Addressing Female Genital Mutilation/Cutting (FGM/C) in the Era of Clitoral Reconstruction: Plastic Surgery

FGM/C and clitoral reconstruction are complex issues with medical, social, gendered, and psychosexual implications [9••]. Body image and gender identity play a determinant role in health, well-being, sexuality [15], in all complex and multifactorial aspects for research in the context of clitoral reconstruction. To optimize care for women who have undergone FGM/C, such research could contribute to guidelines for patient selection and who could benefit from surgery.

There is an increasing body of evidence available which explores motives and expectations of women seeking clitoral reconstruction. The reports state that women disclose a desire to improve sexual function, wanting to recover one’s identity, and hoping to reduce vulvar pain as the strongest motives for undergoing clitoral reconstruction [2, 3, 11, 16‐18]. An unpublished study from Sweden shows that women opting for clitoral reconstruction do so as they want to symbolically reclaim what they perceived as forcefully taken from them during the act of cutting, aesthetically repair the visibly “damaged” genitalia, improve their sexual function, and eliminate physical pain. These factors were all intertwined, indicating that the reasons for seeking surgery are often multiple and complex [19].

A recent publication from Germany presents a novel approach in reconstructing both the clitoris as well as the labia majora and clitoral hood [20]. The publication does not describe the surgical techniques in detail, merely presents them as a novelty. The author presents a method he calls “neurotizing and molding of the clitoral stump,” where the clitoral nerves are re-integrated to the distal clitoral stump. A pedicled fasciocutaneous flap is raised from the inner thigh and tunneled to the vulva to reconstruct the labia majora as an aesthetical unit after FGM/C type III (with infibulation) [21]. The flap, designed oval in shape, is based on a perforator from the anterior obturator artery. The clitoral hood is reconstructed with a local skin flap, cranially based, in an omega shape, called the omega dome flap [20, 22].

A preliminary report from Chang et al. [23] of three women undergoing clitoral reconstruction after WHO type II FGM/C describes a novel technique of anchoring the labia majora to the pubic bone to reduce the risk of labial fusion. Furthermore, the authors describe that instead of excising a small part of the skin over the clitoral stump, they incise and spare all the skin, scarred or not, for resurfacing of the labia majora. Instead of releasing the clitoral stump from the pubic bone, as has been described by previous authors [3, 6], only the surrounding tissue was released and labia anchored besides the clitoris. Postoperative wound care of the clitoris was managed with sutured petroleum dressing with daily moistening by the patient with local anesthetic cream and antibiotic ointment until the clitoris re-epithelialized [24].

A recent study from Spain reported the outcome of clitoral reconstruction using vaginal mucosal grafts on 32 women affected by FGM/C. The surgical technique included excision of fibrotic scar tissue, dissection of the suspensory ligament for clitoral stump mobilization, and fixation. The surgeons then harvested a 3–4-cm-long and 2-cm-wide mucosa graft from the posterior vagina that was transplanted on to the reconstructed clitoris up to the labia majora. A urinary catheter was left in place for 5 days while the patient was on bed rest. Loss to follow-up were five patients. The results showed successful graft survival in all cases (n = 27) but two cases of partial necrosis of the graft that healed by secondary intention. Patients answered two validated questionnaires preoperatively and 6 months postoperatively, the Female Sexual Function Index and the Female Genital Self-Image Index. There was a significant increase in the scores of both questionnaires postoperatively. No intraoperative or postoperative complications were noted [25•].

Reconstructive surgery after FGM/C, besides clitoral reconstruction, includes defibulation [26, 27], reconstruction of the labia and removal of cysts [28‐31], and excision of neuromas [32, 33]. These are performed separately or in conjunction with each other to tackle a spectrum of different problems caused by FGM/C. A recent meta-analysis reported a favorable effect of defibulation in general, with respect to cesarean section and perineal tears at birth, as well as an indication of improved sexual function [10••]. A study with a 6-month follow-up on patients operated with excision of cysts has shown a positive outcome when the excision was performed in conjunction with reconstructive surgery of the clitoris, but worsening of sexual function if done solely [6]. A case series published on the effects of excision of neuromas has reported good results [33]. The authors followed up seven women with clitoral pain operated with clitoral reconstruction. Only one of the women was diagnosed with neuroma preoperatively but histological exam revealed neuroma in all seven cases. All women experienced resolution of pain and there were no recurrences of neuroma [33]. A case series of excision of keloids as a complication of FGM/C was recently published. The authors describe clitoral masses of 27 women operated upon. Pathology confirmed all excised masses as keloids and no short-term recurrences (after 1 year) [34].

Sexuality is multifactorial and FGM/C can have a major negative impact, both physically and psychologically, on sexual function [41]. However, not all women subjected to FGM/C experience sexual problems. Some studies indicate that older women that grow up in FGM/C-practicing countries, where being cut is considered normal, have better sexual function compared to women, often younger, who grow up in settings where FGM/C is regarded as mutilation [3, 41]. Women with FGM/C, who are often migrants, also have a higher prevalence of having experienced physical and psychiatric trauma (often resulting from war, rape, and forced marriage) than the majority population in western host countries [42]. Experts in the field have advocated for a multidisciplinary approach by referral centers including psychosexual counseling along with health education with or without subsequent reconstructive surgery for women with FGM/C [1•, 16]. The goal of the multidisciplinary treatment is often to improve psychosexual well-being, treat psychological and sexological comorbidities, and empower women to make an informed decision on treatment choices, which may include clitoral reconstruction, based on medical, psychological, sexological, and cultural aspects [1•, 43, 44].

