Labial Hypertrophy Research Articles

Labiaplasty in Minors: Medicalizing Mutilation?

Labial hypertrophy, which lacks an accepted definition, is generally understood to refer to morphological and aesthetic characteristics of the labia believed to deviate from a perceived norm. Such ostensive deviation has the potential to affect many domains of a person's well-being, as does its surgical treatment, labiaplasty. Nearly 24,000 labiaplasty procedures were performed in the United States in 2022, representing a greater than three-fold increase since numbers were first reported in 2013. Nearly 20% of these procedures were performed on minors, and cases have been reported in children well before complete pubertal development or the age of personal consent. In this article, we explore the indications that are used to designate labiaplasty as "medically necessary" in minors, a status that, we argue, is required for such procedures to avoid fitting the definition of "medicalized FGM" (i.e., "female genital mutilation") according to the World Health Organization. As a part of this, we consider the particular ways in which outcomes are measured in this population. We shed light on persistent methodological shortcomings in the research on labiaplasty, discuss ethical and legal implications, and make recommendations to improve the relevance, reliability, and generalizability of future investigations into this increasingly common, controversial surgical procedure.

Vulvo-Perineal Crohn’s Disease: A Challenging Diagnosis!

Crohn's disease (CD) is a chronic inflammatory bowel disease with polymorphous cutaneous manifestations. Vulvar localization is rare and may be either isolated, revealing the disease, or associated with digestive manifestations. Treatment is difficult and not well codified. Based on 4 case reports of vulvo-perineal involvement, we present a reminder of the diagnostic and therapeutic challenges of this particular site. In 2 out of 4 patients, vulvar involvement was incipient, with no gastrointestinal symptoms at the time of diagnosis. The vulva may present with many dermatological manifestations: knife-like ulcerations, oedema, labial hypertrophy, lymphangiectasia, abscesses and fistulae. The presence of non-caseating granulomas on histology may help to confirm the diagnosis. Vulvar CD affects quality of life and requires long-term medical and surgical management with a multidisciplinary approach involving gastroenterologists, dermatologists, gynecologists and pathologists.

Labia minoraplasty - the balance between technique and untoward effects: A case report

Case presentation: A 45-year-old nulliparous patient presented with a long-standing history of genitaldiscomfort in the form of friction, laceration, and dyspareunia. She was also esthetically displeased withher labia minora, which she considered too large and long. Her labia minora appearance was also notedto cause emotional distress. The patient requested labia minoraplasty. Despite correct techniqueselection, she was noted to have notching, fenestration, and pigment mismatch eight weekspostoperatively, and required revision surgery.Discussion: Wedge resection versus edge trimming is an active topic in cosmetic gynecology. Patientselection and hypertrophied labia minora are important considerations in technique selection. Thesehave a bearing on the eventual esthetic appearance and development of untoward effects.Conclusion: Even with the correct technique selection for a specific type of labial hypertrophy, untowardeffects may develop postoperatively, requiring reconstruction or revision later.

Long-Term Follow-up in Labiaplasty in 414 Women: A Single-Center Experience in China.

Women with labial hypertrophy may opt for labiaplasty. The aim of the study was to analyze the complications, long-term follow-up of clinical outcomes and satisfaction in this population over the past 10 years.All women who underwent labiaplasty with or without clitoral hood reduction at our center between January 2008 and August 2020 were retrospectively identified. Retrospective study was conducted, recording follow-up outcomes, motivations, techniques, postoperative complications, reasons requiring reoperation, and surgical satisfaction concerned different clinical characteristics. A concrete analysis of each specific outcome and a detailed knowledge of these procedures were performed.A total of 52.41% reported functional impairment, 20.25% cited aesthetics complains, and 27.34% were motivated by both the previously mentioned reasons. Women undergoing surgical correction sometimes mixed with various psychological aspects. A total of 91.06% reported that they were moderately (6.04%) or extremely (85.02%) satisfied with the outcomes after surgery, and 37 (8.94%) reported dissatisfied. Revision surgery was needed in a small number of patients (n = 7 of 414 patients, 1.69%) because of undesirable appearance. The most common complication in our patients was asymmetry (6.28%). Women requested labiaplasty in the last 2 reasons or procedures or without psychological distress were more likely feel satisfied with the results (satisfaction rate >90%). There was a significant difference in satisfaction among the 3 concerns as well as between the 2 kinds of psychological conditions ( P < 0.05). Satisfaction of patients with aesthetic complains compared with the other 2 worries was significantly lower ( P < 0.05). There was no significant difference among the 3 procedures in this comparison group ( P > 0.05). In addition, satisfaction in labiaplasty with or without clitoral hoodoplasty, neither of which was statistically different ( P > 0.05). Patients aged 30 to 39 years reported the lowest satisfaction in comparison with the other age groups.Labiaplasty of the labia minora is the most commonly performed genital cosmetic surgery procedure. This study on 414 patients demonstrated that it is associated with a high degree of patient satisfaction and low morbidity and provided evidence of safety and effectiveness preliminary, indicating that the procedure may be regarded as safe.

