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O'Dey DM, Kameh Khosh M, Boersch N. Anatomical Reconstruction following Female Genital Mutilation/Cutting. Plast Reconstr Surg 2024; 154:426-438. [PMID: 37647530 DOI: 10.1097/prs.0000000000011026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND International migration from high-prevalence regions has increasingly confronted nonendemic countries with female genital mutilation/cutting (FGM/C), and Western-based health care providers have seen a greater 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 outcomes of the omega domed flap, neurotizing and molding of the clitoral stump (NMCS procedure), and anterior obturator artery perforator flap for preputial, 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 sensation 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 ability 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. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Dan Mon O'Dey
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Hand Surgery, Center for Reconstructive Surgery of Female Genitalia, Luisenhospital Aachen, Teaching Hospital of the Aachen University of Technology
| | - Masih Kameh Khosh
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Hand Surgery, Center for Reconstructive Surgery of Female Genitalia, Luisenhospital Aachen, Teaching Hospital of the Aachen University of Technology
| | - Nina Boersch
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Hand Surgery, Center for Reconstructive Surgery of Female Genitalia, Luisenhospital Aachen, Teaching Hospital of the Aachen University of Technology
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Lopez CD, Yusuf CT, Girard AO, Lake IV, Cooney DS, Redett RJ. Penile Transplantation in Gender Affirmation Surgery: A Theoretical Feasibility Study. J Reconstr Microsurg 2024; 40:96-101. [PMID: 37142254 DOI: 10.1055/a-2085-9943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND It can be argued that individuals in the transgender and gender nonbinary (TGNB) community suffer from a similar impact on quality of life in the face of gender dysphoria, with psychosocial and physical consequences. Indications for penile allotransplantation for patients wishing to undergo gender affirmation surgery have yet to be elucidated, but technical lessons for feasibility can be gleaned from penis transplants that have already been performed on cisgender males to date. METHODS This study investigates the theoretical feasibility for penile-to-clitoral transplantation, prior penile transplants, and current multidisciplinary gender affirmation health care modalities. RESULTS Penile allotransplantation offers a potential solution for individuals in the TGNB community for a more aesthetic penis, improved erectile function without the need of a prosthesis, optimal somatic sensation, and improved urethral outcomes. CONCLUSION Questions remain about ethics, patient eligibility, and immunosuppressive sequelae. Before these issues are addressed, feasibility of this procedure must be established.
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Affiliation(s)
- Christopher D Lopez
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cynthia T Yusuf
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Plastic and Reconstructive Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Alisa O Girard
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Isabel V Lake
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Damon S Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Chaisson N, Johnson-Agbakwu CE, Finch A, Salad M, Connor JJ, Chen M, Robinson BBE. Beautiful vulvas: expanding illustrative visual imagery of female genital cutting types. J Sex Med 2023; 20:1301-1311. [PMID: 37721173 PMCID: PMC10627781 DOI: 10.1093/jsxmed/qdad102] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/18/2023] [Accepted: 06/04/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Visual imagery has been used to educate healthcare providers, patients, and the lay public on female genital cutting (FGC) typology and reconstructive procedures. However, culturally inclusive, diverse, and anatomically accurate representation of vulvas informed by women possessing lived experience of FGC is lacking. AIM We sought to apply World Health Organization (WHO) FGC typology to the development of type-specific visual imagery designed by a graphic artist and culturally informed by women with lived experience of FGC alongside a panel of health experts in FGC-related care. METHODS Over a 3-year process, a visual artist created watercolor renderings of vulvas with and without FGC across varying WHO types and subtypes using an iterative community-based approach. Somali women possessing lived experience of FGC were engaged alongside a team of clinician experts in FGC-related care. Women and clinicians provided descriptive input on skin color variation, texture, and skin tone, as well as the visual depiction of actions necessary in conducting a genital examination. OUTCOMES A series of vulvar anatomic illustrations depicting WHO FGC typology. RESULTS FGC types and subtypes are illustrated alongside culturally informed descriptors and clinical pearls to strengthen provider competency in the identification and documentation of FGC WHO typology, as well as facilitate patient education, counseling, shared decision making, and care. CLINICAL IMPLICATIONS Ensuring equitable representation of race, gender, age, body type, and ability in medical illustrations may enhance patient education, counseling, and shared decision making in medical and/or surgical care. FGC provides a lens through which the incorporation of patient-informed and culturally relevant imagery and descriptors may enhance provider competency in the care of FGC-affected women and adolescents. STRENGTHS AND LIMITATIONS The strengths of this study include the development of visual imagery through an iterative community-based process that engaged women with lived experience of FGC alongside clinicians with expertise in FGC-related care, as well as the representation of historically underrepresented bodies in the anatomical literature. Study limitations include the lack of generalizability to all possible forms or practices of FGC given the focus on one geographically distinct migrant community, as well as the reliance on self-report given the inability to clinically verify FGC status due to the community-based methodology employed. CONCLUSION Patient-informed and culturally representative visual imagery of vulvas is essential to the provision of patient-centered sexual health care and education. Illustrations developed through this community-engaged work may inform future development of visual educational content that advances equity in diverse representation of medical illustrations.
