Anatomical Reconstruction Following Female Genital.42

RECONSTRUCTIVE
Anatomical Reconstruction following Female

Genital Mutilation/Cutting
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0
Dan mon O’Dey, MD, PhD

Background: International migration from high-prevalence regions has increas-
Masih Kameh Khosh, MSc ingly confronted nonendemic countries with female genital mutilation/cut-
hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 07/25/2024
Nina Boersch, BSc ting (FGM/C), and Western-based health care providers have seen a greater
Aachen, Germany demand for surgical reconstruction of female anatomic units. The authors
introduce novel surgical techniques developed by the first author for clitoral
and vulvovestibular reconstruction and examine operative outcomes.
Methods: The authors performed a retrospective cohort study of operative out-
comes of the omega domed flap, neurotizing and molding of the clitoral stump
(NMCS procedure), and anterior obturator artery perforator flap for prepu-
tial, clitoral, and vulvovestibular reconstruction, respectively. Between 2014
and 2021, the authors treated patients with all types of FGM/C, and analyzed
various data, including demographics, clitoral sensation, and symptoms such
as dysmenorrhea, dysuria, dyspareunia, and anorgasmia. The authors aimed to
examine the efficacy and safety of these techniques in improving clitoral sensa-
tion and reducing symptoms.
Results: A total of 119 women (mean age, 31.0 ± 10.4 years) were included.
The authors performed the omega domed flap (85%), the NMCS procedure
(82%), or the anterior obturator artery perforator flap (36%), and had a
1-year follow-up period, which was attended by 94.1% of patients. Patients
reported significant postoperative reduction of dysmenorrhea, dysuria, and
dyspareunia, as well as significant improvement of clitoral sensation and abil-
ity to achieve orgasm (P < 0.001). There was 1 major complication (loss of
flap) reported. Secondary ambulatory interventions were performed in 10
patients (8.4%).
Conclusion: By allowing for safe and effective anatomic reconstruction of the
female genitalia, the described surgical techniques represent a new stage of
treatment possibilities for women with FGM/C. (Plast. Reconstr. Surg. 154:
426, 2024.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
F
emale genital mutilation/cutting (FGM/C) Organization has classified FGM/C into 4 major
comprises all procedures involving the par- types and various subtypes.1
tial or total removal of the external female FGM/C is internationally recognized as a form
genitalia or other injury to the genital region for of gender-based violence and an extreme mani-
cultural, nonmedical reasons. The World Health festation of gender inequality that inflicts severe
physical and mental harm to girls and women.
In addition to immediate complications, such as
From the Department of Plastic, Reconstructive, and bleeding, shock, infection, and death, FGM/C
Aesthetic Surgery, Hand Surgery, Center for Reconstructive
survivors may sustain consequences that last long
Surgery of Female Genitalia, Luisenhospital Aachen,
Teaching Hospital of the Aachen University of Technology.
Received for publication February 20, 2023; accepted Disclosure statements are at the end of this article,
August 22, 2023.
following the correspondence information.
This trial is registered under the name “Anatomical
Reconstruction after Female Genital Circumcision,” German
Register of Clinical Trials identification no. DRKS00031017
(https://drks.de/search/de/trial/DRKS00031017). Related digital media are available in the full-text
Copyright © 2023 by the American Society of Plastic Surgeons version of the article on www.PRSJournal.com.
DOI: 10.1097/PRS.0000000000011026
426 www.PRSJournal.com
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 154, Number 2 • Female Genital Anatomic Reconstruction
beyond the initial procedure. These include dys- expand on existing treatment options, we present
menorrhea, dysuria, and recurrent infections. novel surgical techniques for clitoral and vulvoves-
Women who have been subjected to FGM/C may tibular reconstruction in patients who have experi-
report psychologic disturbances, notably depres- enced FGM/C and report operative outcomes in a
sion, anxiety, lowered self-esteem, and posttrau- retrospective cohort study.
matic stress disorder. The physical removal of
sexually essential genital zones and development

of inelastic scar tissue combined with psychopatho- PATIENTS AND METHODS
logic sequelae can result in sexual dysfunction.2,3