The First Report of Isolated Clitoral Hood Hair-Thread Tourniquet Syndrome: A Study of Six Patients.

Background and objectiveHair-thread tourniquet syndrome (HTTS) is a rare and potentially dangerous condition that occurs when a hair strand or fabric thread is wrapped around the penis, clitoris, toes, fingers, or other appendages, leading to focal edema, ischemia, and necrosis. This study aimed to examine the cases of six female patients with isolated clitoral hood HTTS.MethodsThis was a retrospective study involving six female patients (age range: two to six years) with isolated clitoral hood tourniquet who presented to the outpatient department (OPD) and emergency room (ER) of the pediatric and adolescent gynecology service at King Abdulaziz University Hospital, Jeddah, Saudi Arabia between January 2010 and December 2021. Data related to patients’ clinical presentation, symptom duration, and management were recorded.ResultsThe most common symptom of isolated clitoral hood HTTS in all six cases was pain, followed by redness, itching, discomfort while sitting, and dysuria. Local signs included edema in three cases, tight hair tourniquet around a portion of the clitoral hood in four cases, and loose hair tourniquet around a portion of the clitoral hood in two cases, one of which was during the first episode in a patient who had recurrence (Case 1). Sedation and local anesthetic were used in five cases involving the local removal of four hairs and a strangulated skin. This was followed by local care and antibiotic ointment application. The edges were closed by interrupted stitches in two of the cases as the resulting wounds were broad. Limited clitoral unhooding was performed under general anesthesia in one patient, who had repeated bouts of autoamputation of parts of the hood tissue with resulting disfiguration of the remaining redundant hood, to avoid the additional risk of organ loss. Only two patients experienced recurring episodes.ConclusionsA high index of suspicion should be maintained when encountering these patients, which can facilitate a prompt resolution to save the affected tissue. HTTS should be suspected in all females presenting with a prominent clitoral hood, genital pain, structural abnormality, swelling, or discomfort. This is the first study to report isolated clitoral hood HTTS; it describes the presentation, manifestation, and management of patients with HTTS. It also addresses preventive strategies to alert mothers and treating physicians of the pediatric and adolescent-age group females to the defect and its underlying causes, particularly when patients have genital structural abnormalities such as excessive clitoral hood labial hypertrophy or ambiguous genitalia.

Ectopic Labial Tissue in an Adolescent Patient

Background: There is a broad differential for vulvar skin disorders in adolescence which include infectious causes such as condlyoma, skin tags that may reflect insulin resistance, or other anatomic causes such as labial hypertrophy. The external genitalia also changes during puberty with elongation and growth of the labia minora. We present a case of a vulvar lesion with the appearance of an ectopic labia minora that presented with growth after pubertal onset.

