surfaced as a way to improve the value of care by improving patient outcomes and reducing the cost required to achieve those outcomes,” he said.

European Association of Urology updates guidelines on urinary incontinence


https://speciality.medicaldialogues.in/european-association-of-urology-updates-guidelines-on-urinary-incontinence/

New Technology developed for faster healing of chronic wounds


https://speciality.medicaldialogues.in/new-technology-developed-for-faster-healing-of-chronic-wounds/

4 fold reduction in Diabetic microvascular complications after Bariatric surgery


https://speciality.medicaldialogues.in/4-fold-reduction-in-diabetic-microvascular-complications-after-bariatric-surgery/

New Data Challenge Beliefs About Concussion


Experts respond to recent study implicating repetitive small blows to the head

New research is challenging the notion that the serious brain damage now seen in professional football players is caused mainly by blows to the head leading to overt concussions.

In a study published in Brain, researchers from Boston University examined the brains of eight teenagers and young adults. Four had “recent sports-related closed-head impact injuries sustained 1 day to 4 months prior to death.” Four had no such history. The researchers found evidence of chronic traumatic encephalopathy (CTE) in the four teenagers who had recent head injury. “These results indicate that closed-head impact injuries, independent of concussive signs, can induce traumatic brain injury as well as early pathologies and functional sequelae associated with chronic traumatic encephalopathy,” the researchers concluded. It may be the best evidence yet that it is the routine head impacts that occur on virtually every play, and not concussions per se, that cause CTE.

This research raises questions about the NFL’S efforts to deal with concussions. It also may influence what advice physicians give to parents who ask about whether their children should play youth football.

Below, the NFL’s chief medical officer, a professor of emergency medicine and neurosurgery, and a pediatrician discuss these questions.

Allen Sills, MD, NFL chief medical officer, past co-director of the Vanderbilt Sports Concussion Center

“Important research advancements have been made over the last several years around traumatic brain injury (TBI) and chronic traumatic encephalopathy (CTE), which have aided awareness and understanding around this important issue. As highlighted in the most recent study, repetitive hits to the head have been consistently implicated as a cause of CTE by this research group. How and why exactly this manifests, who is at risk, and why — these are questions that we as researchers and clinicians are working to answer.

“As the research community continues to explore these critical questions, the NFL has made significant strides to try to better protect our players and reduce contact to the head including implementing data-driven rules; changes intended to eliminate potentially dangerous tactics and reduce the risk of injuries, especially to the head and neck; enforcing limits on contact practice; and mandating ongoing health and safety education for players and training for club and non-affiliated medical personnel.

“For kids, being active, getting outside, playing sports, particularly team sports, is important. There are also concerns about the risks involved in playing sports, including football, which is why it has been encouraging to see similar developments at the youth level such as the certification of over 130,000 youth and high school coaches through USA Football’s Heads Up program; USA Football’s National Practice Guidelines — including limits on full contact; Pop Warner’s initiatives, from no intentional head-to-head contact to requiring players who suffer a suspected head injury to receive medical clearance from a concussion specialist before returning to play; and 50 states have a Return to Play law, which can help reduce the rates of recurrent concussions. We hope that all youth sports will continue to take measures to reduce head contact through similar rules changes, education, and improved protective equipment.”

Jeffrey Bazarian, MD, MPH, professor of emergency medicine, physical medicine and rehabilitation, neurology, neurosurgery, and public health science, University of Rochester

The National Football League has done an admirable job of supporting research to better identify, prevent and treat sport-related concussions. But more recent research data suggest that the real threat to the long-term neurologic health of contact athletes like football players is not concussion, but the repetitive head hits that do not result in acute symptoms of concussion. These head hits are experienced by all players during nearly every football practice and game. They have been associated with acute changes in brain function and structure, and with short-term cognitive deficits. They have also been reported to have clinically-relevant, long-term adverse consequences on the brain. Repetitive head hits experienced by football players should be reconceived as an occupational exposure that can be assessed, controlled, and managed. The NFL is uniquely positioned to foster research to identify, prevent, and treat the neurologic consequences of these hits, and would be wise to turn its attention in the direction of repetitive head hits as soon as possible.

