New reconstructive surgery for female genital mutilation

There is new hope for the hundreds of millions of women worldwide who have been subjected to genital mutilation. A surgeon in Penn Medicine's Center for Human Appearance has developed a reconstructive procedure that can increase sexual function and, patients' early experiences suggest, help heal the emotional and psychological wounds associated with the mutilation. Ivona Percec, MD, PhD, an assistant professor of Surgery in the division of Plastic Surgery and associate director of Cosmetic Surgery in the Perelman School of Medicine at the University of Pennsylvania, reports on her use of the technique in three patients this month in the Aesthetic Surgery Journal. She also calls for greater awareness of this human rights issue in support of women who've suffered these experiences across the world.

"Plastic surgeons have a crucial role to play in this recovery, and it's important for physicians to be informed and prepared to address the surgical and emotional needs of women who seek care for this," Percec said. "Our procedure is simple yet effective and can help victims restore their physical and psychological sense of well-being."

The World Health Organization (WHO) defines Female Genital Mutilation (FGM) as, "any procedure that intentionally alters or causes injury to female genital organs for non-medical reasons and with no health benefits." An estimated 200 million women have been subjected to FGM around the world, usually between the first week of life and adolescence, and often by their caregivers. It is a cultural ritual in parts of Africa, the Middle East, and Asia to encourage female sexual fidelity. It is internationally recognized as a violation of human rights.

FGM can also have long-term consequences, including severe pain, post-traumatic stress disorder, cysts, recurrent infections, and even death.

The WHO breaks the mutilation into four distinct classes depending on the extent of the damage. All three patients in Percec's report suffered from Grade II mutilation - defined as the partial or total removal of the clitoris and the labia minora (the inner folds of the vulva), with or without the removal of the labia majora (the outer folds of skin of the vulva). All three women were between the ages of 30 and 33 and had recently immigrated to the United States from Sierra Leone. In each case, the women were married but had not told their husbands they had undergone FGM as children.

"These women were embarrassed that they were subjected to this procedure, in particular since relocating to the United States," Percec said. "All of them were able to have intercourse, but without pleasure - usually with pain. None of them ever let their partners see their vaginal area."

The patients wanted to know if there were any surgical options available to help them look and feel more normal. After Percec's research turned up little in the way of established procedures, she used her knowledge of other reconstructive techniques in hopes of restoring appearance and function.

Percec's surgeries involved separating the labia majora, which were connected by scar tissue, then suturing them to make sure they did not re-adhere to each other. The clitoris, or its remnant, which is naturally covered in mucosa tissue, was left raw to let it regenerate the mucosa on its own. This also prevented excessive scarring and made it more likely for sensation to return to the area.

"The other key was treatment after the surgery, which included an antibiotic and pain-reducing ointment twice each day," Percec said. "It's a naturally sensitive area anyway, so using that ointment was important until the clitoris healed and formed its own mucosa again."

With an average follow up of almost a year, all three patients reported improved sexual function and decreased embarrassment with their partners. All three women said they would recommend this procedure to others who have suffered FGM.

"Female genital mutilation is a violation of the basic rights of women and children," Percec said. "As nations around the world work to eliminate this custom, plastic surgeons can play an important role in the physical, emotional, and psychological recovery of women everywhere."