35. Asymmetric Labial Hypertrophy in an Adolescent with History of Prepubertal Straddle Injury

<h3>Background</h3> Long term follow up of straddle injuries (SI) in prepubertal females is not well documented in current literature. It is unclear how these patients should be counseled about how prepubertal SI could affect pubertal development of genital structures. We present a case of post pubertal asymmetric right labial hypertrophy in a patient with prepubertal SI. <h3>Case</h3> Our patient initially presented at 8 years old (YO) to our emergency department (ED) after sustaining a SI from falling on a playground beam. Evaluation in the ED showed a hemostatic shallow right labial laceration at 9 o'clock. Repair was not indicated and she was discharged home. Follow up in the office 2 weeks later showed the area had healed well, no anatomic abnormalities noted. At 13 YO, she presented to the office for evaluation of abnormal right labia minora (LM), discovered after getting a hair tourniquet on the area. At her visit, she reported normal pubertal development and menarche at 12 YO. In addition to the hair tourniquet, she reported the area of abnormal tissue was causing discomfort, frequently catching on underwear and clothes. On physical exam, she was noted to have Tanner stage IV pubic hair. The bilateral labia majora were normal and symmetric. The left LM was normal in shape and appearance, and approximately 1 cm in length. The right LM was abnormal, having a pedunculated length of tissue measuring 6 cm in length and 1 cm in width, with the base of the LM extending from the clitoral hood to approximately 9 o'clock, below which there was no identifiable LM tissue. There was no visible scar in the area of her prior SI, however that was the location where the right LM tissue ended. The patient and her parents elected for surgical correction of the abnormal area. She underwent right labiaplasty, and the excess pedunculated right LM tissue was removed without complications. On post operative follow up, the area was well healed. <h3>Comments</h3> Most studies on prepubertal SI only include short term follow up, typically until healing of the injury has occurred. There is a paucity of data regarding long term outcomes. Though most SI are minor and will likely have no long term effect, our case demonstrates how even a seemingly minor prepubertal SI with no visible scarring in the area can lead to abnormal development of the genitalia with puberty.

Outcomes of labiaplasty in women with labial hypertrophy.

High-quality data are lacking to understand outcomes in women who undergo labiaplasty for labial hypertrophy and whether there is an association with body dismorphic disorder (BDD). This was a cross-sectional study of a retrospective cohort of women who underwent labiaplasty for labial hypertrophy at a tertiary care referral center. Women were identified by CPT codes and were included if the procedure was performed by a urogynecologist. The health record was queried for demographic, pre-, intra-, and postoperative data. For the cross-sectional component of the study, participants were contacted to complete a survey. Thirty-six women met study inclusion criteria; 21 participated in the survey, and retrospective data were available for 20. At the time of labiaplasty, the women had a mean age of 30 ± 12years and mean BMI of 23.9 ± 4.4kg/m2. The most common preoperative motivation for undergoing labiaplasty, based on the medical record, was pain (85.0% 17/20). Complications were uncommon and minor. No women met criteria for BDD. Participant survey-reported primary motivation for undergoing partial simple vulvectomy was "pinching" in 10 (47.6%), "pain" in 4 (19.0%), and "appearance" in 7 (33.3%). The majority of women reported that labiaplasty achieved their preoperative goal (20/21, 95.2%). Women who underwent labiaplasty were primarily motivated by functional concerns, and outcomes indicate a high satisfaction with genital appearance postoperatively as well as a positive effect on body image and quality of life. We recommend that surgeons work to understand what motivates women to pursue surgical intervention by asking about cosmetic concerns.

A preliminary observational study on the vascular, nerve, and lymphatic anatomy and histology of the labia minora from cadaveric and surgical samples.

To better understand details of the fine anatomy of the labia minora, present images of the vascular anatomy and characterize the nerve and lymphatic distribution of the labia minora. Two fixed and five fresh cadaveric specimens were perfused and dissected, and the vascular network was photographed. Labia minora samples, prepared from cadavers, and tissue resulting from labia reduction surgery underwent hematoxylin and eosin staining and S100 and D2-40 immunohistochemical staining. Arteries emanated from the base to the edge of the labia minora, where there was a larger feeding artery, and the arteries were anastomosed. The veins formed anastomotic branches in the same direction as the edge of the labia minora. Arteries and veins that accessed the labia minora were successfully perfused at the same time with no obvious association. Sensory nerve endings were abundant, mostly larger with myelinated nerve trunks and Schwann cells in the central area with suggested neurovascular associations and smaller with no obvious aggregation at the edge. The medial area had 23.63 ± 11.82 nerves/view, the lateral area 21.30 ± 11.49 nerves/view (P > 0.05). The thickest nerve bundle was 3.16 ± 1.41mm from the medial epidermis and 3.13 ± 1.47mm from the lateral epidermis. Lymphatic vessels showed no obvious regional distribution. Labia minora were 21.77 ± 5.69mm wide with 252.87 ± 63.01 lymphatic vessels at 3.67 ± 1.61/mm2 density. The shortest inner diameter of dilated lymphatic vessels was 161.09 ± 49.99 μm. A larger feeding artery exists in the labia minora, which should be noticed in the pre-surgery design of labiaplasty. No difference was observed in the nerve distribution between the medial and lateral sides. Lymphedema might not be the cause of labial hypertrophy.

