Reconstructive and Aesthetic Surgeries on the Female Genitalia. Guideline of the DGGG, DGPRÄC, OEGGG and SGGG (S2k-Level, AWMF Registry No. 009/019, May 2022)

Abstract

Aim This official guideline was coordinated and published by the German Society for Gynaecology and Obstetrics (DGGG), the German Society for Plastic, Reconstructive and Aesthetic Surgery (DGPRÄC), the Austrian Society for Gynaecology and Obstetrics (OEGGG), and the Swiss Society for Gynaecology and Obstetrics (SGGG). The guideline aims to provide a consensus-based overview of reconstructive and aesthetic surgeries on female genitalia based on an evaluation of the relevant literature.

Methods This S2k-guideline was developed by representative members from different medical professions on behalf of the guidelines commission of the DGGG, DGPRÄC, OEGGG and SGGG using a structured consensus process.

Recommendations Statements and recommendations on the epidemiology, aetiology, classification, symptoms, diagnosis, and treatment of acquired changes of the external genitalia are presented and special situations are discussed.

Key words

guideline - reconstructive surgeries - aesthetic surgeries - female genitalia - female genital mutilation (FGM)

I  Guideline Information

Guidelines programme of the DGGG, OEGGG and SGGG

For information on the guidelines programme, please refer to the end of the guideline.

Citation format

Reconstructive and Aesthetic Surgeries on the Female Genitalia. Guideline of the DGGG, DGPRÄC, OEGGG and SGGG (S2k-Level, AWMF Registry No. 009/019, May 2022). Geburtsh Frauenheilk 2023; 83: 802–826

Guideline documents

The complete long version in German and a slide version of this guideline as well as a list of the conflicts of interest of all the authors are available on the homepage of the AWMF: https://register.awmf.org/de/leitlinien/detail/009-019

Guideline authors

See [Tables 1] and [2].

Tab. 1 Lead and/or coordinating guideline author.

Author	AWMF professional society
Prof. Dr. M. W. Beckmann	German Society for Gynaecology and Obstetrics [Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e. V.] (DGGG)
Univ.-Prof. Dr. J. Beier	German Society for Plastic, Reconstructive and Aesthetic Surgery [Deutsche Gesellschaft für Plastische, Rekonstruktive und Ästhetische Chirurgie] (DGPRÄC)

Tab. 2 Contributing guideline authors.

Author Mandate holder	DGGG working group (AG)/ AWMF/non-AWMF professional society/ organization/association
1  Participated in the online survey carried out from 29.11.2021 to 23.12.2021 2  Attended the online consensus conference with voting rights on 21 January 2021
Prof. Beckmann1,2	German Society for Gynaecology and Obstetrics (DGGG)
Prof. Beier	German Society for Plastic, Reconstructive and Aesthetic Surgery (DGPRÄC)
PD. Dr. phil. Borkenhagen1	German Society for Psychosomatic Gynaecology and Obstetrics [Deutsche Gesellschaft für psychosomatische Frauenheilkunde und Geburtshilfe e. V.] (DGPFG)
Dr. Fahlbusch1,2	German Society for Paediatric and Adolescent Medicine [Deutsche Gesellschaft für Kinder- und Jugendmedizin e. V.] (DGKJ)
Assoc. Prof. PD Dr. D. Gold	Austrian Society for Gynaecology and Obstetrics [Österreichische Gesellschaft für Gynäkologie und Geburtshilfe] (OEGGG)
Dr. Hoffmann1,2	German Society for Gynaecology and Obstetrics (DGGG)
Dr. Löhrs1,2	German Society for Gynaecology and Obstetrics (DGGG)
Dr. Luze1	Austrian Society for Plastic, Reconstructive and Aesthetic Surgery [Österreichische Gesellschaft für Plastische, Ästhetische und Rekonstruktive Chirurgie] (ÖGPRÄC)
Prof. Mirastschijski	German Society for Plastic, Reconstructive and Aesthetic Surgery (DGPRÄC)
PD Dr. OʼDey1,2	German Society for Plastic, Reconstructive and Aesthetic Surgery (DGPRÄC)
Dr. Pöschke
Dr. Remmel1,2	German Society of Surgery [Deutsche Gesellschaft für Chirurgie] (DGCH)
Prof. Schaefer1,2	Swiss Society for Plastic, Reconstructive and Aesthetic Surgery [Schweizerische Gesellschaft für Plastische, Rekonstruktive und Ästhetische Chirurgie] (SGPRÄC)
Dr. Schulmeyer
Dr. Schuster1,2	German Society for Paediatric and Adolescent Medicine (DGKJ), German Society for Paediatric Surgery [Deutsche Gesellschaft für Kinderchirurgie e. V.] (DGKCH)
Prof. Sohn1,2	German Society of Urology [Deutsche Gesellschaft für Urologie e. V.] (DGU)
Dr. von Fritschen	German Society for Plastic, Reconstructive and Aesthetic Surgery (DGPRÄC)

