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

Anatomy and Therapeutic Options

It is important to first understand normal female genital anatomy to fully appreciate the extent of the anatomical and corresponding physiologic changes in the context of FGM (Figure 3). The clitoris comprises several components that work with other anatomical elements to facilitate aspects of sexual stimulation. The glans is the external portion and is covered by the prepuce or hood. The body connects the glans to the pubic symphysis via the suspensory ligament of the clitoris and to the crura. The crura then attach to the ischiopubic rami.[5] The bulbs engorge during arousal and are situated beneath the labia and are covered by the bulbocavernosus muscle and are innervated by branches of the pudendal nerve. The bulbs provide additional sensory stimulation, aiding in sexual arousal, and engorge with arousal providing vaginal wall rigidity.[23] Sensory tissue under the labia minora and around the urethra are also thought to convey sexual stimuli.[3,5,24]

Figure 3.

Illustration of the female perineum. Used with permission from Chang CS, Low DW, Percec I. Aesthet Surg J. 2017 37(8): 942–46.

In the early to mid 20th century, clitoromegaly was treated with clitoral reduction surgery. Early techniques primarily involved debulking the body of the clitoris. Unfortunately, the now devascularized glans would subsequently necrose. This then lead to the practice of clitorectomy for clitoromegaly. Those patients who underwent clitorectomy were subsequently found to have issues with sexual arousal and satisfaction. Thus, a historic parallel exists between patients who underwent FGM and clitorectomy.[23] However, despite Western medicine's historic experience with clitorectomy and its resulting morphology, little is known about the correlation between each type of FGM and the resulting impact on sexual function/satisfaction.

One possible explanation for this is that many procedures are performed by nonmedical practitioners without a universally accepted technique. Although each practitioner may often perform the same type of FGM in a similar way, their technique may vary considerably from a neighboring practitioner. The high rate of infection, scaring, and trauma (eg, from sexual intercourse) may further add variation to the resultant morphology. Therefore, trying to find patterns across geographic regions and different populations can prove challenging as there can be a high degree of variation within the same type.

Whether secondary to the loss of clitoral tissue, the altered appearance of the female genitalia, or the psychological trauma incurred during the procedure, many women subject to FGM report a deleterious effect on their sexuality. Although some investigators have studied how FGM impacts sexuality and sexual function, there is still a general lack of understanding of the mechanisms by which and the extent to which the changes occur. Alsibiani and Rouzi[12] studied the impact of FGM on sexuality and sexual function by comparing 136 women who had undergone FGM to 130 women who had not using the female sexual function index, a validated tool for assessment of sexual function. They found statistically significant differences in arousal, lubrication, orgasm, and satisfaction. However, their results did not stratify the different types of FGM.[12]

One of the many unanswered questions that have been investigated is whether or not more aggressive types of FGM confer worsening sexual outcomes. Abdulcadir et al.[5] conducted a cross-sectional study to identify the anatomical changes after FGM and attempted to correlate magnetic resonance imaging to changes in sexual function and satisfaction using validated questionnaires.[5] They compared 15 women who had undergone FGM in their home countries, now living in Switzerland, with 15 non-FGM patients, native to Switzerland. They were able to show that FGM patients had smaller volumes of clitoral tissue but were unable to correlate the amount of remaining tissue, and therefore the extent of resection, to sexual function.

Even though the WHO's classification describes type 3 as the total removal of clitoral tissue, typically not all sexually responsive tissue is removed during FGM. Therefore, the possibility exists to restore some or possible all of the function by removing scar tissue and reconstructing the external portion of the organ. Thabet and Thabet[25] and Foldès et al.[26] were among the first to publish on the subject of vulvar/clitoral reconstruction.[27] Many groups have also described their experiences with vulvar reconstruction.[26,28–31] Foldès et al.[26] have subsequently published their results on almost 3,000 FGM reconstructions with a complication rate of 5%. They observed no serious complications or mortality suggesting reconstruction is a safe procedure.[26] Although there is a paucity of high-level literature documenting a causal relationship between vulvar reconstruction and improved sexual function, there is a large body of anecdotal evidence. In addition, the morbidity is acceptably low, thereby providing justification to further pursue vulvar reconstruction.