Despite international condemnation by politi- Patient Inclusion
cal and medical authorities, deeply entrenched We conducted a single-center retrospec-
social and cultural traditions continue to propa- tive cohort study in our department for plastic
gate FGM/C. Available data from large-scale rep- and reconstructive surgery at the Luisenhospital
resentative surveys estimate that more than 200 Aachen, Germany. All 119 patients who had
million women and girls have been subjected to presented to our department and undergone
various forms of genital mutilation, with 3 million reconstructive surgery between 2014 and 2021
more being at risk every year.4 The practice is pre- for the treatment of symptomatic genital defor-
dominantly concentrated in a swath of countries mities attributable to FGM/C were included ret-
in Africa, extending from the Atlantic coast to the rospectively. Preoperative assessment, surgery,
Horn of Africa, and certain regions of the Middle and postoperative follow-up (inpatient as well
East, most often notwithstanding national legisla- as outpatient) were done by the first author.
tion. Because of globalization and international Presentation occurred either through patient
migration from high-prevalence regions, nonen- self-initiative, nongovernmental organizations,
demic countries have increasingly been confronted or referral by primary health care providers, usu-
with FGM/C and its harmful consequences. ally gynecologists. All primary FGM/C types were
Statistical analyses estimate that 299,520 women included in our study, as well as patients who
and girls from FGM/C-practicing countries have had already undergone surgical intervention
sought asylum in the European Union between elsewhere, such as defibulation (in clinical and
2013 and 2017, with 37% of applicants already hav- nonclinical settings) or unsatisfactory previous
ing experienced FGM/C.5 A data-extrapolation surgery. A clinically plausible correlation between
study based on the results of European census and physical findings and reported symptoms must
demographic data has indicated that, as of 2011, be established to provide eligibility for surgical
more than half a million first-generation women therapy. In cases of suspected psychopathologic
residing in Europe have undergone FGM/C, gen- confounding, surgery was withheld and referral
erally before immigration.6 to psychologic counseling was advised.
Migration and the concomitant change in A comprehensive medical history was taken,
social context can induce or compound pathologic and all patients were examined in a standardized
sequelae of FGM/C.7 As affected women adapt to manner with findings documented and coded using
the customs of the host country and acquire a differ- International Classification of Diseases, 10th Revision,
ent frame of reference, they may become increas- codes as indicated.11 Verbal and written informed
ingly aware of the negative physical, emotional, consent was acquired after extensive patient edu-
and social consequences of FGM/C.8 This may lead cation with respect to anatomy, pathoetiology of
to a major shift in how they perceive the practice symptoms, treatment options and risks, and dis-
and themselves, evoking the sense of being victims cussion of patient expectations. An interpreter
who are defective as women.9 Comparison with was used when necessary. Photographic images
the majority nonexcised female population and of previous cases were shown to demonstrate
exposure to Western representations of feminin- preoperative and postoperative findings. An indi-
ity and sexuality further accentuates this percep- vidualized sketch of the anatomic findings and
tion.10 Correspondingly, Western-based health care proposed surgical strategy were provided to aid in
providers have been confronted with an increas- visualization and improve understanding of the
ing demand for surgical treatment of complica- intended treatment. Our study complies with the
tions as well as reconstruction of female anatomic ethical principles outlined in the Declaration of
units with the aim of reducing physical complaints, Helsinki12 and is based on the specifications of the
improving sexual function, and restoring female Strengthening the Reporting of Observational
appearance and identity. To address this need and Studies in Epidemiology guidelines.13
427
Plastic and Reconstructive Surgery • August 2024
Table 1. Reconstructive Algorithm for FGM/Ca

Removed Tissue (FGM/C Classification)
Type I Type II Type III
a b a b c a b a/b
Prepuce, Minor Labia, Minor Labia, Minor labia, + Prepuce
Reconstructive Clitoral Minor Prepuce, Prepuce, Clitoral Minor labia, Major Labia, and Clitoral
Procedure Prepuce Glans Labia Clitoral Glans Glans, Major Labia Infibulation Infibulation Glans
OD flap X X X X X
NMCS X X X X
aOAP flap X X X X X X
LTRA X X X X X X
Defibulation X X X
aOAP, anterior obturator artery perforator; FGM/C, female genital mutilation/cutting; LTRA, local tissue release and alignment; NMCS, neu-
rotizing and molding of the clitoral stump; OD, omega domed.
a
Modified from O’Dey DM. Vulvar Reconstruction Following Female Genital Mutilation/Cutting (FGM/C) and Other Acquired Deformities. 1st ed. Cham,
Switzerland: Springer International Publishing; 2019.
Operative Techniques
A self-customized algorithm aided the decision-
making process concerning the array of various
reconstructive options of the female genital units
(Table 1). All techniques were developed and
performed by the first author. Procedures were
done under general anesthesia in lithotomy posi-
tion with additional infiltration of local anesthesia
(xylocaine 1% with 1:200,000 epinephrine). We
administered a single shot of cefuroxime 1500 mg
and metronidazole 500 mg intraoperatively as
antibiotic prophylaxis.
Clitoral and Preputial Reconstruction

