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Autologous Fat Grafting (Lipofilling) for FGM/C-Related Vulvar Scars

Autologous fat grafting for FGM/C-related vulvar scars is an emerging minimally invasive regenerative approach that targets the most common long-term sequela of FGM/C — vulvar hypertrophic scarring — using the anti-fibrotic and tissue-remodeling properties of adipose-derived stem cells (ADSCs). The Almadori, Hansen, Butler & Salgarello (2025) study is the first and only published clinical application of fat grafting specifically for post-FGM vulvar scars, demonstrating significant improvements in scar architecture (VASS), sexual function (FSFI), genital self-image (FGSIS), and psychological well-being (HADS) in 13 women at 12-month follow-up.[1][2]

For the broader treatment menu see the Vulvar Reconstruction Atlas. For the workhorse FGM/C clitoral technique see Foldès Clitoral Reconstruction; for the published non-Foldès coverage option see Mañero Vaginal Mucosal Graft; for the vulvovestibular perforator-flap variant see aOAP Flap.

Rationale and Unmet Need​

Vulvar scarring is the most common long-term effect of FGM/C, yet it has been one of the most neglected aspects of FGM/C care.[1] Clitoral reconstruction (Foldès technique) addresses the clitoral stump but does not specifically treat the surrounding vulvar scar tissue — which can cause chronic pain, dyspareunia, cosmetic distress, and psychosexual dysfunction. The AAP notes that FGM/C-related scarring can include unintended labial fusions, inclusion cysts, and obstructive infibulation scars.[3]

Fat grafting was proposed because regenerative therapies based on ADSCs are considered standard-of-care for ameliorating scarring and fibrosis in other body regions — supported by a large evidence base (> 3,000 patients across 45 studies in a 2020 meta-analysis).[1][4]

Mechanism of Action​

Fat grafting exerts anti-scarring effects through dual mechanical and biological mechanisms:[4][5][6]

Mechanical (rigottomy effect)​

  • Physical injection of fat beneath and within scar tissue creates micro-tunnels that mechanically disrupt fibrotic bands and adhesions.
  • Releases scar contracture and improves tissue pliability immediately.[4][7]

Biological / regenerative (ADSC-mediated)​

Adipose tissue is rich in ADSCs, which exert potent anti-fibrotic, pro-angiogenic, and immunomodulatory effects through paracrine signaling:[5][8][9]

MechanismDetail
ECM remodelingADSCs upregulate MMP-1 and MMP-2 and increase the MMP/TIMP ratio — promoting degradation of excess collagen in hypertrophic scars[8][10]
Anti-fibrotic cytokinesADSCs secrete HGF and TGF-β3, inhibiting fibroblast proliferation and reducing collagen I, collagen III, fibronectin, α-SMA, and CTGF[8][11]
Decorin-mediated TGF-β1 trappingRecent transcriptomic / proteomic analysis identified decorin (DCN) as the principal anti-fibrotic component of the ADSC secretome — binds and sequesters TGF-β1, preventing activation of the TGF-β / Smad2 signaling pathway in fibroblasts[12]
Pro-regenerative immune responseLipofilling induces infiltration of M2 macrophages, T lymphocytes, and mast cells — shifts the local immune environment from pro-fibrotic to pro-regenerative[6]
NeoangiogenesisADSCs promote new blood-vessel formation within the scar — improving perfusion and oxygenation[6][13]
Epidermal normalizationAfter lipofilling, epidermal cell proliferation increases to levels similar to normal skin[6]
Neuropathic pain reductionFat grafting reduces expression of PGP 9.5 (neuropathic-pain marker) in treated tissues[13]

The Almadori 2025 Study[1]​

Study design: Prospective cohort, Level of Evidence IV.

Population: 13 FGM survivors with vulvar hypertrophic scars.

Technique: Autologous fat grafting to affected vulvar aesthetic units.

Follow-up: Mean 12.23 ± 3.03 months.

Outcome measures and results​

OutcomeDescriptionResult
VASS (Vulvar Architecture Severity Scale)Clinician-assessed 6-region 4-point grading of vulvar scar severitySignificant improvement in all vulvar aesthetic units (p < 0.001)
FGSIS (Female Genital Self-Image Scale)Patient-reported genital self-imageSignificant improvement (p = 0.001)
FSFI (Female Sexual Function Index)Patient-reported sexual function across 6 domainsSignificant improvement (p = 0.019)
HADS (Hospital Anxiety and Depression Scale)Patient-reported psychological well-beingSignificant improvement (p = 0.002)

The Vulvar Architecture Severity Scale (VASS)​

Developed and validated by Almadori et al. (2020) as a 6-region 4-point clinical grading system based on the aesthetic-unit principle to evaluate vulvar disease severity.[14] Originally designed for vulvar lichen sclerosus, subsequently applied to FGM/C scar assessment:

  • 6 vulvar aesthetic units independently scored — clitoral hood, labia minora, labia majora, perineum, and surrounding areas.
  • Each region graded on a 4-point severity scale: none / mild / moderate / severe — taking into account both vulvar architecture and skin involvement.
  • Validation: intra-observer reliability Pearson's r > 0.9 (mean 0.994); inter-observer ICC 0.928–0.944 — high reliability.[14]

Provided the objective clinical outcome measure for the Almadori fat-grafting study.