The guideline was moderated by Dipl.-Biol. Simone Witzel and Dr. rer. medic. Susanne Blödt, MScPH (AWMF Institute for Medical Knowledge Management).

II  Guideline Application

Purpose and objectives

The procedures used were evaluated based on an interdisciplinary consensus of specialists and provide neutral support free of any financial interests to physicians and patients in making their decisions. The aim is also to show clearly which aesthetic and reconstructive surgical procedures have always been reconstructive procedures. To do this, this guideline, in contrast to other guidelines, also describes surgeries, partially step-by-step.

Targeted areas of care

In-patient, outpatient care.

Target audience

This guideline is aimed at the following people:

• hospital-based plastic surgeons

• plastic surgeons in private practice

• hospital-based gynaecologists

• gynaecologists in private practice

• paediatric surgeons

• hospital-based urologists

• urologists in private practice

The guideline provides information for:

• hospital-based paediatricians

• paediatricians in private practice

• nursing staff

Adoption and period of validity

The validity of this guideline was confirmed by the executive boards/representatives of the participating medical professional societies, working groups, organizations, and associations and the board of the DGGG and the DGGG Guidelines Commission as well as the boards of the DGPRÄC, SGGG and OEGGG in April 2022 and was thereby approved in its entirety. This guideline is valid from 30 April 2022 through to 1 May 2027. Because of the contents of this guideline, this period of validity is only an estimate.

III  Methodology

Basic principles

The method used to prepare this guideline was determined by the class to which this guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective rules and requirements for different classes of guidelines. Guidelines are differentiated into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined as consisting of a set of recommendations for action compiled by a non-representative group of experts. In 2004, the S2 class was divided into two subclasses: a systematic evidence-based subclass (S2e) and a structural consensus-based subclass (S2k). The highest S3 class combines both approaches. This guideline was classifed as: S2k.

Grading of recommendations

The grading of evidence based on the systematic search, evaluation, and synthesis of an evidence base which is then used to grade the recommendations is not envisaged for S2k guidelines. The individual statements and recommendations are only differentiated by syntax, not by symbols ([Table 3]).

Tab. 3 Grading of recommendations (based on Lomotan et al., Qual Saf Health Care 2010).

Description of binding character	Expression
Strong recommendation with highly binding character	must/must not
Regular recommendation with moderately binding character	should/should not
Open recommendation with limited binding character	may/may not

Statements

Expositions or explanations of specific facts, circumstances, or problems without any direct recommendations for action included in this guideline are referred to as “statements.” It is not possible to provide any information about the level of evidence for these statements.

Achieving consensus and level of consensus

At structured NIH-type consensus-based conferences (S2k/S3 level), authorised participants attending the session vote on draft statements and recommendations. The process is as follows. A recommendation is presented, its contents are discussed, proposed changes are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes) is not achieved, there is another round of discussions, followed by another vote. Finally, the extent of consensus is determined based on the number of participants ([Table 4]).

Tab. 4 Level of consensus based on extent of agreement.

Symbol	Level of consensus	Extent of agreement in percent
+++	Strong consensus	> 95% of participants agree
++	Consensus	> 75 – 95% of participants agree
+	Majority agreement	> 50 – 75% of participants agree
–	No consensus	< 51% of participants agree

Expert consensus

As the term already indicates, this refers to consensus decisions taken relating specifically to recommendations/statements issued without a prior systematic search of the literature (S2k) or where evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical consensus point” (CCP). The strength of the recommendation is graded as previously described in the section “Grading of recommendations”, i.e., purely semantically (“must”/“must not” or “should”/“should not” or “may”/“may not”) and without the use of symbols.