Omega Domed Flap for Reconstruction of
the Clitoral Hood
The omega domed (OD) flap is a local random-
pattern flap that can be used to reconstruct the
clitoral hood (Figs. 1 and 2). The incision tech-
nique may also serve primarily as a method to
acquire access to the retracted clitoral organ.
After identification of the anterior tip of the clito-
ris, a semicircular incision is made centrally on the
overlying skin and flanked by opposing Z-plasties
laterally. Transposition of the Z-plasty limbs and
elevation of the central semicircular skin flap cre-
ates a structure that domes over the upper pole of
the clitoral tip and whose schematic appearance
resembles an omega. The ventral part and lower
pole of the (neo) glans should remain uncovered Fig. 1. The OD flap. (Above) Incision design and demonstration
by the OD flap, to preserve clitoral sensation and of the underlying clitoral stump. (Below) Flap transposition and
heal by secondary intention. preputial forming. (Reprinted with permission from Schuenke
M, Schulte E, Schumacher U. Prometheus: LernAtlas der Anatomie
Neurotizing and Molding of the Clitoral und Bewegungssystem. 6th ed. Voll M and Wesker K, illustrators.
Stump for Reconstruction and Sensitization of Stuttgart: Thieme; 2022.)
the Clitoral Glans
After careful palpation of the skin, an incision of the clitoral bodies and may be retracted dor-
is made at the presumed location of the clitoral sally because of unopposed pull of the deep sus-
stump. The clitoral stump consists of the remnants pensory clitoral ligaments after (functional) loss
428
Fig. 2. Intraoperative demonstration of the OD flap and neurotizing and molding of the
clitoral stump (NMCS) procedure in a 27-year-old patient with FGM/C type Ib. (Above, left)
Incision design of the OD flap over the palpated location of the underlying clitoral stump.
(Above, right) Demonstration of the freed clitoral stump including parts of suspensory liga-
ments and the partly neurolyzed dorsal clitoral nerves held by vessel loops. (Below, left)
Demonstration of the right dorsal clitoral nerve, held by the upper microforceps, after tun-
neled transposition onto the dissected clitoral stump plateau freed from the suspensory
ligaments, scars, and neuromas. (Below, right) Final intraoperative result of the neoclitoris
created with the NMCS procedure placed inferiorly to and partially covered by the newly
formed preputial hood of the OD flap.
of the superficial suspensory ligament. After exci- the surrounding fibrous tissue. A fundamental
sion of scar tissue and neuromas, the clitoral bod- component of the surgical technique involves the
ies are identified and carefully mobilized from microsurgical dissection and subsequent tunneled
429
Fig. 3. The NMCS procedure. (Left) Tunneled transposition of dorsal clitoral nerves onto the clitoral
stump plateau. (Right) The capping of the clitoral stump and the transposed dorsal clitoral nerves
using the tunica albuginea. (Reprinted with permission from Schuenke M, Schulte E, Schumacher
U. Prometheus: LernAtlas der Anatomie und Bewegungssystem. 6th ed. Voll M and Wesker K, illustra-
tors. Stuttgart: Thieme; 2022.)
transposition of the dorsal clitoral nerves, which form the anatomic basis for complex vulvoves-
lie blindly on the outer surface of the remaining tibular reconstruction and usually precedes the
clitoral organ, into the clitoral stump plateau.14 anterior obturator artery perforator (aOAP) flap
The tunica albuginea is then enveloped around to fill the widened incision site and further add
the clitoral stump plateau (capping procedure) essential tissue and volume to the vulvovestibular
and molded into a conical shape. The newly zone (Fig. 4).
formed, reinnervated clitoral tip is then reposi-
tioned ventrally in an anatomically appropriate Anterior Obturator Artery Flap
position and a 3- to 5-mm section is externalized The aOAP flap is a pedicled fasciocutaneous
(Figs. 2 and 3). perforator flap located in the genitofemoral sul-
Exploration may reveal an intact clitoral cus, which receives its blood supply from the cuta-
organ that has been covered by scar tissue. There neous branch of the obturator artery and vein.15,16
is no indication for the NMCS procedure in these The flap is designed in a pointed elliptical shape
cases, as clitoral reexposure suffices as surgical and tunneled toward the receiving defect. Its
treatment. consistent vascular anatomy, pliability, and easy
accessibility allow for reliable, tension-free tissue
Vulvovestibular Reconstruction transfer and reconstruction of extensive defects
Local Tissue Release and Alignment of the outer female genitalia and vaginal opening
In FGM/C type II and defibulated type III, (Figs. 5 and 6). (See Video [online], which dem-
loss of vulvovestibular tissue combined with scar onstrates anatomic reconstruction in FGM/C type
contractures may lead to impaired closure of the IIc performed in the patient shown in Figures 6
vaginal introitus, leading to chronic exposure of and 7.) Adequate fixation of the fascia lata to the
the vestibule, including the urethral orifice, with inferior pubic ramus during closure of the genito-
consequent drying, irritation, and pain. The lost femoral donor site prevents lateral tension on the
vulvovestibular tissue should therefore ideally be vulva or vaginal opening when the legs are spread
replaced with structurally appropriate, locore- (Figs. 6 through 8).
gional tissue to improve introital covering. To Additional operative techniques were performed
this end, a curved longitudinal incision is made as indicated. These include defibulation in patients
lateral to the vaginal introitus. The adjacent tissue with FGM/C type III, or scar revision and introital
is then mobilized, formed, and released so that it widening using the Z-plasty and variations thereof,