Steven Hicks, MD, assistant professor of pediatrics, Penn State Health and Milton S. Hershey Medical Center

As a general pediatrician, I believe we can do several things to make sports like football (with high concussion risk) safer for our children: 1) be open to rule changes that may make the game safer by minimizing concussive events; 2) ensure that medical personnel are on the sideline at games, to accurately assess potential concussions and ensure that concussion guidelines are followed; 3) teach children to tackle safely and reduce full-contact scenarios in daily practice; and 4) support research that improves our understanding, prevention, and treatment of concussions. Making decisions about youth football participation will require us to balance risks and benefits. By minimizing concussion risks on the field we can hopefully find ways to allow children to continue to benefit from participation in this team sport.

DIEPflap Breast Reconstruction: Aesthetic Questions to Ask Your Plastic Surgeon


DIEPflap Breast Reconstruction: Aesthetic Questions to Ask Your Plastic Surgeon

DIEPflap Breast Reconstruction: Aesthetic Questions to Ask Your Plastic Surgeon

DIEPflap breast reconstruction & aesthetic questions to ask your plastic surgeon involves more than  you may or may not have given much thought to.  You have had a mastectomy due to breast cancer. You have tested positive for the BRCA gene and are facing the decision to have a prophylactic bilateral mastectomy to significantly decrease your chances of getting breast cancer. Perhaps you are even going in for a consult to repair damage done at another practice and are looking for better results.  Now you’re researching and thinking about breast reconstruction options. You found a board certified plastic surgeon with great skill and a high rate of success. The consult appointment has been set up. You write down as many questions as you can and hope beyond hope that you will be given the time to have all of them answered.  Your main concern might be moving beyond the diagnosis or possibility of getting cancer if you are BRCA positive.  It was for me.

concrete bustThe Natural and Aesthetic Beauty of our Bodies

The truth is that you simply won’t think of everything in that first visit. This is an important consult and I want to share with you points of discussion and what to ask your surgeon about the aesthetic outcomes of your surgery.

Honoring our Bodies

The aesthetic work alone done on your body during this intensive surgery is extensive and complex. Here is a list of questions that I hope will help in the discussion with your plastic surgeon if you’re having DIEP flap breast reconstruction. I will speak specifically to this procedure since it is what I had done and what I can reference through my own experience.

check listThe List of Aesthetic Questions … The More You Know

  • How long will my abdominal scar be?
  • How high up will the scar be on my “new, flat, tummy”? If I choose to wear a bikini will it show? Fair question!
  • What will the scar look like after surgery; a year from surgery? A qualified plastic surgeon knows about the progression, makeup and life of scars. Ask! Scars heal differently for everyone depending on your skin color, elasticity, lifestyle, and in particular if you’re a smoker. If you’re seriously considering DIEP flap surgery, stop smoking now.  It is a must for this surgery.
  • What will the scars on my breast look like?  Will they be straight?  Curved?  Thick?  Thin?  Where will you make the incisions?
  • Where will they be placed? A plastic surgeon knows how to strategically hide those scars for wardrobes.  Remember, a good plastic surgeon is a perfectionist and artist and has a keen eye for body contouring and outcomes for this surgery.
  • Will the flaps become a bit smaller or closed up for phase 2?
  • Will I need physical therapy to help heal the scars to avoid adhesion?
  • Will the skin from my belly used to make the flap be the same color as my breast when it is transferred to make the new breast mound?
  • How about that tummy hair?  Will it be on my new breast flaps?  If so, what can I do about it?  Electrolysis or any other suggestions?
  • I have some divots (areas that are sunken in on your chest after a mastectomy). Will these go away or look better after my reconstruction? This will depend on how much breast tissue you had removed and if you are a delayed or immediate reconstruction.
  • What kind of stitches can I expect and will they be dis-solvable or not?
  • What will my belly button look like? Can you explain to me the process of rebuilding my bellybutton?
  • How long will my belly button take to heal and when can I see it?
  • Will my pubic hair line be changed? Trust me… the pulling up and pulling down of the abdominal wall will change that line of pubic  hair. It’s a fair question and the change is one that many women are surprised by after surgery!  Your plastic surgeon has probably been asked questions that are this intimate and even more so.
  • For those who have had a NSM (nipple sparing mastectomy): Will the color of my areola change after surgery?
  • For those who did not have NSM: If I have my nipples rebuilt what will they look like? Will they have that “headlights on” look all the time? Again, I’ve spoken to others about this concern. It’s a fair question, ladies! Some like that look and some don’t.
  • What size cup will I be after reconstruction?
  • How will my breast look after phase 1 and how will that look improve or change after phase 2 when symmetry and fill from fat grafting is done?
  • Will I be able to wear under-wire bras?
  • Will my breasts be soft, warm, and natural feeling?