IV  Guideline

1  Preoperative preparation

1.1  Planning the surgery

Surgical planning is based on the symptoms and disorders described by the patient and the clinical findings, supported by additional diagnostic measures. Conservative and alternative options as well as the limits of what is surgically possible must be explained to the patient beforehand. This chapter contains no statements or recommendations.

1.2  Preoperative diagnosis

Consensus-based recommendation 1.E1
Expert consensus	Level of consensus +++
Physical and psychological trauma, particularly to paediatric or adolescent patients, must be avoided when carrying out clinical examinations and diagnostic procedures.

Consensus-based recommendation 1.E2
Expert consensus	Level of consensus +++
A urological or paediatric urological consultation, which can include further diagnostic investigations (e.g., ultrasound of the urinary tract), should be carried out if the urinary system is also involved.

1.3  Diagnoses where the cost assumption by the patientsʼ insurance is indicated

Consensus-based recommendation 1.E3
Expert consensus	Level of consensus +++
No aesthetic surgical procedures of the female genitalia must be carried out if body dysmorphic disorder is suspected. In this case, the patient should be transferred to a suitable department for specific evaluation.

1.4  Patient information

Consensus-based statement 1.S1
Expert consensus	Level of consensus +++
In addition to the standard surgical risks such as complications of bleeding, infections, wound healing disorders with scarring, skin/ tissue/nerve damage, the risks which are specific to the planned procedures and to the individual patient must be presented. The specific risks associated with surgery of the female genitalia particularly include risks which will affect the patientʼs sexuality.

Consensus-based recommendation 1.E4
Expert consensus	Level of consensus +++
Prior to all procedures carried out affecting the female genitalia, the patient must be informed in detail about the specific risks such as infections, changes in sensitivity, dyspareunia, adhesions and scarring, and changes which can affect the patientʼs sexuality.

1.5  Documentation requirements

The patientʼs complete medical history on which the indication is based or which triggered the patientʼs independent wish to undergo reconstructive or aesthetic surgery of the female genitalia must be documented in written form. The clinical findings, diagnostic results, and consultations involving other medical specialties must be documented. The consequences of these investigations must be transparent [1]. The patient should also be specifically questioned about symptoms and problems which existed preoperatively.

Consensus-based recommendation 1.E5
Expert consensus	Level of consensus +++
The extensive information on which the diagnosis is based and the patientʼs consent to the procedure and acceptance of the risks of the surgical intervention must be individually documented in written form with time and date by the responsible physician.

2  Anatomy and nomenclature of female genitalia

This chapter contains no statements or recommendations. This chapter presents basic information about the anatomy of the external female genitalia, the structure of the female pelvic floor as well as the nerves and blood supply of the female pelvic floor ([Figs. 1], [2] and [3]).

Abb. 1 External genitalia and anal region. Source: Jörg Pekarsky with the kind permission of Prof. M. W. Beckmann. [rerif]

Abb. 2 Structure of the female pelvic floor. Source: Jörg Pekarsky with the kind permission of Prof. M. W. Beckmann. [rerif]

Abb. 3 Nerves and vasculature of the female pelvic floor. Source: Jörg Pekarsky with the kind permission of Prof. M. W. Beckmann. [rerif]

2.1  External female genitalia

See [Fig. 1].

2.1.1  Vascularisation, innervation and lymphatic circulation

See [Fig. 2].

2.2  Female internal genitals – vagina

See [Fig. 3].

3  Reconstructive and aesthetic surgeries of the female genitalia

3.1  Introduction

Reconstructive and aesthetic surgeries of the external female genitalia include a wide range of diagnoses and treatment options which, because of the existing range of options, are still not very standardised/have not been standardised. It is therefore important to be informed about the current status of different surgical options and possibilities to be able to offer individualised therapy to patients. The aim must be to achieve anatomically oriented results and the technique must be selected accordingly.