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Affiliation(s)
- Nicole Chaisson
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Crista E Johnson-Agbakwu
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, UMass Chan Medical School and UMass Memorial Health, Worcester, MA, United States
| | - Ashley Finch
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Munira Salad
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Jennifer Jo Connor
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Muzi Chen
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Beatrice Bean E Robinson
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, United States
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von Fritschen U, Strunz C, Scherer R, von Fritschen M, Fricke A. Postoperative Course of Reconstructive Procedures in FGM Type III-Proposal for a Modified Classification of Type III Female Genital Mutilation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4439. [PMID: 36901456 PMCID: PMC10002091 DOI: 10.3390/ijerph20054439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Reconstruction after female genital mutilation (FGM) has developed from being merely a therapy for complications to addressing body perception and sexuality. However, evidence regarding a direct correlation between FGM and sexual dysfunction is scarce. The present WHO classification provides an imprecise grading system, which makes it difficult to compare present studies with treatment outcomes. The aim of this study was to develop a new grading system based on a retrospective study of Type III FGM, evaluating operative time and postoperative results. METHODS The extent of clitoral involvement, operative time of prepuce reconstruction and lack of prepuce reconstruction, and postoperative complications of 85 patients with FGM-Type III were retrospectively analyzed at the Desert Flower Center (Waldfriede Hospital, Berlin). RESULTS Even though universally graded by the WHO, large differences in the degree of damage were found after deinfibulation. In only 42% of patients, a partly resected clitoral glans was found after deinfibulation. There was no significant difference in operative time when comparing patients who required prepuce reconstruction and patients who did not (p = 0.1693). However, we found significantly longer operative time in patients who presented with a completely or partly resected clitoral glans when compared to patients with an intact clitoral glans underneath the infibulating scar (p < 0.0001). Two of the 34 patients (5.9%) who had a partly resected clitoris required revision surgery, while none of the patients in whom an intact clitoris was discovered under the infibulation required revision. However, these differences in the complication rates between patients with and without a partly resected clitoris were not statistically significant (p = 0.1571). CONCLUSIONS A significantly longer operative time was found in patients who presented with a completely or partly resected clitoral glans when compared with patients with an intact clitoral glans underneath the infibulating scar. Furthermore, we found a higher, though not significantly significant, complication rate in patients with a mutilated clitoral glans. In contrast to Type I and II mutilations, the presence of an intact or mutilated clitoral glans underneath the infibulation scar is not addressed in the present WHO classification. We have developed a more precise classification, which may serve as a useful tool when conducting and comparing research studies.