Your consult should also include the risks and possible complications of this surgery.  I know there are many more questions others will likely think of but this is a good start for now. Remember, this is only the aesthetic questions.

 

Knowledge is Power

 

 

Disclaimer

References made to my surgical group, surgeon and healthcare team are made because they are aligned with my values and met my criterion after I did research of their practices and success rates. Any other healthcare provider that displays the same skill, compassion education and outreach to patients will be given consideration and recognition on this website.  The information contained on this website is not a substitute for or should be construed as medical advice. Please consult a licensed physician for medical advice.

98% Of Mastectomy Patients Would Have Reconstruction Again, Study Says


Women who have breast reconstruction after an mastectomy are satisfied with their decision, have low complication rates and 98% would do it again, reports a study in Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

In addition, breast reconstruction after preventive mastectomy was as safe as, or safer than, reconstruction in women with breast cancer and had excellent cosmetic results.

“Breast cancer is a terrible diagnosis and decisions regarding treatment are never easy. This study shows that women with cancer in one breast who choose to have their other breast removed as a preventive measure are happy with their decision and a high percentage would do it again,” said Scott Spear, MD, study co-author and past ASPS president.

The study examined 74 women who had preventive mastectomies and subsequent breast reconstruction between 2000 and 2005. Forty-seven patients had breast cancer in one breast and elected to surgically remove their other breast (unilateral prophylactic mastectomy). Twenty-seven patients did not have breast cancer, but chose to surgically remove both breasts due to a high-risk of developing breast cancer (bilateral prophylactic mastectomy). The cosmetic outcome was scored by 14 surgeons who looked at post-reconstruction photos and evaluated the result on a 1 to 4 scale (4 being an “excellent” result).

The study found that women who had a bilateral prophylactic mastectomy were 100% satisfied with their breast reconstruction and 100% of them would have the surgery again. 94% of women who had unilateral prophylactic mastectomy were satisfied with their reconstruction and 96% of them would have reconstruction again.

The complication rate for reconstruction in women who had bilateral prophylactic mastectomy was 3% and 10% for those who had unilateral prophylactic mastectomy. Additionally, the study noted the cosmetic assessment for all patients was a score of 3 out of 4.

“These women look and feel the same or better and their risk of cancer has been taken off the table,” said Dr. Spear. “For women who know they are at risk, this option [bilateral prophylactic mastectomy] gives them the opportunity to be active about their health and appearance rather than reactive. They can have excellent cosmetic results, low surgical risk and a high level of satisfaction with their breast reconstruction. This is empowering for women.”

Here’s the Only Time You Actually Need Labia Surgery


Hint: You probably don’t.
Fruit resembling female anatomy

Labia and ice cream flavors have two essential things in common: Their beauty lies in their variation, and there’s basically no way to go wrong.

It’s completely normal for your labia to look different from what you see online, on your partner, or even from one side to the other. Still, a growing number of people are asking their doctors about having labiaplasty to trim their vaginal lips. In fact, the most recent data available shows that labiaplasty procedures jumped 39 percent between 2015 and 2016, according to the American Society of Plastic Surgeons (ASPS). Clearly, many people are electing to get a labiaplasty, but the chances that you actually need one are incredibly low.

Quick biology lesson: Your labia are the part of your vulva that kind of look like vertical lips.

Your vulva (often called your vagina as a catch-all) houses your external female genitalia, including your labia, of which you have two sets. The labia majora are the outer lips that grow hair, and the labia minora are tucked inside those, putting them closer to all the greatness that is your clitoris, urethra, and vaginal opening. Labiaplasty typically is performed on the labia minora.