3.2  Medical history

When taking the patientʼs medical history, both the existing morphological disorders/changes as well as any possibly existing psychosexual interactions should be determined to optimally tailor the diagnosis to the expected healing/therapeutic success.

3.3  Indications and contraindications

Reconstructive and aesthetic surgeries of the female genitalia include the restoration or approximation of the form and function of the vulva after partial or total resection, in cases with congenital and/or acquired disorders or disease- and age-related changes or where the patient has a specific idea of what the outcome should look like. Contraindications proceed from medical-ethical considerations or age-related limitations.

3.3.1  Ritual circumcision (female genital mutilation)

Female circumcision or FGM (female genital mutilation) is a culturally rooted ritual practice which is widely prevalent in certain countries. In Germany and Austria, FGM constitutes an act of actual bodily harm and therefore contravenes the right to physical integrity and self-determination as defined by law (German constitution). [Table 5] outlines the primary and secondary complications after female genital mutilation.

Tab. 5 Primary and secondary complications following female genital mutilation (FGM).

Primary complications
Somatic	pain bleeding shock infection urinary obstruction wound healing disorders hypertrophic scarring urethral trauma clitoral trauma loss of clitoral sensation
Psychological	anxiety disorder stress response (e.g., peritraumatic dissociation)
Secondary complications
Somatic	dysuria scar-related menstrual problems recurrent infections epidermoid/clitorial cysts neuroma of the dorsal nerve of the clitoris urinary retention, urinary stones incontinence, urinary urgency, hyperactive bladder, etc. dysmenorrhoea hematocolpos hematometra dyspareunia fistula dystocia neonatal outcome higher episiotomy rate/higher rate of perineal tears higher rate of caesarean sections gynaecological diagnosis/catheterisation more difficult/impossible
Psychological	post-traumatic stress disorders, visual intrusions/flashbacks/hyperarousal sexual dysfunction anxiety disorder/depression

Consensus-based statement 3.S2
Expert consensus	Level of consensus +++
Female genital mutilation (FGM) has been included in the ICD system (International Classification of Diseases) since 2013 and has been recognised and defined as physical and mental suffering.

Consensus-based statement 3.S3
Expert consensus	Level of consensus +++
Each of the listed forms of female genital mutilation (FGM) justifies the diagnosis that medical therapy is required if the corresponding physical and/or mental complaints and impairments are present.

Consensus-based recommendation 3.E6
Expert consensus	Level of consensus +++
An interdisciplinary approach should be used when treating girls and women affected by female genital mutilation (FGM). This can be provided in a standardised form either centrally (centre-based infrastructure) or locally (cooperation infrastructure).

Because of the differences in the severity of FGM, the differences in how the ritual practice was experienced, and the changes in physical and mental development of the individual affected women and girls, the somatic and psychological symptoms and complaints also differ.

Consensus-based statement 3.S4
Expert consensus	Level of consensus +++
Especially women with Type III FGM have a higher risk of sustained health problems affecting the urogenital region such as traumatic obstetric and vestibular-perineal complications and secondary fistula formation.

Defibulation is a surgical procedure which improves overall functionality with regards to urination, the passage of menstrual blood, sexual penetration, and vaginal delivery [2], [3] ([Table 6]).

Tab. 6 Obstetric defibulation after FGM type III.

Antepartum defibulation	reduces urogenital complications, such as infections risk of bleeding vestibular, perineal, urethral tears allows diagnostic workup prepartum, including inspection microbiological smears cytology vaginal ultrasound
Intrapartum defibulation	reduces patientʼs surgical stress

Consensus-based recommendation 3.E7
Expert consensus	Level of consensus +++
During pregnancy, defibulation may be performed before (antepartum) or during (intrapartum) birth. Antepartum defibulation should be carried out from the second trimester of pregnancy. Intrapartum defibulation should be carried out during the first stage of labour to make it easier to monitor the birth process and carry out bladder catheterisation if required.