With regard to surgical reconstruction, the cooperation of different specialties includes the efforts of plastic surgeons, gynecologists, and urologists. Bringing together aspects from the field of experts can enhance and improve the outcome as seen in for example gender reassignment surgery [45]. Gender reassignment surgeons often have extensive knowledge in genital anatomy and well-developed surgical skills with regard to the clitoris. One example is skills in metoidioplasty which is a widely used technique for phallus reconstruction in transsexual men. This technique uses the hypertrophied clitoris, achieved by cross-hormone therapy, to reconstruct a microphallus. To elongate the clitoris, the clitoral hood is lifted and the suspensory ligament dissected and urethral lengthening done with local flaps from adjacent mucosa and labia minora [46]. This underlines the importance of sharing knowledge and skills to the benefit of the relatively new patient group of women who seek reconstructive surgery after FGM/C.

Migration from FGM/C-practicing countries resulted in an estimated 38,000 FGM/C-affected women and girls living in Sweden [47]. This combined with the low overall population numbers in Sweden means that Sweden has one of the highest prevalence figures of women living with FGM/C in Europe. Almost half of the cut women in Sweden are from Somalia where WHO type III FGM/C is common [47]. Because immigration to Sweden from FGM/C-practicing countries is likely to continue, the Swedish health care system must be prepared to receive patients with FGM/C-related health care needs. Clitoral reconstruction was introduced in Sweden in early 2015 and is covered by the National Health Insurance. The team responsible for the patient group decided that the surgery should be carried out in the context of multidisciplinary cooperation, and that the women opting for surgery should meet a psychotherapist and sexologist both pre- and postoperatively. The team includes specialists in gynecology, reconstructive plastic surgery, psychiatry, psychotherapy, sexology, and midwives. Regular multidisciplinary meetings are held to discuss patients and their needs. The patients are planned to be followed up short and long term, at 1 and 3 years post-operatively, and assessed with regard to motives and expectations, psychosexual well-being, complications, and outcome of the surgery.

The surgical protocol for clitoral reconstruction involves general anesthesia. Long-acting local anesthesia as well as postoperative topical and oral analgesia is used. The surgical technique described by Foldès [3] is performed, often with modifications: (1) Full thickness mucosal graft from the lateral vaginal wall is transplanted to the clitoral neo-glans to promote faster healing (Fig. 1); (2) fat grafting of the labia majora and above the clitoris is done in case of severe tissue loss and scarring after FGM/C; (3) local skin flaps are used to reconstruct the clitoral hood if there is sufficient adjacent unscarred skin. Mean operation time is 45 min and length of stay 24 h.

Future research should focus on multicenter collaboration and identifying validated scales, or create new ones, to improve homogeneity of outcome measures.

Engorgement of the clitoral tissue is seen as a prerequisite for orgasm due to the stimuli of the clitoris [12] and, when impaired, can have a significant impact on sexual function. This has been shown in women with atherosclerosis and metabolic syndrome with color Doppler ultrasound [12, 48, 49]. The remaining clitoral tissue of women subjected to FGM/C is often embedded in scar tissue, retracted to the pubic bone [3]. The theory behind clitoral reconstruction is to relieve the clitoral stump from the scar bed, make it more available, and facilitate engorgement and erection for improved orgasmic function. The anatomical study by Abdulcadir et al. [13•] found a slight difference between the total volumes of clitoral and bulbar tissue between cut and uncut women, but not between the volumes of the clitoris alone. To provide information on clitoral erectile insufficiency of women with FGM/C, imaging studies (e.g., ultrasound Doppler, MRI) of both objective and subjective clitoral function of women with FGM/C are warranted. It would be interesting to compare volume differences and blood flow to the clitoris in both non-aroused and aroused state, as well as compare to uncut women and between non-reconstructed and reconstructed women with FGM/C in the context of subjective functionality.

Furthermore, basic plastic surgery treatment principals have been established for vulvovaginal reconstruction for congenital malformations or tissue loss after cancer surgery and trauma. However, these techniques have not yet been described thoroughly for treatment of the FGM/C population of women. The techniques could include free and pedicled flaps and less invasive techniques more likely to be applicable for FGM/C women, like local flaps, fat grafting, full thickness skin, or mucosa grafts. Non-FGM/C-related reconstruction of the labia majora with fat grafting has been reported for both reconstructive [50] and aesthetic [51] purposes. As FGM/C can leave the labia majora scarred [13•] or partially or totally remove them, this procedure could propose a possible beneficial treatment of vulvar pain both from labia majora and clitoral area as for increased protection of sensitive structures of the vulva, vaginal introitus, urethral meatus, and clitoral area after loss of tissue.

In clitoral reconstruction, the neo-glans is left to heal by secondary intention. Full thickness skin grafts and mucosal skin grafts are widely used in reconstructive plastic surgery and could be beneficial for faster healing of the neo-glans, reducing infection rates, postoperative pain, and give a more aesthetically pleasing appearance and texture [25•]. Sensitivity measurements, of vibratory and tactile thresholds, of the clitoris of uncut women exist [52] as well as for transsexual women with reconstructed neo-clitoris [53]. To date, there are no sensitivity measurements of women with FGM/C published. A study of the sensitivity thresholds of women with FGM/C before and after clitoral reconstruction correlated with psychosexual outcome would shine more light on this.