Manifestações orofaciais da lipodistrofia generalizada congênita: uma revisão sistemática

O presente estudo objetiva-se a verificar os achados orofaciais da lipodistrofia generalizada congênita (LGC) em pacientes diagnosticados com essa condição. Trata-se de uma revisão sistemática da literatura, realizada em conformidade com as bases de dados PubMed, Web of Science e Scopus. Foram incluídos 14 estudos publicados nos últimos 15 anos que abordassem os achados clínicos orofaciais da LGC. A LGC é uma condição autossômica recessiva rara, apresentando uma ampla variedade de manifestações que acometem as regiões oral e facial. Os principais achados orofaciais identificados foram prognatismo, ausência de gordura subcutânea facial, saliências frontais e supraorbitais proeminentes, linha frontal do cabelo baixa, face triangular, hirsutismo facial, macroglossia, hipertrofia labial, morfologia dentária anormal, cárie dentária, ausências dentárias, diastemas e apinhamentos dentários. Os resultados indicam que a LGC pode causar alterações orofaciais significativas nos indivíduos, sendo importante que esses pacientes sejam acompanhados por uma equipe de saúde multiprofissional, e que esses profissionais tenham conhecimento baseado em evidências científicas a respeito desses achados clínicos, para oferecer um melhor prognóstico para esses pacientes.

Perception of Labial Size and Objective Measurements-Is There a Correlation? A Cross-Sectional Study in a Cohort Not Seeking Labiaplasty

IntroductionPoor genital self-image is a common phenomenon leading to an increasing interest in female genital surgery over the last years. AimThe aim was to correlate objective measurements of the labia minora with the individual subjective perception of the labial size. MethodsIn a cross-sectional study with 200 premenopausal women (median age 33.5 years) presenting for gynecological issues other than vulvar diseases, labial width and length were measured, and psychological and physical complaints were assessed. Multivariable logistic regression analyses were performed to identify factors that influenced self-reported complaints and subjective perception of labia size. Main Outcome MeasureThe main outcome measure was labial appearance (width and length in mm, color), subjective perception of the labial size, and complaints. ResultsThe median width of the labia minora was 19.0 mm (interquartile range = 12.6–27.5), and the median length was 35.5 mm (interquartile range = 27.8–48.9). The objective size of the labia was significantly associated with womens' subjective perception of the labial size, but not with self-reported complaints. Nearly one-third of the women (n = 53, 27%) reported complaints of their labia minora which were mainly physical (n = 41, 77%) or a combination of physical and psychological problems (n = 9, 17%), while only a small group reported experiencing only psychological complaints (n = 3, 6%). Predictors of complaints were previous cosmetic surgery and the subjective perception of the labia size. The latter was significantly associated with discomfort during intercourse and when visiting a sauna and by labia minora that protruded over the labia majora. Clinical ImplicationsCutoff values to define labial hypertrophy and to justify labial reduction surgery should be avoided. Strength & LimitationsThis is a large sample of labial measurements in women not seeking labiaplasty. Standardized and validated questions regarding quality of life, sexuality, and body image could have provided more insight into psychological aspects. ConclusionThese data demonstrate the variability of labial anatomy and its perception.Widschwendter A, Riedl D, Freidhager K, et al. Perception of Labial Size and Objective Measurements-Is There a Correlation? A Cross-Sectional Study in a Cohort Not Seeking Labiaplasty. J Sex Med 2020;17:461–469.

MON-129 An Unusual LMNA Mutation Causing a Complex Phenotype: When the Genetic Diagnosis Uncovers Novel Features