3.3.2  Dysplasia of the vulva and vagina (VIN, VaIN)

Consensus-based recommendation 3.E8
Expert consensus	Level of consensus +++
If the patient has dysplasia of the cervix, vulva and vagina, the diagnosis, therapy and follow-up of the patient must be carried out in accordance with the relevant S3-guidelines “Prevention of Cervical Cancer” (AWMF registry number 015-027OL) and “Diagnosis, Therapy and Follow-up in Patients with Cervical Cancer” (AWMF registry number 032-033OL) and the S2k-guidelines “Diagnosis, Therapy and Follow-up of Vaginal Cancer and Its Precursors” (AWMF registry number 032-042) and “Diagnosis, Therapy and Follow-up of Vulvar Cancer and Its Precursors” (AWMF registry number 015-059).

3.3.3  Pagetʼs disease of the vulva

Extramammary Pagetʼs disease is a very rare entity with a prevalence of 1% of all vulvar malignancies. The primary therapy for vulvar Pagetʼs disease is based on surgical removal of the lesion.

3.3.4  Lichen sclerosus/lichen ruber planus

Lichen sclerosus and lichen ruber planus are inflammatory skin diseases of the anogenital area which are underdiagnosed. Symptoms include pain, burning, itching, sexual dysfunction, dysfunction of the urinary tract as well as atrophy and sclerosis of the labia and/or the vaginal introitus with introitus stenosis. Local therapy consists of treatment with corticosteroid cream (methylprednisolone aceponate or clobetasol propionate) combined with regular lubrication or moisturising care [4].

3.3.5  Benign tumours of the vulva

Benign tumours of the vulva include syphilis chancre, Behcetʼs disease, folliculitis, condyloma and granulomas, abscesses, Bartholin gland cysts (see chapter 3.3.7), and cysts.

3.3.6  Birth trauma and episiotomy

Keloid formation after birth trauma or suture granulomas (e.g., following the increased use of suture materials) can lead to symptoms such as dyspareunia or pain when sitting or moving [5]. Surgical revision may be considered if the symptoms still persist after three to six months.

3.3.7  Bartholin gland cyst and vulvar abscess

Bartholin glands can develop cysts or abscesses. Treatment consists of an incision with placement of a catheter or marsupialisation. The cyst or gland may be excised following recurrence of the cyst or abscess [6].

3.3.8  Gender incongruence

Readers are referred to the S2k-guideline “Surgical Gender Reassignment Measures for Gender Incongruence and Gender Dysphoria” (registry number 043-052) which is currently being revised.

4  Surgeries listed according to topographic anatomy

4.1  Mons pubis

This chapter contains no statements or recommendations. Deformities in the region of the mons pubis are classified into four grades ([Table 7]). The grades and their treatment are shown in [Table 7].

Tab. 7 Classification of deformities of the mons pubis and appropriate recommended form of treatment.

Classification	Treatment
Grade 1: slight protrusion with minimal/no coverage of the labia majora	Liposuction
Grade 2: moderate protrusion with partial coverage of the labia majora	Panniculectomy with liposuction
Grade 3: significant protrusion with complete coverage of the labia majora	Panniculectomy with liposuction, dermal-fascial suspension suture, poss. vertical wedge resection
Grade 4: no protrusion, strong ptosis with partial or complete coverage of the labia majora	Panniculectomy with dermal-fascial suspension suture and vertical wedge resection

4.2  Vulva/labia majora

Consensus-based recommendation 4.E9
Expert consensus	Level of consensus +++
A big volume reduction of the clitoris and the tissue around the clitoris must be avoided, as this leads to painful exposure of the clitoris.

Consensus-based statement 4.S5
Expert consensus	Level of consensus +++
Too thin or too small labia majora in very slim patients who have lost a lot of weight or who have experienced age-related involution/atrophy may be perceived as inaesthetic and may be associated with dyspareunia requiring treatment.

4.3  Labia minora

Hypertrophy of the labia minora may be acquired (e.g., varicosis, inflammation, culture-related lengthening/elongation) or congenital [7]. If a patient suffers from disproportionately large labia minora, an aesthetically satisfactory appearance may be achieved by resecting the excessive skin [8]. The following images show excision techniques to reduce the labia minora and different types of flap-plasty procedures ([Figs. 4], [5] and [6]).

