What is genital reconstructive surgery and when is it considered? Balanced information on risks, evidence and how to prepare for your doctor.
Genital reconstructive surgery covers repair procedures that are needed for a medical reason, such as severe deformity or scarring due to birth trauma, tissue loss due to gynaecological cancer treatment or radiotherapy, or long-term after-effects following female genital mutilation/cutting (FGM/C). Unlike elective/aesthetic genital surgery, which aims to change appearance, these repairs address documentable damage. Which approach is suitable varies according to the person, the extent of the damage and the doctor's assessment.
What is genital reconstructive surgery; how does it differ from elective/aesthetic surgery?
This group of surgery is conceptually separate from elective/aesthetic genital surgery, which is planned at the request of a person who wants to change their appearance. The aim is to repair tissue loss, scar tissue or loss of function arising from a documentable medical cause such as birth trauma, cancer treatment/radiotherapy or female genital mutilation/cutting. Which approach is used is determined by the doctor according to the extent of the damage and the person's general health; there is no single standard method.
When is repair considered for deformity or scarring due to birth trauma?
This repair may be considered in people whose symptoms continue despite conservative treatment and in whom a marked deformity or fibrotic scar is found on examination. The basic principle of the surgery is to remove irregular scar tissue, to rebuild the tissues in layers in line with the anatomy and, when needed, to rebuild the integrity of the perineal muscle and fascia. Pelvic floor rehabilitation and pain management can be complementary to this process.
What is important in repair after cancer treatment or radiotherapy?
Gynaecological cancer treatment or radiotherapy can lead to tissue loss, scar contracture or loss of function in the area. Because of damage to small blood vessels, chronic lack of oxygen and progressive fibrosis, radiation-related tissue damage is regarded as one of the most challenging areas of gynaecological reconstructive surgery. For this reason assessment before the operation is important, and success is defined not only by anatomical repair but by meaningful functional improvement.
How is repair of long-term after-effects following female genital mutilation/cutting approached?
Female genital mutilation/cutting (FGM/C) is the partial or total removal of, or damage to, the genital area for non-medical reasons; every form of this practice, including when it is carried out by health workers, is clearly condemned by international health organisations. However, for survivors who live with long-term after-effects that can be seen after FGM/C, such as chronic pain, cysts, difficulty with sexual function or problems with urine/menstrual flow, it is recommended that access to repair operations is supported when they request it of their own wish. Condemning FGM/C itself and supporting access to repair of its after-effects do not conflict: one is a stance against a harm, the other is a response to the request of an adult living with that harm. Wanting or not wanting repair is entirely the person's own decision, and the after-effect they live with is not something they are responsible for.
What is the difference between deinfibulation and clitoral reconstruction in repair after FGM/C?
There are two different approaches that are often confused in repair after FGM/C. Deinfibulation is the surgical opening of closed or sewn tissue; this procedure is a more established method, applied mainly to prevent or treat complications related to birth and the urinary tract. Clitoral reconstruction, on the other hand, is a different technique; it aims to reshape the tissue and is a newer approach with more limited evidence than deinfibulation. There is no promise that clitoral reconstruction restores sensitivity or sexual pleasure; the result varies from person to person, and research in this area is generally small in scale and observational.
What is assessed before the operation?
In this kind of surgery, assessment before the operation is a multidisciplinary process that covers emotional state and sexual function as well as surgical suitability. Especially in trauma-related situations such as FGM/C or a cancer diagnosis, it is recommended that expectations and emotional state are addressed before the operation; if this assessment is skipped, the risk of dissatisfaction or emotional difficulty can rise. Which specialties are involved in the process varies from person to person.
Which repair approaches are used?
The technique used in repair varies according to the type and extent of the damage. In tissue loss or scar contracture, different surgical repair techniques can be used, such as removing and rearranging scar tissue or local flaps/grafts. Which method is chosen depends on the examination findings and the doctor's assessment; there is no single standard technique. The operation is performed by Assoc. Prof. Dr. Nurettin Türktekin at Memorial Şişli Hospital.
How strong is the evidence?