can be advanced medially toward the site of the such as the dancing-man flap. Neuroma formation
excised labias to replace them. The local tissue contributes to the multifactorial occurrence of pain
release and alignment (LTRA) procedure may in women after FGM/C, providing an indication for
430
Fig. 4. A case of defibulation, OD flap, NMCS procedure, LTRA procedure, and aOAP flaps for vul-
voclitoral reconstruction performed in a 23-year-old patient with FGM/C type IIIb after clitoral
amputation, partial excision of the clitoral corpora, excision of the minor labia, partial excision of
the major labia, and infibulation. (Above, left) Initial findings with notably reduced tissue elastic-
ity and demonstration of the operative planning. (Above, right) Dissection and release of the skin
lateral to the vaginal introitus toward the midline (LTRA procedure) after defibulation, OD flap,
and NMCS procedure. (Below, left) The medialized skin covers the newly exposed vestibulum after
defibulation and can be folded and shaped to resemble minor labia. (Below, right) Final intraop-
erative result after defibulation, OD flap, NMCS procedure, LTRA procedure, and inset of the aOAP
flaps. The gained elasticity of the vulva and the vaginal introitus is shown.
excision in each case. Neuroma excision is also essen- with FGM/C type IV was tailored to individual needs
tial for successful reintegration of the dorsal clitoral depending on excised structures and patient-specific
nerves into the clitoral tissue. Treatment for patients findings, such as scarring pattern.
431
Fig. 5. The aOAP flap. (Left) Flap design showing the harvest site in the genitofemoral sulcus. (Right) Inset site
in the vestibular region after tunneled transposition under the major labia. In the case of a preceding LTRA
procedure, the aOAP flaps would be positioned lateral to the released and medialized tissue to fill the widened
incision site. (Reprinted with permission from Schuenke M, Schulte E, Schumacher U. Prometheus: LernAtlas der
Anatomie und Bewegungssystem. 6th ed. Voll M and Wesker K, illustrators. Stuttgart: Thieme; 2022.)
After surgery, all patients were admitted to the appointments after 1, 2, and 6 weeks; 3 months; 6
same ward and received a standardized protocol months; and 1 year. On each occasion, we reevalu-
of antithrombotic measures. The patients were ated symptoms and asked patients to rate clitoral
instructed to lie in supine position with their legs sensation. The occurrence of complications was
gently spread and supported by pillows to avoid documented as well. We analyzed the data docu-
compression of the surgical area. mented preoperatively (baseline) and at 3- and
12-month follow-up.
Data Collection
Characteristics such as age, country of origin, Statistical Analysis
FGM/C classification, and previous procedures Data collection and analysis were performed
were determined during the initial consultation. retrospectively using Excel (version 2019) and
Symptom assessment included dysmenorrhea, SPSS (version 27). Loss to follow-up did not lead
dysuria, and dyspareunia, as well as self-perceived to patient exclusion, as all available data were used
satisfaction with genital appearance, clitoral sen- for analysis. A test of normality (Shapiro-Wilk)
sation, and climax ability. We used a single-item showed nonnormal distribution of the reported
questionnaire based on the visual analog scale clitoral sensation as rated on a VAS scale. We
(VAS) to measure the subjective perception of cli- therefore performed a nonparametric Friedman
toral sensation of our patient population. Clitoral test to assess potential difference in outcome
sensation was assessed by local manual stimula- at 3- and 12-month follow-up as compared with
tion by the examining surgeon, and reported baseline sensation. We used a McNemar test to
through a numeric scale, ranging from 0 (com- compare the ratios of binary answers regarding
plete absence of clitoral sensation) to 10 (high dysmenorrhea, dysuria, dyspareunia, and anor-
sensation and excitability). Patients also reported gasmia at 12-month follow-up compared with
on their ability to achieve an orgasm during sex- baseline.
ual intercourse or masturbation. In consideration
of possible linguistic and sociocultural barriers,
symptom improvement was determined by a com- RESULTS
prehensible, binary questionnaire asking whether Between March of 2014 and December of 2021,
the respective symptoms were present. 119 women with symptomatic genital deformi-
After postoperative hospital discharge, ties after FGM/C were operated on in our depart-
we planned regular outpatient follow-up ment. The mean age of the patients was 31.0 ±
432
Fig. 6. A case of the OD flap, NMCS procedure, LTRA procedure, and aOAP flaps for vulvoclito-
ral reconstruction performed in a 29-year-old patient with FGM/C type IIc after clitoral amputa-
tion, partial excision of the clitoral corpora, excision of the minor labia, and partial excision of the
major labia. See Video [online], for associated supplemental material. (Above, left) Initial findings
with spread vulva. (Above, right) Operative planning showing the aOAP flap design (including
location of the perforator vessels determined by doppler probe), OD flap, and incision markings
for the LTRA procedure. (Below, left) Demonstration of the dissected aOAP flaps after tunneled
medial transposition. The skeletonized perforator pedicles can be seen at the harvest sites. (Below,
right) Final intraoperative result after LTRA procedure, inset of the aOAP and OD flaps, and NMCS
procedure.
10.4 years. The predominant country of origin was symptom prevalence, and complications are dis-
Somalia (35%), followed by Guinea (19%) and played in Table 2.