Abb. 4 Excision techniques to reduce hypertrophic labia minora (based on [7]). Source: Jörg Pekarsky with the kind permission of Prof. M. W. Beckmann. [rerif]

Abb. 5 Planning and implementation of a VY-flap plasty. Source: Jörg Pekarsky with the kind permission of Prof. M. W. Beckmann. [rerif]

Abb. 6 Planning and implementation of a lotus petal flap procedure (lotus petal/Singapore flap). Source: Jörg Pekarsky with the kind permission of Prof. M. W. Beckmann. [rerif]

4.4  Clitoral prepuce

This chapter contains no statements or recommendations. Reconstruction of the vulva after FGM also plays an important role (see chapter 5). For example, the “omega domed” flap procedure (OD flap) is a specially developed local flap-plasty procedure to reconstruct the prepuce.

4.5  Vagina

The diagnosis and treatment of female genital prolapse should be based on the guideline “Diagnostics and treatment of the pelvic organ prolaps”, AWMF registry number 015-006, as at April 2016. The diagnosis and treatment of female incontinence should be based on the guideline “Diagnosis and therapy of female urinary incontinence”, AWMF registry number 015-005, which is currently being revised. The diagnosis and therapy of female genital malformations should be based on the guideline “Female Genital Malformations”, AWMF registry number 015-052, as at March 2020.

4.6  Vaginal introitus

Hymen reconstruction plays a special role in those cultural regions where moral significance is attached to female virginity or, rather, the integrity of the hymen edges. The diagnosis and treatment should be based on the guideline “Female Genital Malformations”, AWMF registry number 015-052, as at March 2020.

As with hymen reconstruction, it is also possible to reconstruct the vaginal introitus. The diagnosis and treatment should also be based on the guideline “Female Genital Malformations”, AWMF registry number 015-052, as at March 2020.

4.7  G-spot

Injecting the G-spot with autologous fat or a filler is not a medically indicated procedure as defined in the German Social Code, Book V (SGB), which means that health insurance companies will not cover the costs of this procedure.

5  Female genital mutilation

5.1  Basic facts

Ritual cutting of the external female genitalia (female genital mutilation/FGM) is a global phenomenon which is especially prevalent in Africa, Asia, and South America. According to estimates by the WHO, around 200 000 000 girls and women are affected globally [9]. The WHO categorises the forms of FGM into four different types: I – IV ([Table 8]).

Tab. 8 Forms of female genital mutilation (FGM) based on the classification by the World Health Organisation (WHO), 1997.

Type I	Partial or total removal of the clitoral glans and/or the prepuce/clitoral hood
Type Ia	Removal of the clitoral hood
Type Ib	Removal of the clitoris and the clitoral hood
Type II	Partial or total removal of the clitoris and the labia minora, with or without removal of the labia majora (excision)
Type IIa	Removal of the labia minora
Type IIb	Partial or complete removal of the clitoris and the labia minora
Type IIc	Partial or complete removal of the clitoris, the labia minora and labia majora
Type III	Narrowing of the vaginal opening with creation of a scarred skin covering, through the removal and stitching together of the labia minora and/or labia majora, with or without removal of the clitoral prepuce/clitoral glans and hood (infibulation)
Type IIIa	Removal and stitching together of the labia minora
Type IIIb	Removal and stitching together of the labia majora
Type IV	All other harmful procedures which injure the female genitalia and serve no medical purpose, for example: pricking, piercing, incising, scraping, cauterising, chemically burning

5.2  Reconstruction procedures

Reconstructive surgical procedures of the external female genitalia include many indications and treatment options, few of which are standardised. As regards the technique, there are several standardised flap-plasty techniques which can be used for vulva reconstruction, each of which has different advantages and disadvantages [10], [11], [12], [13], [14], [15], [16]. Inadequate transfer of tissue has a negative effect on vulva reconstruction, e.g., through the creation of excessive volume with unnatural projection, tissue rigidity, deformation, and functional limitations. The choice of flap-plasty technique must be balanced very carefully.

5.2.1  Reconstruction of the clitoral prepuce

This chapter contains no statements or recommendations. In patients with FGM type I to III, the prepuce has usually been affected and often no longer exists. The anatomical area where the tip of the clitoris protrudes from the scarred skin may be excised and removed to obtain surgical access to the clitoral stump or it can be used for a local flap-plasty procedure.