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Affiliation(s)
- Uwe von Fritschen
- Department of Plastic and Aesthetic Surgery, Hand Surgery, HELIOS Hospital Emil von Behring, Walterhöferstr. 11, 14165 Berlin, Germany
| | - Cornelia Strunz
- Desert Flower Center, Center of Colorectal and Pelvic Floor Surgery, Hospital Waldfriede, Argentinische Allee 40, 14163 Berlin, Germany
| | - Roland Scherer
- Desert Flower Center, Center of Colorectal and Pelvic Floor Surgery, Hospital Waldfriede, Argentinische Allee 40, 14163 Berlin, Germany
| | - Marisa von Fritschen
- Department of Plastic and Aesthetic Surgery, Hand Surgery, HELIOS Hospital Emil von Behring, Walterhöferstr. 11, 14165 Berlin, Germany
| | - Alba Fricke
- Department of Plastic and Aesthetic Surgery, Hand Surgery, HELIOS Hospital Emil von Behring, Walterhöferstr. 11, 14165 Berlin, Germany
- Department of Plastic and Hand Surgery, University of Freiburg Medical Centre, Medical Faculty of the University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
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Uloko M, Isabey EP, Peters BR. How many nerve fibers innervate the human glans clitoris: a histomorphometric evaluation of the dorsal nerve of the clitoris. J Sex Med 2023; 20:247-252. [PMID: 36763957 DOI: 10.1093/jsxmed/qdac027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION It is frequently quoted in mainstream media that the clitoris has "8000 nerve endings." However, no study has yet quantified the number of nerve fibers (axons) innervating the human clitoris. The dorsal nerves of the clitoris (DNCs) are the primary source of sensation and somatic clitoral innervation. Therefore, reporting the number of axons in the DNCs is an important step in our understanding of clitoral innervation and sexual response with implications for many fields of medical practice. The purpose of this study is to quantify the mean number of axons in the human DNCs and to report the approximate mean number of nerve fibers that innervate the human glans clitoris. METHODS DNC samples were obtained from 7 transmasculine patients undergoing gender-affirming phalloplasty surgery. At the time of nerve coaptation, a small excess of the DNC (5 mm) was collected for analysis at the proximal level of the clitoral body, just distal of the emergence of the DNCs from underneath the pubic symphysis. Samples were placed into 3% glutaraldehyde fixative, postfixed in 1% osmium tetroxide, and serially dehydrated in ethanol and toluene. Samples were then embedded in araldite, sectioned on an ultramicrotome into 1-μm cross sections, and counterstained with 1% toluidine blue. Histomorphometric evaluation was performed at 1000x magnification with a Leitz Laborlux S microscope and image analysis software (Clemex Vision Professional) to obtain an axon counts. Descriptive statistics were performed to yield a mean and standard deviation of the number of axons in the DNCs. Assuming anatomic symmetry between bilateral DNCs, mean total number of somatic nerve fibers innervating the human glans clitoris was obtained by doubling the mean count of the DNCs. RESULTS Seven sample DNCs were collected. Of those, 5 were analyzed as 2 did not have sufficient nerve tissue present. The mean number of nerve fibers in the human DNCs was 5140 (SD = 218.4). The mean number of myelinated nerve fibers innervating the human clitoris was 10,281 (SD = 436.8). CONCLUSION This study is the first to report the number of axons in the human DNC, at a mean 5140. Given the bilateral nature of clitoral innervation and symmetry of anatomic structures, the approximate mean number of myelinated axons that innervate the human glans clitoris is 10,280. When the uncaptured unmyelinated fibers and contributions from the cavernosal innervation are accounted for, it is clear that far Moree than 8000 axons innervate the human clitoris.
