Reconstruction of the clitoris after female genital mutilation
Professor Hersant - Intimate Surgery at Paris Est Créteil
Reconstruction of the clitoris
Excision is defined as the ritual removal of part of the clitoris. It is now classified by the WHO as female genital mutilation (FGM). This term covers all procedures involving partial or total removal of the external female genitalia or any other injury to the female genital organs, carried out for non-medical reasons(1). Female genital mutilation is internationally recognised as a violation of women’s rights.
Today, it is estimated that 200 million women are circumcised worldwide(2). This type of mutilation is also found among women living in France following successive waves of immigration from sub-Saharan Africa. According to the latest WHO census, there are 90,000 women affected in mainland France.
According to the WHO, female genital mutilation falls into 4 categories:
– Type 1: partial or total removal of the clitoral glans (small, external, visible part of the clitoris and sensitive part of the female genitalia) and/or the clitoral prepuce/capuchon (fold of skin surrounding the clitoris).
– Type 2: partial or total removal of the clitoral glans and labia minora (inner folds of the vulva), with or without excision of the labia majora (outer folds of the vulva).
– Type 3: infibulation: narrowing of the vaginal orifice by covering, performed by sectioning and repositioning the labia minora, or the labia majora, sometimes by suture, with or without removal of the prepuce/clitoral bonnet and glans penis (type 1).
– Type 4: all other harmful interventions to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping and cauterising the genitalia.
The initial technique for reconstructing the clitoris after excision was first described in 2004 by Pierre Foldès(3). It has since undergone a number of modifications and refinements. Nevertheless, surgical treatment cannot be the only therapeutic option available to patients.
Ethnology of excision
The prevalence of female genital mutilation has only been known since the beginning of the twentieth century through the reports of European missionaries in Africa. The first study on the subject was carried out by the Faculty of Medicine at the University of Khartoum in Sudan in 1979. Sudan was therefore the first African country to have complete and reliable statistical data on the frequency of excision. Current estimates are based on the most recent publications and reports produced by WHO and UNICEF.
On an international scale, FGM affects 200 million women alive today. It affects 30 countries on 3 continents (28 countries in Africa, several in Asia and the Middle East, and a few ethnic groups in Central and South America). Half of the victims of excision live in Egypt, Ethiopia and Indonesia (Figure 2). Worldwide, six girls are circumcised every minute(4).
Recent migration has led to an increase in the number of female FGM victims living outside their country of origin. In France, an estimated 60,000 women are living with FGM. Female genital mutilation seems to affect mainly women from Mali, Burkina Faso, Senegal, Guinea and Côte d’Ivoire. According to the French National Institute for Demographic Studies, 45% of women born in a country at risk are mutilated.
Anatomy and function of the clitoris
The clitoris is an essential organ for the proper functioning of three of the four phases of the female sexual cycle: arousal, orgasm and resolution5. Because of its anatomical position, the clitoris is in close contact with the anterior vaginal wall. As a result, the movement of the labia and pressure on the vagina during intercourse result in mobilisation and vibration of the clitoris, allowing it to be stimulated(6).
The anatomical description of the clitoris has only recently been completed(7). Today, we refer to the clitoral complex as a multi-dimensional organ (Figure 3) that can be divided into several segments: the prepuce, glans, body, knee, roots, pillars, clitoral bulbs and clitoral suspensory ligament.
The glans and prepuce make up the visible part of the clitoral complex. The glans is a short erectile organ located in the upper part of the vestibule and totally or partially covered by the prepuce or clitoral bonnet. The clitoral bonnet is formed by the fusion of the two labia minora at the top. The brake is located on the lower part of the clitoris.
The inner part of the clitoris is much larger than the outer part. It contains the largest amount of erectile tissue. The body of the clitoris is made up of two erectile corpora cavernosa. It is connected to the pubic symphysis by the clitoral suspensory ligament. This ligament is a three-dimensional structure, the deep portion of which is fibrous and rigid, while the superficial part is fibro-fatty and therefore more flexible.