Background: Lipodystrophy syndromes are characterized by loss of body fat. Although classical Familial Partial Lipodystrophy (FPLD) and Congenital Generalized Lipodystrophy (CGL) have different clinical presentations, we have encountered a unique case where the distinction was quite challenging. Clinical Case: Our patient first presented to an endocrinologist at age 19 with secondary amenorrhea and hypothyroidism. After normalization of TSH, further investigation revealed central hypogonadism, hypertriglyceridemia (>3,000 mg/dL, normal<150mg/dL), xanthomas and fatty liver disease. By that time, she had adiposity changes such as lack of subcutaneous fat in the limbs and abdomen and prominent muscles. She believed she had those traits since early childhood. After puberty, she developed generalized muscle pain and was noted to have elevated CK. At 59 years old, she developed diabetes as well as liver fibrosis. These led to the diagnosis of lipodystrophy (initially classified as FPLD due to inheritance pattern). However, physical examination revealed acromegaloid features, BMI of 23.2 kg/m2, minimal fat palpable around the neck and minimal fullness of the supraclavicular fossa. The rest of the body was virtually devoid of subcutaneous fat tissue, consistent more with the CGL phenotype and inspection of older photos demonstrated progressive fat loss. She displayed prominent and hypertrophic muscles, phlebomegaly on limbs and trunk, umbilical hernia and acanthosis nigricans around the neck and armpits. Enlarged spleen and liver were also noted. There was labial hypertrophy with no cliteromegaly. Dual-Energy X-ray Absorptiometry (DEXA) showed total fat percentage of 22% and a "fat shadow” was obtained highlighting the generalized pattern of fat loss. Genetic analysis revealed a pathogenic variant (p. Arg541Pro) at exon 8 of the LMNA gene. Upon identification of the variant, her previously obtained muscle biopsy was reevaluated as muscular dystrophy. Cardiovascular investigations demonstrated first-degree atrioventricular block and non-sustained ventricular tachycardia on the ECG and fibrosis on cardiac MRI. Given her family history of sudden death, a dual-chamber implantable cardioverter-defibrillator was placed. When her HbA1c rose to 7.2% on Metformin monotherapy and her triglycerides exceeded 250 mg/dL on fibrates, we presented her case to her insurance company. She was approved for Metreleptin therapy even though she does not meet the consensus definition of generalized lipodystrophy. Conclusion: We present a unique case with lipodystrophy who had progressive fat loss from partial to generalized. Making the correct classification is important in the US where treatment with Metreleptin is approved only for generalized lipodystrophy. We also highlight a complex genotype-phenotype association of laminopathy that challenges the distinction between FPLD and CGL.

Classification of labia minora hypertrophy: A retrospective study of 100 patient cases

The purpose of this study is to establish a new classification system for labial hypertrophy based on shape and clinical symptomatology, rather than on measurement of the length in centimetres. The aim of this classification system is to be able to select surgical strategies based on the type of labial hypertrophy.From 2005 to 2014, we undertook a retrospective study analysing 100 patient files, chosen at random from our database of 400 patient cases and pre-operational photographs to reduce the labia minora, also known as labiaplasty.The author analysed data from each individual patient file concerning the shape of the labia minora, patients' symptomatology and the chosen operational technique.We found three types of labial hypertrophy, constituting a new system of classification:Type I: the anterior one third form, called “flag”. 11 patient cases were observed (11%).Type II: the middle third form, called “oblique”. 29 patient cases were observed (29%).Type III: the posterior third form, called “complete”. 60 patient cases were observed (60%).In symptomatology terms, Type I was characterized by an undesirable aesthetic appearance and discomfort in the crotch area caused by wearing tight clothing, but not by dyspareunia. Type II showed an overall fuller appearance. Type III presented frequent dyspareunia more often than Type I and Type II.For Type I, the surgical technique selected was a superior pedicule flap, with only a moderate labial resection, which follows the edge of the labia minora. For Type II and Type III, the lambda laser technique was systematically proposed.The proposed system of classification seems to correspond better to patient symptomatology as compared to a system based on straightforward measurement of the length in centimetres. The proposed system of classification makes it possible to adjust the surgical strategy to suit patients' expectations.

Non-surgical vs surgical labiaplasty: better outcomes with fewer complications

The demand for the surgical correction of labial hypertrophy has increased since the introduction of labiaplasty in 1983. Many surgical techniques have been modified since then to produce better functional and aesthetic outcomes. However, with unfavourable post-surgical complications, patient satisfaction remains the major outcome that is not often met. Laser labiaplasty is found to be a very convenient procedure for both practitioners and patients. It is a straightforward procedure to perform, with fewer postoperative complications and better aesthetic outcomes. This article reviews a specific type of fractionated CO2 laser labiaplasty technique and compares it with the other standard surgical procedures which are widely used despite achieving less comparative outcomes.

