Expert commentary on Committee Opinion 686: Breast and Labial Surgery in Adolescents.
ABSTRACT: The obstetrician–gynecologist may receive requests from adolescents and their families for advice, surgery, or referral for conditions of the breast or vulva to improve appearance and function. Appropriate counseling and guidance of adolescents with these concerns require a comprehensive and thoughtful approach, special knowledge of normal physical and psychosocial growth and development, and assessment of the physical maturity and emotional readiness of the patient. Individuals should be screened for body dysmorphic disorder. If the obstetrician–gynecologist suspects an adolescent has body dysmorphic disorder, referral to a mental health professional is appropriate. As with other surgical procedures, credentialing for cosmetic procedures should be based on education, training, experience, and demonstrated competence.
Teen body modifications require careful approach
by Christina Davis-Kankanamge, MD
Dr Davis-Kankanamge is a Pediatric Adolescent Gynecology Fellow at the University of Missouri at Kansas City and clinical instructor at Truman Medical Center, Kansas City, Missouri.
Interest is growing among adolescents in permanently modifying aspects of their appearance. With the acceptance of and increased publicity about body modification procedures in adults, teenagers have also begun to seek surgeries to change their bodies. Concerns encountered by ob/gyns are often regarding labia or breast modification. The motivation for change can be either physical or psychological distress, or a combination of both. The recently published Committee Opinion emphasizes education, reassurance, counseling, and evaluation of emotional and physical readiness.
In the adolescent clinic, it is common to see teenagers who complain about how their labia look or feel. Breast concerns are also common. It is important to decipher who prompted the visit, as this is one telling sign about whether hypertrophy is a patient- or parent-guided complaint. In adolescent medicine, our focus is on autonomous decision making.
While counseling patients, it is important to determine whether coexisting mental health disorders are present. One such diagnosis is Body Dysmorphic Disorder (BDD). BDD is a preoccupation with an imagined physical defect or exaggerated concern about a physical defect that would not be apparent to the casual observer. The disorder can also include obsessive behavior.1 BDD can occur alongside other psychiatric diagnoses such as anxiety, depression, and eating disorders. It is important that patients with BDD obtain appropriate support and treatment prior to undergoing any permanent procedures.
Labiaplasty can be considered genital mutilation if not performed for the health of a teenager. As such, federal and state laws criminalize labiaplasty in girls under age 18 if the procedure is not necessary for health reasons.2 If the procedure is planned, it is important to understand the laws in your state and to document the adolescent’s health difficulties. Health difficulties can include, for example, vulvar irritation when walking or playing sports, difficulty with tampon insertion, and anxiety about appearance during activities.
While discussing goals for and expectations about labial surgery, we also discuss the risks of the procedure, which include pain and infection. We advise that long-term data are lacking on labiaplasty’s possible effects on sexual satisfaction later in life. Scar tissue may form and affect function. We also discuss the recuperation time and discomfort post-procedure, highlighting the amount of expected swelling. Goals should be discussed, because surgeons cannot guarantee there will be symmetry after surgery and further growth of the labia may occur. If a patient is a candidate for labiaplasty after an autonomous decision and failure of conservative measures (such as wearing supportive underwear, application of emollients, or arranging the labia minora prior to exercise) we suggest performing surgery during the summer to minimize time away from school, as the surgery is necessary but the timing is elective. The postoperative recovery time is up to 6 weeks, and discomfort and edema are common.
Teenagers may also present with concerns about the size or asymmetry of their breasts desiring breast reduction or augmentation. Large breasts may cause difficulty with exercising, back and neck pain, and self-esteem issues. Conservative measures such as proper garment fitting can be employed to manage large breasts and should be recommended after surgery. Prior to breast reduction surgery, it is important to understand a patient’s motivation and expectations. As in the case of labia surgery, patients should be advised that surgery is not guaranteed to relieve pain, and that there is a possibility that breast size may change in the future due to puberty, weight gain, pregnancy, etc.
Among patients with marked breast asymmetry due to congenital deformity or small breast size, problems with self-esteem can arise. Patients may be teased or bullied, and loss of confidence may lead to changes in emotional and physical health. As with the above procedures, it is important to discuss motivation and goals as well as conservative measures. While implants can be removed, patients should understand that implant lifespan is 10 years, meaning additional surgery may be required. Patients need to be advised that long-term effects may include sensory changes as well as issues with breastfeeding. Referral to an experienced breast surgeon who is comfortable treating patients in adolescence is advised.
There are appropriate reasons to perform body modifying procedures in adolescents. Prior to performing surgery, it is important to reassure patients that differences in anatomy are normal as people progress through puberty and life-changing events. Autonomous decision making in a mature adolescent who has foresight to understand possible long-term consequences and has failed all possible conservative treatment is best.
1. American Psychiatric Association. Diagnostic and Statistical manual of mental disorders. 5th edition. Arlington (VA): APA; 2013.
2. 18 U.S. Code § 116-Female Genital Mutilation. https://www.law.cornell.edu/uscode/text/18/116.