Female Genital Mutilation Reconstruction for Plastic Surgeons

A Call to Arms

Takintope Akinbiyi, MD, MSc; Emily Langston; Ivona Percec, MD, PhD


Plast Reconstr Surg Glob Open. 2018;6(11):e1945 

In This Article

Classification and Sequelae

Many systems have been described to characterize FGM. One of the more popular historic systems was described by Shandall,[13] which was further modified by Verzin[21] in 1975. Currently the most universally recognized and utilized system was developed by the WHO and is illustrated in Figures 1 and 2 and described in Table 1. In brief, type 1 is defined as a partial or total removal of the clitoris, type 2 as the additional removal of labia minora and possibly majora, type 3 as the narrowing of vaginal opening by surgically closing the external portion of the vulva, while type 4 is defined as any other harmful procedure to the female genitalia for nonmedical reasons.

Figure 1.

Schematic representation of The WHO's FGM classification system types 1–3.

Figure 2.

Clinical pictures of WHO female genital mutilation classification type 2 (A) and type 3 with a clitoral remnant cyst (B).

There are a myriad of short- and long-term complications caused by FGM. Most are likely related to the fact that so many procedures are performed: (1) by nonmedical practitioners; (2) with crude and unsharpened instruments that are often not sterilized; (3) under no anesthetic control; and (4) with no follow-up care. Some of the more notable complications include hemorrhage, death, acute or chronic infections, transmission of HIV or hepatitis, dyspareunia, dysmenorrhea, recurrent urinary tract infections (UTIs), psychological disturbances, and higher risk pregnancies.[4,10,22] It is important to note that the full complication profile is unknown because patients with complications may not seek care from the medical establishment secondary to fears of repercussions, shame, or lack of knowledge.

Type 3 "infibulation" involves the surgical narrowing of vaginal opening by closing variable amounts of the external vulva. Urine and menses often flow through a single hole, labeled "watering-can dispersal"[10] (Figure 2B). In many cases, women often have to undergo deinfibulation to reopen the vaginal opening to allow for sexual intercourse and/or childbirth. Even after deinfibulation, some women still experience severe perineal tearing during sexual intercourse and childbirth leading to further scarring. Frustrations with delayed or difficult sexual intercourse can lead to anal intercourse or even using the urethral meatus.[7] Prolonged obstructed labor, secondary to narrowed vulva, and scar tissue can lead to fetal death and vesicovaginal fistulas with ischemia of the septum. Some women will elect to undergo reinfibulation after childbirth, demonstrating how ingrained FGM is in many cultures. Each additional birth then requires another deinfibulation, resulting in multiple procedures and an increased risk of complications.[4] A comprehensive look at both the short- and long-term sequelae is displayed in Table 2.