title: Labia majora labioplasty in HIV-related vaginal lipodystrophy: technique description and literature review.
abstract: BACKGROUND
  We present a rare case involving severe hypertrophy of the labia majora. This 39-year-old married woman developed a clinically noticeable bilateral lipodystrophy of her labia majora following the administration of chronic antiretroviral therapy. Different combination drug regimens that included drugs like Crixivan(®), Epivir(®), and Zerit(®) were administered to the patient from 1998 to 2005. The patient is currently on a single drug regimen of Atripla(®) with the disease under control and no other comorbidities. The severity of the pubic protuberance created an appearance resembling male genitalia, even when covered by underwear. This anatomical abnormality obviously impaired her social life and forced her to avoid wearing tight pants, swimming garments, and tight clothes in general. She also avoided any sexual activity.
  
  
  METHODS
  Her pubic hair was shaved. Crural creases and vulvar mucosa were marked in order not to be violated. The estimated amount of skin and fat to be removed was marked. Intraoperative tailor-tacking suturing was used to mark the extent of the resection of the labia majora. Sutures were left in place to verify the accurate tension of the remaining skin. The procedure was performed with the patient under general anesthesia. Labial skin resection was performed by sharp dissection. Electrocautery was then used to excise the lobulated fat accumulation. Two layers of 3/0 Vicryl(®) sutures were used in the lax subcutaneous tissue. 4/0 Vicryl(®) rapide was used on the skin to approximate wound edges. Suction drains were left in place for 48 h to reduce the dead space and to manage postoperative bleeding. The patient was instructed to keep ice and compression pads on the area for the first 24 h and to keep the area clean. This was followed by the application of antibiotic ointment two times a day on the wounds to avoid blood crust formation and to keep the skin soft.
  
  
  RESULTS
  Stitches were removed on POD 14 after an overall uneventful postoperative course. The sensitivity of the labia majora's interior aspect was preserved, even initially. With the legs slightly open, the labia majora just covered the entrance to the vagina. The clitoris and labia minora became visible again, restoring a normal anatomical appearance. Moderate edema was observed for 4 weeks after surgery.
  
  
  CONCLUSIONS
  The surgical technique used provided an excellent result according to the patient, who regained her self-confidence and started having a normal sexual life again.
  
  
  METHODS
  This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
authors.affiliation: Department of Plastic Surgery, Asl 1 of Umbria, Città di Castello, Perugia, Italy. luigi.lapalorcia@gmail.com
authors.forename: Luigi Maria
authors.initials: LM
authors.lastname: Lapalorcia
authors.forename: Silvio
authors.initials: S
authors.lastname: Podda
authors.forename: Gianluca
authors.initials: G
authors.lastname: Campiglio
authors.forename: Marino
authors.initials: M
authors.lastname: Cordellini
mesh_terms: D000328:Adult; D005260:Female; D005836:Genitalia, Female / Q000473:pathology / Q000601:surgery*; D013509:Gynecologic Surgical Procedures / Q000379:methods*; D039682:HIV-Associated Lipodystrophy Syndrome / Q000601:surgery*; D006801:Humans; D006984:Hypertrophy; D050507:Subcutaneous Fat, Abdominal / Q000637:transplantation; D013536:Suture Techniques