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Affiliation(s)
- Maria Uloko
- Department of Urology, University of California San Diego, San Diego, CA 92121, United States
| | - Erika P Isabey
- Department of Obstetrics and Gynecology, University of Manitoba, Winnipeg R3E EP5, Canada
| | - Blair R Peters
- Transgender Health Program, Oregon Health & Science University, Portland, OR 97239, United States.,Division of Plastic Surgery, Oregon Health & Science University, Portland, OR 97239, United States
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Tognazzo E, Berndt S, Abdulcadir J. Autologous Platelet-Rich Plasma in Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: A Pilot Case Study. Aesthet Surg J 2023; 43:340-350. [PMID: 36251970 DOI: 10.1093/asj/sjac265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/07/2022] [Accepted: 10/07/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Postoperative healing after clitoral reconstruction (CR) for female genital mutilation/cutting can be long and painful due to prolonged clitoral re-epithelialization time (up to 3 months). Autologous platelet-rich plasma (A-PRP) might reduce postoperative clitoral epithelialization time and pain. OBJECTIVES The authors assessed postoperative clitoral re-epithelialization time and pain after intraoperative clitoral administration of A-PRP. METHODS Five consecutive women underwent CR (Foldès technique) followed by the administration of A-PRP Regen Lab SA (Le Mont-sur-Lausanne, Switzerland) plasma and glue, injected inside and applied above the re-exposed clitoris, respectively. We recorded surgical complications, postoperative clitoral pain (visual analogue scale), painkiller intake, time to complete re-epithelialization, and the experienced subjective changes in sexual response and perception of their own body image referred by women. RESULTS Sexual distress/dysfunction as well as the desire to be physically and symbolically "repaired" were the reasons behind women's requests for surgery. None of the women suffered from chronic vulvar or non-vulvar pain. All women achieved complete clitoral epithelialization by day 80, 3 women between day 54 and 70, and only 1 woman was still taking 1 g of paracetamol twice a day at 2 months postoperative. She had stopped it before the 3-month control. There were no short- or long-term complications. All women described easier access and stimulation of their clitoris as well as improved sexual arousal, lubrication, and pleasure and claimed to be satisfied with their restored body image. CONCLUSIONS A-PRP could expedite postoperative clitoral epithelialization and reduce postoperative pain after CR after female genital mutilation/cutting. LEVEL OF EVIDENCE: 4
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Bazzoun Y, Aerts L, Abdulcadir J. Surgical Treatments of Chronic Vulvar Pain After Female Genital Mutilation/Cutting. J Sex Med 2022; 19:290-301. [PMID: 35000888 DOI: 10.1016/j.jsxm.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/18/2021] [Accepted: 11/19/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Vulvar and in particular clitoral pain can affect women with Female Genital Mutilation/Cutting (FGM/C). To date, there is no comprehensive study on the different available treatments for vulvar pain after FGM/C. AIM To study the outcome of surgical treatments of vulvar and/or clitoral pain among women living with FGM/C. METHODS Retrospective review of the consecutive medical files of all 506 women who consulted at a specialized outpatient clinic for women with FGM/C between April 1, 2010 and December 31, 2017. OUTCOME Subjective change in chronic vulvar pain after surgical treatment. RESULTS In total, 36.1% of women (n = 183) experienced chronic pain, all types included, among which 2.8% (n = 14) experienced provoked or unprovoked chronic vulvar pain. Among the 14 women with provoked or unprovoked chronic vulvar pain, ten (71.4%) underwent surgical treatment: 7 underwent resection of vulvar scar complications (cysts, bridles, adhesions) with (n = 4) or without (n = 3) concomitant defibulation, 3 had clitoral reconstruction and one had labium reconstruction with removal of peri-clitoral adhesion. Nine out of ten (90%) experienced resolution of pain after surgery and the remaining woman (10%) was lost to follow-up. CLINICAL IMPLICATIONS Safe and effective surgical treatments exist and patients with chronic vulvar pain post-FGM/C should be referred to specialists who would consider appropriate indications for surgery and support informed decision-making and treatment. STRENGTHS & LIMITATIONS The strengths of this research are the big sample size of women from diverse cultural and religious backgrounds, as well as the availability of pre- and postsurgery iconographic material and histology. Limitations include a subjective reporting of pain without validated questionnaires. CONCLUSION Effective surgical treatments for provoked or unprovoked chronic vulvar pain post-FGM/C are clitoral reconstruction, defibulation, cystectomy, and bridle removal. Surgical treatments should be combined with a culturally sensitive multidisciplinary care and follow-up. Bazzoun Y., Aerts L., Abdulcadir J. Surgical Treatments of Chronic Vulvar Pain After Female Genital Mutilation/Cutting. J Sex Med 2022;19:290-301.
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Affiliation(s)
- Yara Bazzoun
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Leen Aerts
- Division of Gynaecology, Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Jasmine Abdulcadir
- Division of Gynaecology, Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland.