While plastic surgery is and should be a personal choice, many doctors are hesitant to perform labiaplasty unless it’s actually medically necessary, since surgery always comes with potential risks and complications. “I tell patients that your labia are like your earlobes—they’re all different shapes and sizes,” Maura Quinlan, M.D., an ob/gyn with Northwestern Medical Group, tells SELF. “We really don’t want to cut away at normal anatomy.”

There’s a huge range of normal labia lengths, FYI, so you probably don’t need to worry about yours.

There isn’t any kind of medical guide that dictates a standard length for labia, Suzanne Fenske, M.D., assistant professor of obstetrics, gynecology, and reproductive sciences at Mount Sinai Health System, tells SELF. However, she says, many doctors consider labia minora to be excessively long, aka hypertrophic, if they’re more than 5 or 6 centimeters in length when gently stretched out (that’s about 2 inches).

But again, there is a ton of potential variation with labia. Even having labia minora that surpass that benchmark doesn’t mean you need labiaplasty!

There are very few situations that call for a medically necessary labiaplasty.

Labiaplasties for medical reasons are about how your labia minora impact your life, not how the lips look, Dr. Quinlan says. Depending on their length, your labia minora can cause pain during sex if they get tucked into the vagina. They can also cause irritation or discomfort while wearing underwear or a swimsuit, being physically active, or even walking around and doing regular daily activities, Dr. Fenske says. If your labia minora aren’t disrupting your life like this, ob/gyns and gynecologic surgeons will be hesitant to recommend surgery. The only exception is if you have some sort of abnormality on the labia, like a melanoma.

Cosmetic labiaplasty procedures, on the other hand, are usually about wanting your labia minora to look a certain way (typically shorter and more “tucked in”between the labia majora). When Dr. Quinlan has patients who ask about labiaplasty, she counsels them on the basics and encourages them to look up The Great Wall of Vagina, an art installation in the United Kingdom that features plaster casts of different women’s vaginas. “There are so many normal variations in shape and size—sometimes I think it really helps for women to see that,” she says.

If you do end up getting a labiaplasty, the procedure is pretty simple.

Labiaplasty is considered an outpatient procedure (meaning you don’t stay at the hospital overnight afterward), and it can be done under general anesthesia or a mix of local anesthesia and sedation, according to the ASPS.

During the procedure, a doctor will typically trim the labia and use dissolvable sutures to close up the raw edges, Dr. Fenske says. (There’s also something known as a wedge procedure, the ASPS says, which preserves the edges of the labia and instead takes pie-shaped pieces of tissue from other areas of the lips.)

If you have a labiaplasty, your vulva will be sore and swollen. (The ASPS notes that some people take a week off work post-procedure if they’re able.) Dr. Quinlan recommends wearing loose clothing for at least a few days to avoid excess pain and doing a warm sitz bath (i.e., submerging everything below your hips in warm water or a saline solution) to relieve discomfort if you need it. You can also ice the area for 20 minutes on, 20 minutes off to help relieve soreness and swelling, says the ASPS.

When it comes to longer-term healing, your doctor will typically recommend you avoid tampons, sex, and vigorous activities for four to six weeks to let the area heal.

Labiaplasty isn’t without its risks, and it’s important to be aware of them.

For starters, you may have some scarring down there, Dr. Quinlan says, which can make the skin less stretchy than it was in the past. That, or the surgeon accidentally cutting more skin than necessary, could potentially cause vaginal dryness, pain during sex, and easier tearing if you have a vaginal birth in the future. “When some people hear that, it’s not worth it to them,” Dr. Quinlan says. There’s also a chance you could end up with some localized numbness in your labia, according to Dr. Fenske.

If your labia are bothering you to the point where they’re interfering with your daily life, definitely talk to your doctor about your options. But if you just aren’t super into your labia because you think they’re too long, you probably should take a hard pass on labiaplasty. Some labia are short, some are long, and there’s nothing wrong with either.

“Part of my job is to celebrate human variation,” Dr. Quinlan says. “Don’t let someone tell you that you have extra labia—it’s just anatomy.”

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