The body first extends superiorly, then reverses direction to form the knee of the clitoris and extends inferiorly. It then separates into two roots, each consisting of a corpus cavernosum and extending into the pillars of the clitoris. Each root is attached to the ischiopubic ramus laterally and under the skin.
The bulbs contribute to the rigidity of the external and anterior parts of the vaginal wall. They are located under the labia majora and against the anterior vaginal wall. They correspond to the spongy bodies and become gorged with blood during sexual activity.
The clitoris is vascularised via the dorsal clitoral artery and the superficial and deep perineal arteries, which are all branches of the internal pudendal artery. On the other hand, the bonnet of the clitoris is vascularised by branches of the external pudendal artery. Venous drainage occurs via the dorsal clitoral vein into the vesical venous plexus. The venous circulation of the two corpora cavernosa communicates with that of the two bulbs via the venous plexus of Kobelt.
The clitoral complex is innervated by the dorsal clitoral nerve, a branch of the pudendal nerve. This nerve provides purely somatic innervation. This nerve is divided into two branches which run medial to the clitoral body at a position between 11 o’clock and 1 o’clock.
Anatomical areas at risk during clitoral surgery
During clitoral surgery, there are a number of anatomical structures and danger zones that you need to be aware of to avoid damaging the function of this organ.
The first danger zone is located on the dorsal side of the body of the clitoris, between 11 o’clock and 1 o’clock. This is where two very important symmetrical structures run: the dorsal clitoral artery and the dorsal clitoral nerve(8). It is therefore important to perform dissections, haemostasis and section of the suspensory ligament away from this area (Figure 4).
The second danger zone is located anterior to the area where the body of the clitoris separates into two roots. This is the venous plexus of Kobelt (Figure 5), which is crucial for venous drainage of the clitoral bulbs, which play a very important role in clitoral function.
Pre-operative preparation
The reasons for an initial consultation in the context of excision surgery can be varied, and this consultation is not usually carried out directly with the plastic surgeon. The reasons for consultation are usually multiple, and we need to know how to respond to all these complaints, even when the patient is consulting us for the first time.
Where our expertise comes into its own is when the request is about the appearance of sex, and the patient is ashamed of her mutilated body. In our Western society, where genital aesthetic surgery is increasingly present, and where excision is not a cultural practice, women who have undergone it can feel stigmatised by the mere gaze of their partner(s). Aesthetic demand is therefore crucial to assess.
The complaint may also be psychological. In this case, our expertise may have its limits. The psychological disorders that accompany excision are more often linked to the history of the patients who have undergone this mutilation, than to the act itself (although states of post-traumatic stress can result from the act). The backgrounds of these immigrant patients have often been long and painful, marred by rape, war, forced marriage and other atrocities. In such cases, it is important to ask patients about their history, and not to hesitate to refer them to a psychologist before any reconstruction operation, even if they insist on a rapid reconstruction, which they feel could be the “miracle” solution. Regular follow-up before and after the operation will enable these women to rebuild themselves psychologically at the same time as their physical reconstruction.
Complaints can also be sexological in origin. These may relate to a lack of pleasure, pain during intercourse or the need to feel pleasure in order to give it to one’s partner. The sexual function of patients who have undergone FSM is most often impaired, and they experience difficulties with arousal, pleasure and orgasm, diminishing their sexual satisfaction. However, it’s important to distinguish these from the sexological problems that any woman may present outside of FSM. Clitoral transposition surgery will not, for example, resolve a sexual desire problem that may be linked to other factors. In such cases, the patient should not hesitate to be referred to a sexologist for an initial assessment, to identify any risk of dissatisfaction despite the operation.
Finally, sometimes a woman who has undergone female circumcision may wish to undergo surgery solely to repair the damage she has suffered, despite her satisfactory sexual function. In this case, the operation should not be refused, but it is important that she should also be able to discuss her sense of loss of identity with a psychologist.
Similarly, it may be important to carry out a gynaecological check-up before the operation if these women have had no previous gynaecological check-ups.