Eritrea (7.6%). All patients but 1 (0.8%) resided in Complete 1-year follow-up was attended by
Germany at the time of surgery. Demographic char- 112 patients (94.1%), with 2 patients (1.7%) being
acteristics, preoperative diagnoses (FGM/C type), lost to follow-up after the 3-month appointment
433
Fig. 7. Postoperative findings of the patient demonstrated in Figure 6 and the Video, 1 year after surgery. (Left)
Frontal view of the outer genital after reconstruction with the OD flap, NMCS procedure, LTRA procedure, and
aOAP flaps. (Right) Postoperative frontal view with spread vulva showing the inconspicuously healed aOAP
flaps and the epithelialized clitoral tip.
and 5 patients (4.2%) not returning for any of the Transposition of hair follicles in patients who
outpatient follow-up appointments. had undergone the aOAP flap procedure may
We compared mean preoperative and postop- lead to interlabial hair growth, depending on
erative clitoral sensation, as reported by patients preoperative hair growth patterns. This is usu-
undergoing clitoral surgery, on a VAS scale ally inconsequential, as hair growth is sparse and
from 0 to 10. The preoperative score of 1.1 ± 2.8 generally not noticeable. In 2 cases (1.7%), laser
improved significantly, as patients reported mean hair removal was performed because of irritation
clitoral sensation of 7.8 ± 2.1 and 8.2 ± 2.0 at 3- and reduced aesthetics. Three patients devel-
and 12-month follow-up, respectively (P < 0.001). oped a genital abscess related to folliculitis, which
Moreover, there was a significant reduction in the required incision and drainage.
proportion of patients reporting dysmenorrhea,
dysuria, or dyspareunia (P < 0.001). There was
a significant reduction in the number of women DISCUSSION
with anorgasmia (P < 0.001), and 82 patients All women who had undergone surgical
(69%) reported that they had achieved orgasm treatment for FGM/C in our clinic were eligible
through sexual intercourse postoperatively. Of all for inclusion in our study. Patient presentation
patients, 110 (92.4%) were satisfied with the post- occurred both through self-initiative and after pri-
operative appearance, and 109 patients (91.6%) mary referral, limiting selection bias. Therefore,
reported that they had experienced a subjective our patient population is representative of the
increase in their self-perceived femininity (Figs. 7 general population of women who experienced
and 8). FGM/C who are residing in Germany. All proce-
One major complication (unilateral loss of dures were done by the first author, preventing
an aOAP flap) occurred (0.8%). Other com- performance bias. The results of our study dem-
plications were observed in 10 patients (8.4%), onstrate significant improvement of clitoral sen-
including 6 (4.2%) contractures and consequent sation, sexual function, and self-perceived genital
reduction of vaginal elasticity requiring scar revi- aesthetics. Our patients also reported almost com-
sion surgery with Z-plasty or dancing-man flap plete resolution of dysmenorrhea, dysuria, and
as indicated. Among these, 1 case of scarring dyspareunia, as well as increase in climax ability.
(0.8%) led to loss of exposure and sensation of Thabet and Thabet17 first reported on the
the neoglans, which improved after scar revision operative management of FGM/C and surgical
surgery. There was 1 case of wound-healing dis- reconstruction of the clitoris in Egypt in 2003.
order (0.8%), which was débrided and closed by As a result of international migration from high-
secondary suturing. prevalence regions, compounded by humanitarian
434
Fig. 8. A case of defibulation, OD flap, NMCS procedure, LTRA procedure, and aOAP flaps per-
formed in a 26-year-old patient with FGM/C type IIIb after clitoral amputation, partial excision of
the clitoral corpora, excision of the minor labia, partial excision of the major labia, and infibulation.
(Above, left) Initial findings showing tissue loss by infibulation and complex scarring. (Above, right)
Initial findings with spread vulva showing notably reduced tissue elasticity and visibly insufficient
vaginal opening. (Below, left) Postoperative result 1 year after surgery. The LTRA procedure and
the aOAP flaps have created additional tissue volume, projection, and vaginal closure, contribut-
ing to improved form and function of the vulva. (Below, right) Postoperative result 1 year after sur-
gery with spread vulva showing clearly distinguishable reconstructed anatomic units including
the prepuce, the reepithelialized neoclitoris, and the region of both minor and major labia. The
tissue medialized by the LTRA procedure has been formed to resemble minor labia flanked by the
aOAP flaps resembling medial parts of the major labia.
crises, FGM/C has increasingly become a global reconstruction, surgical management of FGM/C
health challenge. A landmark study from France has generally consisted of treatment of secondary
published by Foldès et al.18 in 2012 demonstrated complications, such as cysts and scars, and various
the positive effect of clitoral reconstruction in defibulation techniques.19,20
ritually clitorectomied patients in reducing pain We build on the pioneering work of these
and restoring clitoral sensation and sexual func- colleagues and present several novel techniques
tion. The study boasts a considerable sample size developed by the first author with which we seek
of 2938 patients. However, only 29% attended the to offer a more comprehensive surgical therapy to
1-year follow-up, and 4% were readmitted because restore genital form as well as function in women
of surgical complications. Aside from clitoral who have experienced FGM/C.
435
Table 2. Demographic Characteristics, Diagnoses, makers. In addition, the inclusion of FGM/C in