An Unusual Case of Labial Hypertrophy as a Result of Strangulation of Labia Minora

An Unusual Case of Labial Hypertrophy as a Result of Strangulation of Labia Minora

Attitudes Regarding Labial Hypertrophy and Labiaplasty: A Survey of Members of the Society of Gynecologic Surgeons and the North American Society for Pediatric and Adolescent Gynecology.

The aim of this study was to describe gynecologists' attitudes toward labial hypertrophy and explore possible differences among providers for pediatric/adolescent patients. This was an institutional review board-approved, cross-sectional survey of physician attendees at 2 national meetings in 2014: the Society of Gynecologic Surgeons (SGS) and the North American Society for Pediatric and Adolescent Gynecology (NASPAG). The survey was designed to query demographics and impressions regarding labial hypertrophy and labiaplasty. Three hundred sixty-five surveys were completed (response rate, 50%); 268 were analyzed: 55% from SGS and 45% from NASPAG. Most were older than 41 years; 170 (63%) were women, and 93 (35%) were men. More men than women attended SGS (60%); however, women were the majority at NASPAG (94%).Most respondents believed labial hypertrophy to be infrequently reported and "a condition that impacts body image." Common symptoms were "discomfort with exercise" and "dissatisfaction with appearance naked." The majority felt this to impact sexual function "in some cases," citing "self-esteem" and "comfort" most often.Concerning therapies for provided labial hypertrophy, 83% of practitioners provide reassurance, whereas 77% would offer labiaplasty. Expertise with labiaplasty varied; 28% felt "very comfortable," and 11% felt "very uncomfortable."Provider preference for treatment differed based on meeting attendance. After logistic regression controlling for sex and age, attendance at SGS remained associated with offering labiaplasty (P = 0.001; odds ratio, 4.1; 95% confidence interval, 1.8-9.3), whereas NASPAG attendance was associated with providing reassurance (P = 0.008; odds ratio, 0.30; 95% confidence interval, 0.10-0.70). Although the majority surveyed view labial hypertrophy to be bothersome, gynecologists caring for our youngest patients are more likely to provide reassurance. Consensus guidelines are needed to aid practitioners in appropriate management of labial hypertrophy.

Cosmetic Labiaplasty in an Adolescent Population

Labiaplasty (defined as the surgical reduction of the labia minora) is the most common procedure under the umbrella of female genital cosmetic surgery with the prevalence increasing over the past 10-15 years. However, the concept of labial hypertrophy holds an arbitrary definition, with no research into labial size undertaken within the pediatric and adolescent populations. Under the tenets of medical ethics there is acceptance of the need to avoid harm and so, for reasons to be outlined, performance of labiaplasty in children and adolescents should be avoided. This Mini-Review does not extend to pathological conditions that affect the labia minora.

Labia minora reduction techniques: a comprehensive literature review.

Many studies of techniques to reduce the labia minora have been published in recent decades, including case reports and retrospective case series. However, to date, there has been no study of the overall complications or satisfaction rates associated with the broad spectrum of techniques. The authors performed a comprehensive literature review to determine outcomes and complications of labiaplasty techniques, including patient satisfaction. A search on PubMed/Medline was performed with the keywords labiaplasty, labioplasty, labial hypertrophy, and techniques plus labia minora reduction. The inclusion criterion was clinical studies in which techniques of labia minora reduction were described. Excluded from the study were publications not dealing with surgical procedures and review articles. Thirty-eight studies, published from 1971 through 2014, were included; this represented 1981 treated patients. Eight labiaplasty techniques were identified from these studies: edge resection, wedge resection, deepithelialization, W-plasty, laser labiaplasty, custom flask, fenestration, and composite reduction. Satisfactory results, judged from clinical examination, were observed with all 8 techniques. Few postoperative complications occurred. In a small number of cases, complications required surgical revision or secondary resection. All 8 labiaplasty techniques resulted in good outcomes, including high patient satisfaction and low morbidity.

Attitudes Regarding Labial Hypertrophy: A Survey of SGS and NASPAG Members

Attitudes Regarding Labial Hypertrophy: A Survey of SGS and NASPAG Members

Unilateral Labial Hypertrophy in Adolescents: when should we Interfere? Two Case Reports

Unilateral Labial Hypertrophy in Adolescents: when should we Interfere? Two Case Reports