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Gutierrez-Ontalvilla P, Andjelkov K, Ruiz-Valls A. Invited Discussion on: Clinical and Patient Reported Outcomes of 19 Patients Undergoing Clitoral and Labial Reconstruction After Female Genital Mutilation/Cutting. Aesthetic Plast Surg 2022; 46:478-479. [PMID: 34859272 DOI: 10.1007/s00266-021-02696-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 11/21/2021] [Indexed: 11/30/2022]
Affiliation(s)
- P Gutierrez-Ontalvilla
- Department of Plastic and Reconstructive Surgery, La Fe University Hospital, Tower E, 2th Floor, 106 Avenida Abril Martorell, 46026, Valencia, Spain.
| | - K Andjelkov
- Faculty of Medicine and BelPrime Clinic, University of Belgrade, Belgrade, Serbia
| | - A Ruiz-Valls
- Department of Plastic and Reconstructive Surgery, La Fe University Hospital, Tower E, 5th Floor, 106 Avenida Abril Martorell, 46026, Valencia, Spain
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Botter C, Botter M, Pizza C, Charpy C, Pineau V, La Padula S, Meningaud JP, Hersant B. The Suspensory Ligament of the Clitoris: A New Anatomical and Histological Description. J Sex Med 2022; 19:12-20. [PMID: 34802957 DOI: 10.1016/j.jsxm.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/03/2021] [Accepted: 10/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The importance of the clitoris as an organ has been neglected by doctors and anatomists over the centuries. Its central role in female sexuality is widely recognized and respected. Although multiple studies have been conducted on the fundiform ligament of the penis, the literature concerning the suspensory ligament of the clitoris is extremely poor. The possibility to describe its complex structure may help us understand female orgasm and sexuality. AIM Carrying out an anatomical and histological study about the supporting ligaments of the clitoris and in particular the suspensory ligament of the clitoris. STUDY DESIGN A total of 10 female cadavers were dissected specifically for this study. All the supporting structures of the clitoris were studied, photographed and measured. A histological study of these structures was also carried out. RESULTS The suspensory ligament of the clitoris is a multidimensional structure consisting of three anatomically and histologically distinct components. The superficial layer originates from the anterior abdominal wall, it is the anatomical extension of the fascia superficialis of the abdomen. It mainly consists of loosely organized elastic fibers, fibroblasts and few loosely organized collagen fibers. The intermediate component also originates from the anterior abdominal wall through the extensions of the abdominal aponeurosis that reach the body of the clitoris. It completely encloses the clitoral body and sends lateral extensions to the labia majora. Histologically, this layer mainly consists of well-organized collagen fibers as well as fibroblasts. The deep component is shorter and extends from the pubic symphysis to the knee of the clitoris and also connects the two crus to the pubic symphysis. It almost exclusively consists of very well organized collagen fibers. CONCLUSION The suspensory ligament of the clitoris is a multidimensional structure that extends from the anterior abdominal wall to the clitoris. Unlike previous descriptions of the ligament supporting the clitoris, we observed that this structure consists of three anatomically and histologically distinct layers. These new anatomical considerations must be taken into account for any surgery affecting the subcutaneous tissues of the pubis and the abdomen as well as for reconstructive surgery of the clitoris and metoidioplasty.
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Affiliation(s)
- Charles Botter
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Mégane Botter
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Chiara Pizza
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Cécile Charpy
- Department of Anatomic pathology, Henri Mondor Hospital, Créteil, France
| | - Virginie Pineau
- Department of Plastic, Reconstructive, Aesthetic Surgery, Rene Huguenin Curie Institute, Saint-Cloud, France
| | - Simone La Padula
- Department of Anatomic pathology, Henri Mondor Hospital, Créteil, France
| | - Jean-Paul Meningaud
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Barbara Hersant
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
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Manin E, Taraschi G, Berndt S, Martinez de Tejada B, Abdulcadir J. Autologous Platelet-Rich Plasma for Clitoral Reconstruction: A Case Study. ARCHIVES OF SEXUAL BEHAVIOR 2022; 51:673-678. [PMID: 34779981 PMCID: PMC8858308 DOI: 10.1007/s10508-021-02172-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 06/13/2023]
Abstract
Clitoral reconstruction after female genital mutilation/cutting (FGM/C) is associated with significant post-operative pain and months-long recovery. Autologous platelet-rich plasma (A-PRP) reduces the time of healing and pain in orthopedic and burn patients and could also do so in clitoral reconstruction. In the present case, a 35-year-old Guinean woman who had undergone FGM/C Type IIb presented to our clinic for clitoral reconstruction. Her request was motivated by low sexual satisfaction and body image. We surgically reconstructed the clitoris using the Foldès method and applied plasma and glue of A-PRP. The patient was highly satisfied with the procedure. Two months post-operatively, her pain had ceased entirely and re-epithelialization was complete. We conclude that A-PRP may improve pain and healing after clitoral reconstruction. Extensive studies investigating long-term outcomes are needed.
