We would like to thank Dr. Oranges et al. for the constructive comments regarding our article entitled “The Impact of Labiaplasty on Sexuality.”1 Dr. Oranges has stressed some points about self-image and self-esteem related to patients that are undergoing labiaplasty, and the factors that lead these patients to look for this type of procedure. It is important to mention that no self-image questionnaire was used in our study. Patients have been evaluated since 2011, when the Veale questionnaire,2 which is used to evaluate the genital area, was not available. The Female Genital Self Image Scale3 was not yet available in Portuguese when this study was performed. This outstanding questionnaire was translated into Portuguese and validated by our group in 2017.4 Although body image and self-esteem were identified as the subjective variables that better represent the patient’s perception of their deformities,5 self-esteem is a more stable parameter over time, and to change it is a more difficult process compared with body image. Therefore, self-esteem seems to be a better parameter with which to evaluate a patient after plastic surgery.
After these considerations, we feel that the results found in our study do not differ completely from those found by Goodman et al.,6 as different evaluation methods were used. Whereas in his study the Index of Sexual Satisfaction7 and the Body Esteem Scale8 were used, the Female Sexual Function Questionnaire and the Rosenberg Self-Esteem Scale were used in our study to evaluate sexual function and self-esteem, respectively, of patients. There was a decrease in values of the Rosenberg Self-Esteem Scale after the operation, which demonstrates that patients had an increase in self-esteem; however, the difference was not statistically significant. It is possible that with an increase in the number of patients there would be a significant difference. The questionnaire used to evaluate quality of life in our study was the Medical Outcomes Study 36-Item Short Form Health Survey, which is a more general questionnaire. In fact, there was also an increase of the absolute values after the operation with no statistical significance.
Most of the patients in our study were searching for a cosmetic improvement of the genital area, as in other studies found in the literature.9 It is important to stress that some of these patients also had a functional complaint, but the main reason they sought treatment for the deformity was cosmetic.
We agree that there is a low risk of complications when performing an edge resection in these cases. This is because of the simplicity of the technique performed under epidural anesthesia with a reduced amount of local injection of lidocaine. The use of 5-0 catgut and the closure performed with low tension also play important roles in decreasing local complications in an area that usually presents massive subcutaneous edema in the early postoperative period. The low number of complications is similar to what was found in other studies in which edge resection of the labia minora was used.10–12 Interestingly, Choi and Kim,13 who have used a different technique but with the same type of suture that we have used in our patients, had no dehiscence in their series.
The cosmetic and functional improvement of the genital area has been constantly studied by our group over the past few years. We have focused not only on the labia minora, but also on the hair changes during the aging process and its restoration,14 on the effects of the repositioning of the clitoris, and the improvement in clitoris sexual stimulation after abdominoplasty.15 Plastic surgery aims to improve not only the cosmetic and functional aspects but also the related issues of the patient’s quality of life, such as self-esteem, sexuality, and self-image. We believe that an increasing number of studies that aim to evaluate results in plastic surgery will use these parameters.
The authors have no financial interest to declare in relation to the content of this communication. No funding was received for this work.
Tatiana Turini, M.D.Ana Cláudia Weck Roxo, M.D., Ph.D.Fernando Serra-Guimarães, M.D., Ph.D.Maria Lidia Abreu, M.D., Ph.D.Cláudio Cardoso de Castro, M.D., Ph.D.José Horácio Aboudib, M.D., Ph.D.Fábio Xerfan Nahas, M.D., Ph.D., M.B.A.Hospital Universitario Pedro ErnestoRio de Janeiro, Brazil
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