Clinical Data, and Outcomes the International Classification of Diseases guide-
Characteristics Values a lines in 2013 made complete reimbursement of
Age at surgery, yrs 31.0 ± 10.4 treatment costs by the German health care sys-
Diagnosis (FGM/C type) tem possible,21 minimizing any potential financial
Type I 13 (11) barriers.
Type II 57 (48) Considering the complex nature of sexual plea-

Type III 44 (37) sure and urogenital dysfunction, care must be taken
Type IV 5 (4.2) not to confound anatomic alterations related to

Previous interventions 27 (23) FGM/C with other psychopathologies or patholo-
Reconstruction 3 (2.5) gies.22 History taking should therefore always assess
Defibulation 24 (20) for past incidences of violence, including sexual
Preoperative symptoms
violence, and informed consent must include con-
Dysmenorrhea 68 (57)
Dysuria 32 (27)
sideration of possible posttraumatic stress disorder
Dyspareunia 97 (82) and other forms of psychopathology so that real-
Anorgasmia 108 (90.7) istic expectations may be established. Only after
Postoperative symptoms extensive discussion of surgical risks and possible
Dysmenorrhea 0 shortcomings as well as consideration of conserva-
Dysuria 0 tive treatment options in a nonstigmatizing setting
Dyspareunia 2 (1.7) with respect for individual patient autonomy can
Anorgasmia 3 (2.5) informed consent be taken and surgical therapy
Operative and perioperative data performed. This is in accordance with the latest
Operative time, min 206 ± 128 German gynecologic guidelines for treatment of
OD flap 101 (85) FGM/C.23 Under these circumstances, patients
NMCS procedure 97 (82) have occasionally declined surgery in favor of con-
Clitoral reexposure 8 (6.7)
servative treatment. Patients with extensive cases of
aOAP flap 43 (36)
LTRA 48 (40)
FGM/C may decide on a more limited reconstruc-
Defibulation 26 (22) tive therapy than initially proposed.
Clitoral neuroma excision 101 (85) Our follow-up attendance was high. The com-
Z-plasty 12 (10) plication rate was low, with only 1 major postoper-
Dancing-man flap 16 (13) ative complication requiring readmission. In this
Removal of clitoral cyst 12 (10) case, premature mobilization and inappropriate
Fistula excision 9 (7.6) weight bearing (sexual intercourse and bicycling)
Removal of foreign objects 12 (10) led to unilateral loss of an aOAP flap. Defect clo-
Length of hospital stay, days 6.3 ± 2.5 sure was eventually achieved by bilateral local
Complications 11 (9.2) advancement flaps after débridement. Other
Loss of flap 1 (0.84) minor complications were treated in an ambula-
Scar contracture 6 (5.0) tory setting.
Wound-healing disorder 1 (0.84)
Several limitations should be noted. Although
Abscess 3 (2.5)
a variety of questionnaires have been developed
aOAP, anterior obturator artery perforator; FGM/C, female genital
mutilation/cutting; LTRA, local tissue release and alignment; NMCS, for the purpose of assessing female sexual func-
neurotizing and molding of the clitoral stump; OD, omega-domed. tion and pleasure, none has been validated in
a
Values are expressed as mean ± SD or no. (%). an FGM/C population. Linguistic and cultural
taboos may limit extensive discussion of symptoms
Health practitioners in Germany witnessed a related to FGM/C by the patient.24 We therefore
notable increase in the number of patients seek- opted for a single-item VAS to measure clitoral
ing help after the 2014/2015 migrant crisis. This sensation, and symptom improvement was deter-
is reflected in our own patient numbers, with mined by a binary questionnaire. This approach
growing demand for surgery throughout the years allows for a basic appraisal of the therapeutic
(eg, 7 total operations performed for FGM/C in effect, although conclusive interpretation of
2014, compared with 15 in 2018 and 33 in 2021). results is limited by lack of quantified outcomes.
Besides a surge in the absolute number of affected Although comparison of surgical techniques
women, this could be explained by increasing for clitoral and vulvar reconstruction remains
awareness about FGM/C and its treatment pos- challenging because of a lack of standardized
sibilities among patients, physicians, and policy testing, the discussed novel methods offer several
436
essential functional and aesthetic advantages. 52064 Aachen, North Rhine-Westphalia, Germany
Reconstruction of the clitoral hood with the OD [email protected]
Facebook: Dan O’Dey
flap protects the clitoral glans against friction. The Instagram: @odeydan
microsurgical reintegration of the dorsal clitoral X/Twitter: @ODeyDanmon
nerves induces nerve sprouting into the clitoral
tip and may lead to improved and earlier sensa-
tion of the clitoral tip and increased sexual plea- DISCLOSURE