Surgical technique for clitoral transposition
The first techniques for surgical transposition of the clitoris were described by Thabet in Egypt(9) and by Foldès in France in 2004. Subsequent modifications of the technique have been reported by plastic surgeons such as O’Dey in Germany(10), Chang in the USA(11) and Manero in Spain(12). At present, there are 5 techniques performed by 3 types of specialists (urologists, gynecologists and plastic surgeons).
Installation and anesthesia
The patient is positioned supine in the gynecological position. The procedure can be performed under general anesthesia or spinal anesthesia. For antibiotic prophylaxis, Cefazolin 2 grams is used. Surgery is performed on an outpatient basis.
Incision of the scarred skin zone
The area to be incised often has an irregular scar, even keloid. The incision is made with a cold-blade scalpel in an inverted median V-shape (Figure 6).
Dissection of the body and pillars of the clitoris
a 4-0 Vicryl rapid suture is placed over the sclerotic nodule at the clitoral excision site, and clamped to pull and tension the clitoral body to facilitate dissection (Figure 7). Initial dissection of the body is performed with Metzenbaum scissors, preserving the median area of the dorsal surface of the clitoris where the artery and dorsal nerve of the clitoris run. Dissection in contact with the lateral surfaces of the clitoris is carried out right up to the pubic symphysis. It is possible to perform punctiform hemostasis with bipolar forceps, while preserving the dorsal median zone. Sappey’s sacks of fat are then pushed back on either side by retractors, to free the clitoral knee giving rise to the roots. During this release, it is important to maintain good contact with the posterior surface of the pubic symphysis, away from the clitoris. The suspensory ligament is then isolated.
Sectioning the clitoral suspensory ligament
This step is crucial to correctly freeing the clitoris. The ligament is tensioned by pulling on the thread previously placed on the sclerotic nodule of the clitoris. The dissection zone in contact with the pubic symphysis is then an avascular zone, at a distance from the dorsal nerve. The suspensory ligament is then cut as close as possible to the pubic symphysis. This procedure allows optimal mobilisation of the clitoris for transposition (Figure 8).
Resection of scar tissue (sclerotic nodule)
Resection of the sclerotic nodule distal to the clitoral body is necessary to reduce pain and improve sensation. Resection can be performed with a cold blade or scissors.
Transposition of the clitoris
The clitoral neo-gland, freed from its sclerotic nodule, is then pulled and transposed at the skin incision. To restore normal anatomy, the new clitoral head needs to be externalised about half a centimetre from the cutaneous plane.
Suturing the neo-clitoris
The two sacs of Sappey on either side of the clitoris are brought together with two stitches of 2-0 Vicryl to prevent the clitoris from re-ascending. The neo-clitoris is then attached to the skin with separate mucocutaneous stitches of Vicryl rapid 4-0 around the clitoris, taking care to avoid stitches at the upper median level so as not to damage the vascular-nervous pedicle (Figure 9). It is important to allow the neo-clitoris to protrude approximately 5 mm from the vulvar skin, in order to recreate the original anatomy.
Post-operative care
The patient is given a prescription for local care and level 1 and 2 analgesics. This consists of gentle daily washing with soap and water in the shower, and the application of a compress soaked in antiseptic (vaginal betadine) twice a day for 1 month. It may also be useful to prescribe xylocaine gel to be applied several times a day to the operated area to reduce pain, which is significant in the first week. The patient is given 1 week’s leave from work.
Patients are reviewed at 7 days, 1 month, 6 months and 1 year to assess the cosmetic, sensory, sexual and psychological results. It is important to explain to patients that the neo-clitoris will keratinize over time and will take on its definitive colour after 6 months to 1 year (Figure 10).
Complications
Most authors report only minor complications. The most commonly reported complication is scar dehiscence and retraction of the neo-gland into its original position. Scar-related pain may also occur at a distance. Post-operative neuroma has also been described by various authors and can be difficult to treat. Finally, more serious complications such as post-operative haemorrhage and infection can sometimes occur, but their incidence remains to be assessed.
Bibliography
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