5.2.2  Reconstruction of the clitoral glans

This chapter contains no statements or recommendations. Clitoral reconstruction is a key procedure of vulva reconstruction after FGM, as this procedure aims to restore fundamental organ integrity for normal sexual functioning.

5.2.3  Reconstruction of the labia majora/minora

This chapter contains no statements or recommendations. Reconstruction of the labia minora and majora after FGM type II and III is usually only possible with tissue grafting due to the extensive loss of tissue in the area.

5.2.4  Reconstruction of the vaginal vestibule

This chapter contains no statements or recommendations. The flexibility of vulvar tissue often ensures that primary wound closure is still possible despite extensive tissue defects. In terms of anatomical function, wound closures of such defects may result in restrictions which affect both form and function, for example, deformations, loss of elasticity, and tissue tension.

5.3  Reconstruction after subsequent secondary injuries and/or changes

The range of reconstructive options after secondary injury and/or changes after FGM is broad and ranges from procedures to improve function such as correction of scarring and fistula remediation including perineal reconstruction to the removal of tumours and clitoral cysts and even complex tissue transfers [17].

Consensus-based recommendation 5.E10
Expert consensus	Level of consensus +++
During reconstruction after FGM (Female Genital Mutilation), also secondary changes and impairments should be recognized anamnestically and clinically and should be classified accordingly and included in the surgical planning.

6  Other procedures for the reconstruction of female genitalia

6.1  Vaginal lifting using lasers

Consensus-based recommendation 6.E11
Expert consensus	Level of consensus +++
There is no evidence from prospective randomised studies about the clinical efficacy and side effects of vaginal lifting carried out without a medical diagnosis for purely cosmetic reasons using CO2 lasers or non-ablative erbium-YAG (yttrium aluminium garnet) lasers or radiofrequency therapy. These procedures should therefore only be offered to patients in the context of clinical studies.

6.2  Vaginal lifting using radiofrequency therapy (RF)

This chapter contains no statements or recommendations. Several prospective studies are reported which describe the effect of radiofrequency therapy on vaginal laxity.

6.3  Vaginal lifting using muscle training

There are currently no prospective randomised studies on remedying vaginal laxity using muscle training. No recommendation can therefore be given. This chapter contains no statements or recommendations.

7  Postoperative Procedure

Follow-up treatment after surgery of the female genitalia depends on the type and extent of the surgical intervention and the patientʼs physical condition. Most aesthetic procedures should be carried out on an outpatient basis.

7.1  Postoperative monitoring

This chapter contains no statements or recommendations. The basics of postoperative monitoring are presented.

7.2  Peri- and postoperative medication

This chapter contains no statements or recommendations. The use of local analgesics (creams/sprays) is not recommended to avoid unnecessarily affecting the mucosal milieu. The prophylactic administration of antibiotics depends on the type of surgical procedure and the patientʼs medical history (see S3-guideline “Strategy for the Rational Use and Administration of Antibiotics in Hospital”, AWMF registry number 092/001).

7.3  Dressing changes and hygiene

This chapter contains no statements or recommendations. Basic methods to change dressings and maintain hygiene are described as well as other important aspects, for example, the prevention of adhesions in postoperative wounds.

7.4  Follow-up treatment

This chapter contains no statements or recommendations. Basic postoperative follow-up is described.

8  Complications during reconstructive and aesthetic surgeries of the female genitalia

The complication rate depends on the type of procedure, patient age, and the patientʼs comorbidities. All complications usually associated with surgical procedures may occur [18]. Different reporting systems and classification systems (e.g., Clavien-Dindo classification [19]) have been developed to accurately record such complications. Complication rates of 22% of cases and a mortality rate of 0.8% have been reported in literature [20]. Careful preoperative assessment and selection of patients and advance planning can have a positive effect on the complication rate.

8.1  Rate of complications

Consensus-based statement 8.S6
Expert consensus	Level of consensus +++
There are currently no official statistics or quality indicators for specific complications associated with reconstructive and aesthetic surgeries of the female genitalia.

8.2  General surgical complications

This chapter contains no statements or recommendations. Surgeries of the female genitalia can cause special complications. These are mentioned within this chapter.