sure.25 Histologic examination of the neurotized The authors have no competing interests or finan-
clitoral neoglans is not practicable; therefore, we cial disclosures to declare. There was no funding source
rely on clinical results to determine treatment for this study.
effect. Considering that no recurrence of pain was
observed, we hypothesize that the transposition-
ing and enveloping of the refreshed nerves into REFERENCES
their well-vascularized “native” tissue, as opposed 1. World Health Organization. Female genital mutilation.
Available at: https://www.who.int/news-room/fact-sheets/
to leaving them blindly on the surface of the cli- detail/female-genital-mutilation. Accessed June 14, 2024.
toral bodies, prevents new neuroma formation. 2. Buggio L, Facchin F, Chiappa L, Barbara G, Brambilla M,
Although loss of projection of the clitoral tip may Vercellini P. Psychosexual consequences of female genital
occur in the months after reconstruction, no asso- mutilation and the impact of reconstructive surgery: a narra-
ciated loss of clitoral sensation was observed in tive review. Health Equity 2019;3:36–46.
3. Nzinga AM, De ACS, Hermann J, Feipel V, Kipula AJ, Bertuit
our study. J. Consequences of female genital mutilation on women’s
The aOAP flap creates tension-free adapta- sexual health: systematic review and meta-analysis. J Sex Med.
tion of the region of the labia, reducing exposure 2021;18:750–760.
and subsequent mucosal irritation and recurring 4. Ortensi LE, Menonna A. Migrating with special needs?
infections. Compared with other flaps border- Projections of flows of migrant women with female genital
mutilation/cutting toward Europe 2016-2030. Eur J Popul.
ing the urogenital region (eg, Singapore flap), 2017;33:559–583.
a greater degree of tissue pliability and freedom 5. United Nations High Commissioner for Refugees. Too
of orientation exists at insetting, yielding a more much pain, female genital mutilation and asylum in the
favorable cosmetic result. In addition, the flap European Union: a statistical overview. Published February
design hides the donor-site scar in the genito- 2013. Available at: https://www.unhcr.org/us/media/too-
much-pain-female-genital-mutilation-and-asylum-european-
femoral sulcus. The end result is a replacement of union-statistical-overview. Accessed June 14, 2024.
lost tissue that respects the aesthetic units of the 6. Van BL, Ortensi L, Leye E. Estimates of first-generation
female genitalia, with anatomically normal size women and girls with female genital mutilation in the
and projection. European Union, Norway, and Switzerland. Eur J Contracept
Apart from FGM/C, we regularly use the Reprod Health Care 2016;21:474–482.
7. Vloerberghs E, Knipscheer JW, van der Kwaak A, Naleie
described techniques for a variety of other indi- Z. Veiled pain: psychological, social and relational con-
cations, including traumata (eg, impalement sequences of female genital mutilation among immi-
lesions), complex episiotomy injuries, poston- grant women in the Netherlands. Psychologie Gezondheid
cologic reconstruction, skin diseases (eg, lichen 2011;39:145–151.
sclerosus et atrophicans), chronic pain syndromes 8. Pastor-Bravo MDM, Almansa-Martínez P, Jiménez-Ruiz I.
Living with mutilation: a qualitative study on the conse-
(eg, vulvodynia), malformations, and gender reas- quences of female genital mutilation in women’s health and
signment surgery. the healthcare system in Spain. Midwifery 2018;66:119–126.
These techniques contribute to normalization 9. Johnsdotter S. The impact of migration on attitudes to
of the female genital appearance and recovery female genital cutting and experiences of sexual dysfunc-
of physical and psychologic integrity. By allowing tion among migrant women with FGC. Curr Sex Health Rep.
2018;10:18–24.
for safe and effective anatomic reconstruction of 10. Villani M, Bodenmann P. Reparative approaches in medi-
the female genitalia, the described surgical tech- cine and the different meanings of “reparation” for women
niques represent a new stage of treatment possi- with FGM/C in a migratory context. Diversity Equality Health
bilities for women affected by FGM/C. Care 2017;14:264–267.
11. Young J, Nour NM, Macauley RC, Narang SK, Johnson-
Dan mon O’Dey, MD, PhD Agbakwu C; Section on Global Health. Diagnosis, manage-
Department of Plastic, Reconstructive, and ment, and treatment of female genital mutilation or cutting
Aesthetic Surgery in girls. Pediatrics 2020;146:e20201012.
Center for Reconstructive Surgery of Female Genitalia 12. World Medical Association. WMA Declaration of
Luisenhospital Aachen Helsinki: ethical principles for medical research involv-
Teaching Hospital of the Aachen University of Technology ing human subjects. Published September 6, 2022.
Boxgraben 99 Available at: https://www.wma.net/policies-post/
437
wma-declaration-of-helsinki-ethical-principles-for-medical- 20. Krause E, Brandner S, Mueller MD, Kuhn A. Out of Eastern

