Reduction of the Hypertrophied Clitoris: Surgical Refinements of the Old Techniques

Abstract

Sir: Several pathologies can cause clitoris hypertrophy. It can be caused by hormones (such as in congenital adrenal hyperplasia), drugs, or tumors, or it can be idiopathic.1 The incidence varies, from one out of 10,000 newborns for congenital adrenal hyperplasia2 to a total of three cases described in the literature for isolated clitoral hypertrophy.1 The average clitoris should be less than 5 mm wide and 16 mm long. A measure of more than 35 mm2 is suggestive of clitoral hypertrophy.1,2 When a hormonal pathology has been demonstrated, hormonal replacement therapy is necessary, followed by surgical reduction of the clitoris hypertrophy (performed for psychological and cosmetic reasons). The surgical goal is to achieve a normal-appearing clitoris while preserving function (sensitivity). The following techniques have been described: total amputation of the clitoris,3 bending of the clitoris and attachment of it to pubic bones,4 dorsal amputation of the corpora cavernosa,5,6 severing of the clitoris at its root and reattachment of the glans as a composite graft,7 ventral8 shortening, and excision of the corpora cavernosa, which is eventually associated with island excision of preputial skin.9 Preservation of a neurovascular pedicle, used by Kogan et al.10 and Papageorgiou et al.,11 is fundamental in maintaining the sensitivity of the glans clitoris. Table 1 presents the specific disadvantages and possible complications of each technique (such as viability of the remaining tissue, preservation of sensation, and difficult or unacceptable shaping).Table 1: Surgical Techniques to Reduce the Hypertrophied Clitoris: Advantages and DisadvantagesOn the basis of a deep study of these techniques, we treated a single case in which we individuated and combined the most important points of other techniques with our refinements, to obtain a better cosmetic result and to preserve clitoral sensitivity (Table 2).Table 2: Fundamental Points of Surgical Correction of the ClitorisA 19-year-old girl, diagnosed at infancy with non–salt-wasting 21-beta-hydroxylase deficiency (nonclassic congenital adrenal hyperplasia) and treated since childhood with hormonal therapy, presented as an adult with isolated clitoris hypertrophy, which she found socially embarrassing. In adulthood, the phallus was about 2 cm long (Fig. 1) and increased to about 3.5 cm with arousal.Fig. 1.: Hypertrophied clitoris.The surgical steps performed were as follows: 270-degree circumferential incision at the dorsal and distal parts of the clitoris shaft, just before the origin of the glans clitoris; dissection of the skin shaft; dissection of the dorsal neurovascular pedicle (Fig. 2) from the corpora cavernosa, which were cut together with the underlying skin (ventral excision) in their middle and distal thirds; bending of the neurovascular pedicle glans on the pubic bone; glans reduction laterally; excision of the dorsal preputial skin; and reduction of the connection between the clitoris and the labia minora.Fig. 2.: The dorsal neurovascular pedicle and the glans clitoris are completely dissected.Lastly, the connection between the clitoris and labia was minimally reduced. No complication occurred in the immediate and late postoperative periods. The patient was discharged 2 days postoperatively. Sensation and sexual satisfaction were reported to be normal and satisfactory at short- and long-termfollow-up (1 year); also, our patient was very pleased with the final cosmetic result (Fig. 3).Fig. 3.: Final result at 1-year follow-up.We believe this surgical approach can overcome specific disadvantages and complications posed by older techniques, as well as allow for a good cosmetic result. Still, we believe it is possible to obtain an even better result, particularly at the connection between the ventral part of the clitoris and the labia minora. Surely, scarring can influence the final result. Gennaro Selvaggi, M.D. Department of Oncology Catholic University “Sacro Cuore” Campobasso, Italy Cosmo Maurizio Ressa, M.D. Giovanni Ostuni, M.D. Department of Plastic and Reconstructive Surgery “Ospedaliera” University Hospital Bari, Italy Luigi Selvaggi, M.D. Department of Obstetric and Gynecology II University Hospital Bari, Italy