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Affiliation(s)
- Emily Manin
- Weill Cornell Medical College, New York, NY, USA
| | - Gianmarco Taraschi
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, 30 Blvd de la Cluse 1211, 14, Geneva, Switzerland
| | - Sarah Berndt
- Regen Lab SA, En Budron b2, 1052, Le Mont-sur-Lausanne, Switzerland
| | - Begoña Martinez de Tejada
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, 30 Blvd de la Cluse 1211, 14, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jasmine Abdulcadir
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals, 30 Blvd de la Cluse 1211, 14, Geneva, Switzerland.
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11
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Bah M, Abdulcadir J, Tataru C, Caillet M, Hatem-Gantzer G, Maraux B. Postoperative pain after clitoral reconstruction in women with female genital mutilation: An evaluation of practices. J Gynecol Obstet Hum Reprod 2021; 50:102230. [PMID: 34536588 DOI: 10.1016/j.jogoh.2021.102230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/14/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION More than 200 million women and girls have undergone genital mutilation. Clitoral reconstruction (CR) can improve the quality of life of some of them, but is accompanied by significant postoperative pain. OBJECTIVE Assess and describe the management of postoperative pain after CR, and the practices amongst specialists in different countries. METHODS Between March and June 2020, 32 surgeons in 14 countries (Germany, Austria, Belgium, Burkina Faso, Canada, Ivory Coast, Egypt, Spain, United States of America, France, the Netherlands, Senegal, Switzerland, Sweden) responded to an online questionnaire on care and analgesic protocols for CR surgery. RESULTS At day 7 post CR, 97% of the surgeons observed pain amongst their patients, which persisted up to 1 month for half of them. 22% of the participants reported feeling powerless in the management of such pain. The analgesic treatments offered are mainly step II and anti-inflammatory drugs (61%). Screening for neuropathic pain is rare (3%), as is the use of pudendal nerve block, used by 8% of the care providers and only for a small percentage of women. CONCLUSION Pain after CR is frequent, long-lasting, and potentially an obstacle for the women who are willing to undergo clitoral surgery and also their surgeons. Most surgeons from different countries follow analgesic protocols that do not use the full available therapeutic possibilities. Early treatment of neuropathic pain, optimisation of dosing of standard analgesics, addition of opioids, use of acupuncture, and routine intraoperative use of pudendal nerve block might improve the management of pain after CR.
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Affiliation(s)
- Marly Bah
- Service de Gynécologie-Obstétrique, Hôpital Lariboisière, 2 Rue Ambroise Paré, 75010 Paris, France; La Maison des Femmes, Hôpital Delafontaine, Saint Denis, 1 Chemin du Moulin Basset, 93200 Saint-Denis, France.
| | - Jasmine Abdulcadir
- The Obstetrics-Gynaecology Emergency Unit FGM/C Outpatient clinic, Department of Woman, Child and Adolescent, Faculty of Medicine. UNIGE, Rue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland
| | - Consuela Tataru
- Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Centre Hospitalier Intercommunal de Créteil, Université́ Paris-Est Val de Marne, 40 avenue de Verdun, 94000 Créteil, France
| | - Martin Caillet
- Département de Gynécologie-Obstétrique, CHU Saint Pierre, Rue Haute, 322, 1000 Bruxelles, Belgique
| | - Ghada Hatem-Gantzer
- La Maison des Femmes, Hôpital Delafontaine, Saint Denis, 1 Chemin du Moulin Basset, 93200 Saint-Denis, France
| | - Barbara Maraux
- Service de Gynécologie-Obstétrique, Hôpital Lariboisière, 2 Rue Ambroise Paré, 75010 Paris, France
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