The evidence in this area is limited overall. According to a cohort study carried out in France, it was reported that after clitoral reconstruction most patients reported improvement in pain, or at least no worsening, at follow-up; this study is a single-centre, non-comparative observational study with a low follow-up participation rate. Other studies in the field are also generally small in scale, and no standard outcome measure has been used. Although supporting access to repair is recommended, you need to weigh this together with the knowledge that the evidence is limited: supporting access does not mean the result is achieved to the same extent in everyone. In repair after radiotherapy too, the result varies according to the degree of tissue damage, and a definite improvement cannot be promised beforehand.
What are the risks?
As with any surgical procedure, infection, bleeding and haematoma, wound separation, hardening of scar tissue or contracture, change in sensation, adhesion or narrowing in the vulva or vagina, pain that continues or newly appears, expectations not being met and the need for a repeat operation can be seen. In repair after radiotherapy, the risk of tissue death (necrosis) due to damage to small vessels in the tissue is also taken into account. In repair after FGM/C, it should be recalled again that deinfibulation and clitoral reconstruction have different levels of evidence. In trauma-related situations, not assessing expectations and emotional state beforehand can raise the risk of dissatisfaction or emotional difficulty.
How are consent, adulthood and expectations assessed?
These repairs are planned in adults who have completed their development, with the decision being entirely their own and with informed consent obtained. If a child or adolescent who is a victim of FGM/C is involved, this is a separate matter of protection and referral; surgical repair planned in adults is assessed separately from this. Realistic expectations are important; the operation may not completely remove every complaint, and the result varies from person to person.
What questions can you ask when preparing for the assessment?
- What are the cause and extent of my complaint or damage?
- Which specialties (surgery, emotional/sexual function, oncology if needed) will be involved in the process?
- What is the level of evidence for the recommended approach, and are there alternatives?
- What are the risks and possible complications?
- What should I expect during recovery, and which symptoms are regarded as urgent?
- Is there a possibility that the result will not meet my expectation, and might a revision be needed?
Frequently Asked Questions
Are these operations needed for every birth trauma?
No. Most of the scarring or mild change of shape after birth eases over time or with non-surgical methods such as pelvic floor rehabilitation. Even when reconstructive surgery is considered, the decision rests first on a detailed investigation of the cause of the complaint.
Does clitoral reconstruction restore sensitivity?
No definite promise can be made on this. In the French cohort study, most participants reported improvement, or at least no worsening, in both pain and sexual pleasure; however, this study is a single-centre, non-comparative observational study, the follow-up participation rate at one year is low, and the results rest on participants' own reports. For this reason it cannot be said that the result will be achieved to the same extent in everyone.
When is repair planned after radiotherapy?
No generally valid time can be given; timing depends on the healing condition of the tissue, the time that has passed since radiotherapy was completed and the doctor's assessment. The greater the tissue damage, the more carefully the planning is done.
Where should someone who wants repair after FGM/C go?
According to the practice of the national health system in the United Kingdom, surgery for clitoral sensitivity after FGM/C is assessed under a policy separate from general cosmetic surgery services; this shows that the field needs separate expertise and assessment. No particular doctor or centre is recommended; for a suitable assessment it is recommended first to go to a doctor who works with a multidisciplinary approach.
Are congenital genital structural differences also within this scope?
Some congenital structural differences can also come within reconstructive surgery in the broad sense; however, this page focuses on repair after birth trauma, cancer/radiotherapy and FGM/C, and does not cover congenital differences in detail.
Is there a single standard technique for everyone in these repairs?
No. The technique is determined according to the type and extent of the damage, your general health and the examination findings.
Are deinfibulation and clitoral reconstruction the same procedure?
No. Deinfibulation is the opening of closed or sewn tissue and is a more established method. Clitoral reconstruction is a different, newer technique with more limited evidence.
Does supporting access to repair mean the result is certain?
No. Supporting access does not show that the same result is achieved in every person. The evidence is limited overall, and the result varies from person to person.
Are emotional state and sexual function also assessed before the operation?
Yes. The assessment covers emotional state and sexual function as well as surgical suitability. Addressing expectations is recommended, especially in trauma-related situations.
Can radiotherapy-related tissue damage affect the repair?
Yes. Small vessel damage, chronic lack of oxygen and fibrosis can make planning harder. The risk of tissue death is also taken into account; a definite improvement cannot be promised.
Does the operation completely remove every complaint?
No. There are possibilities such as complaints continuing or new pain, a change in sensation, expectations not being met and the need for a repeat operation. Expectations should be realistic.
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