8.3  Complications following procedures using autologous tissue

This chapter contains no statements or recommendations. Procedures using autologous tissue include all flap-plasty procedures. Arterial blood supply and venous drainage are critical for the survival of the flap and therefore for the success of the surgery.

8.4  Complications following procedures using non-autologous materials

This chapter contains no statements or recommendations. Non-autologous materials basically include all types of silicone implants, non-resorbable suture materials, and acellular dermal matrix (ADM). The most common complications associated with non-autologous materials are infections and seromas which may require follow-up interventions.

8.5  Revision and follow-up surgeries

The most common indication for acute revision is haemorrhage, which requires immediate intervention. Its urgency depends on the location (arterial or venous) and the severity of the secondary haemorrhage, the patientʼs general condition, and the lab test results (hemoglobin test).

Surgical revision must be carried out immediately in cases with reduced arterial blood flow or disordered venous drainage. Any delay can cause flap necrosis. Such cases require revision of the vascular anastomosis.

9  Special aspects affecting children and adolescents

9.1  General information on reconstruction and aesthetic surgery of the female genitalia during childhood

The most important aspects of reconstructive and aesthetic surgical interventions in childhood and adolescence deal with symptoms (see chapter 9.2) and functionality, especially restrictions in fertility (e.g., in the context of aplasia of the internal reproductive organs as occurs with Müllerian agenesis/Mayer-Rokitansky-Küster-Hauser syndrome [MRKH] and complete androgen insensitivity syndrome [CAIS]) and diminished functionality with regards to continuity and preservation of continence of the urinary tract and intestinal system. Information on these points can be obtained from the S2k-guideline “Female Genital Malformations” (AWMF registry number 015/052) [21].

Consensus-based recommendation 9.E12
Expert consensus	Level of consensus +++
Non-medically indicated surgeries of the female genitalia must not be carried out during childhood.

9.2  Reconstructive procedures for congenital malformations

For reconstructive procedures to treat congenital malformations, readers are referred to the guideline “Female Genital Malformations”, AWMF registry number 015/052 [21].

9.3  Genital (alignment) surgery for variants of sexual development

This chapter contains no statements or recommendations. Formerly, it was the patientʼs guardian who gave their consent to genital surgery in cases with variants of sexual development. This has now changed fundamentally and the individualʼs right to self-determination is specifically emphasised. The S2k-guideline “Variants of Sexual Differentiation”, AWMF registry number 174/001, is currently being revised with a special focus on this topic.

9.4  Reconstructive surgery of the female genitalia during childhood after previous female genital mutilation

Carrying out a reconstructive procedure during childhood requires a very stringent indication. For this reason, interventions performed in children must only be considered if they are clearly medically indicated. In addition to urogenital or rectovaginal fistula, which are very rare in Germany, a medical indication will usually only be considered for cases with infibulation or partial stenosis of the vulva.

Consensus-based statement 9.S7
Expert consensus	Level of consensus +++
The treatment of patients with FGM and its associated problems requires an extensive understanding of the complex sociocultural and medical aspects involved, particularly for patients who are children or adolescents.

Consensus-based recommendation 9.E13
Expert consensus	Level of consensus +++
Physical and psychological trauma caused by unnecessary and insensitive examinations of patients during childhood and adolescence must be avoided.

10  Psychosomatics

10.1  Sexual dysfunction

This chapter contains no statements or recommendations. Several studies on sexual dysfunction disorders are presented.

10.2  Contraindication: psychological disorders

This chapter contains no statements or recommendations. Body dysmorphic disorder is a contraindication for cosmetic surgeries of the female genitalia because the distortion of reality associated with this psychological disorder negatively affects their ability to make an informed decision and their capacity to consent.

10.3  Patient satisfaction and quality of life

Consensus-based recommendation 10.E14
Expert consensus	Level of consensus +++
Aesthetic and functional surgical therapy may be considered for patients with body dissatisfaction relating to their genitalia to improve their sexual self-image and sexual satisfaction.

Conflict of Interest/Interessenkonflikt

The authorsʼ conflicts of interests are listed in the long version of the guideline./Die Interessenkonflikte der Autoren sind in der Langfassung der Leitlinie aufgelistet.

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Publication History

Received: 08 March 2023

Accepted after revision: 26 March 2023

Article published online:
03 July 2023