research-involving-human-subjects. Accessed June 14, 2024. Africa: defibulation and sexual function in woman with
13. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, female genital mutilation. J Sex Med. 2011;8:1420–1425.
Vandenbroucke JP; STROBE Initiative. The Strengthening 21. German Bundestag. On coverage of treatment costs follow-
the Reporting of Observational Studies in Epidemiology ing female genital circumcision. Published 2020. Available
(STROBE) statement: guidelines for reporting observa- at: https://www.bundestag.de/resource/blob/811316/1e
tional studies. Lancet 2007;370:1453–1457. 325ea46ce6fe552731eb6864704bdc/WD-9-078-20-pdf-data.
14. O’Dey DM. Vulvar Reconstruction Following Female Genital pdf. Accessed June 14, 2024.
Mutilation/Cutting (FGM/C) and Other Acquired Deformities. 1st ed. 22. Sharif MF, Wild V, Earp BD, Johnson-Agbakwu C, Abdulcadir
Cham, Switzerland: Springer International Publishing; 2019. J. Clitoral reconstruction after female genital mutilation/
15. O’Dey DM. Complex vulvar reconstruction following female cutting: a review of surgical techniques and ethical debate. J
genital mutilation/cutting. Urologe A. 2017;56:1298–1301. Sex Med. 2020;17:531–542.
16. O’Dey DM, Bozkurt A, Pallua N. The anterior obturator 23. Beckmann MW, Borkenhagen A, Fahlbusch C, et al.
artery perforator (aOAP) flap: Surgical anatomy and appli- Reconstructive and aesthetic surgeries on the female geni-
cation of a method for vulvar reconstruction. Gynecol Oncol. talia. Guideline of the DGGG, DGPRÄC, OEGGG and
2010;119:526–530. SGGG (S2k-Level, AWMF Registry No.009/019, May 2022).
17. Thabet SM, Thabet AS. Defective sexuality and female cir- Geburtshilfe Frauenheilkd. 2023;83:802–826.
cumcision: the cause and the possible management. J Obstet 24. Kimani S, Kabiru CW, Muteshi J, Guyo J. Exploring barriers
Gynaecol Res. 2003;29:12–19. to seeking health care among Kenyan Somali women with
18. Foldès P, Cuzin B, Andro A. Reconstructive surgery after female genital mutilation: a qualitative study. BMC Int Health
female genital mutilation: a prospective cohort study. Lancet Hum Rights 2020;20:3.
2012;380:134–141. 25. Botter C, Sawan D, SidAhmed-Mezi M, et al. Clitoral recon-
19. Nour NM, Michels KB, Bryant AE. Defibulation to treat structive surgery after female genital mutilation/cutting:
female genital cutting: effect on symptoms and sexual func- anatomy, technical innovations, and updates of the initial
tion. Obstet Gynecol. 2006;108:55–60. technique. J Sex Med. 2021;18:996–1008.
438

Anatomical Reconstruction Following Female Genital.42

Uploaded by

Copyright:

Available Formats

Anatomical Reconstruction Following Female Genital.42

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Anatomical Reconstruction Following Female Genital.42

Uploaded by

Copyright:

Available Formats

RECONSTRUCTIVE