Surgical Technique​

General principles of autologous fat grafting for scar treatment:[4][7][15]

Step 1 — Fat harvest​

  • Donor sites: abdomen, thighs, or flanks.
  • Low-pressure liposuction with blunt-tipped cannulas (3.0–3.7 mm) connected to Toomey syringes or a closed power-assisted system.
  • Low-pressure technique minimizes adipocyte damage and preserves ADSC viability.[7]

Step 2 — Fat processing​

  • Lipoaspirate processed to separate viable fat from blood, oil, and tumescent fluid.
  • Methods: centrifugation (Coleman: 3,000 rpm × 3 min), decanting, or filtration.
  • For scar treatment: microfat (standard processed fat) for volumetric correction; nanofat (emulsified, filtered, ADSC-enriched) for intradermal regenerative injection.[15][16]
  • Lipoconcentrate further condenses the lipoaspirate into a progenitor-cell-rich fluid via combined centrifugation and emulsification.[15]

Step 3 — Fat injection​

  • Small-caliber blunt cannulas (0.9–1.2 mm for fine areas).
  • Multiple passes in a fan-shaped pattern at different tissue planes — micro-tunnels both release scar contracture and deposit fat parcels for optimal graft survival.
  • Small aliquots per pass to maximize contact between grafted adipocytes and the recipient vascular bed.[7][15]

Step 4 — Postoperative care​

  • Outpatient / day-case procedure.
  • Minimal postoperative restrictions; patients generally resume normal activities within days.

Supporting Evidence from General Scar Literature​

StudyDetail
Krastev 2020 SR / meta-analysis[4]45 studies, 3,033 patients. Significant improvement in patient and surgeon satisfaction (p = 0.001); most notable improvement in scar stiffness (p < 0.001)
Al Qurashi 2022 SR / meta-analysis[17]Most prominent POSAS improvements: color (2.4 pts), stiffness (2.9 pts), irregularity (2.2 pts), thickness (1.8 pts); pain 1.3 pts; itch 0.6 pts
Spiekman 2022 prospective clinical[6]n = 27, 2 lipofilling treatments. Total POSAS 73.2 → 32.3. Histology: M2 macrophage infiltration, ↑ vascularization, epidermal proliferation normalization, ECM remodeling toward normal skin architecture
Huang 2015 neuropathic scar pain[18]n = 13. VAS pain ↓ 5.62 pts at 24 wk (7.54 → 1.92); NPSI 49.38 → 14.62; 77% achieved ≥ 5-pt VAS improvement

Fat Grafting in the Female Genital Area — Related Evidence​

Lai 2023 — MAFT in the vulvovaginal area (n = 20, non-FGM):[13]

  • Mean 21.9 mL injected vaginally, 20.8 mL in vulva / mons pubis.
  • FSFI 43.8 → 68.6 (p < 0.001).
  • Histological evidence of ↑ collagenesis, angiogenesis, and estrogen-receptor expression in vulvar tissue.

Menkes 2021 microfat / nanofat in genital rejuvenation:[16]

  • VHI and FSD scores significantly improved at 1 and 3 mo (p < 0.05).

Fat Grafting vs Other FGM/C Reconstructive Approaches​

ApproachNatureTargetInvasivenessAnesthesiaKey advantageKey limitation
Fat graftingRegenerative / minimally invasiveVulvar scar tissueMinimalLocal ± sedationAddresses scarring directly; cost-effective; repeatable; applicable in low-resource settingsSingle study (n = 13); does not reconstruct clitoris[1]
Foldès clitoral reconstructionSurgicalClitoral stumpModerateGeneralLargest evidence base (n = 2,938); restores clitoral anatomyDoes not address surrounding scar tissue[19][20][21]
aOAP combined techniques (O'Dey)Surgical (flaps)Clitoris + prepuce + vulvovestibularModerate-highGeneralComprehensive anatomic reconstructionSingle-surgeon experience; complex[22]
A-PRPRegenerative adjunctNeoclitoral surfaceMinimal (adjunct)Applied intraoperativelyAccelerates re-epithelialization; reduces postoperative painAdjunct only; 5-patient pilot[23][24]

Potential as Adjunct or Standalone Therapy​

Almadori et al. emphasize several unique advantages of fat grafting for FGM/C:[1][2]

AdvantageDetail
Minimally invasiveNo major incisions, no general anesthesia required (local + sedation feasible), minimal recovery
Cost-effective and scalableBasic surgical equipment (syringes, cannulas); no specialized microsurgical expertise — potentially deployable in low-resource settings where the majority of FGM/C survivors live
Addresses the most common sequelaVulvar scarring affects most FGM/C survivors; Foldès / O'Dey techniques target clitoral / anatomic reconstruction rather than scar remodeling per se
RepeatableMultiple sessions possible (average 1.4 sessions for scar treatment in general literature)[4]
CombinableCould potentially be used as an adjunct to clitoral reconstruction — addressing scar tissue while Foldès addresses the clitoral stump — though this combination has not yet been studied

Limitations​

LimitationDetail
Very limited evidenceOnly one study (n = 13) from a single center; Level of Evidence IV[1]
No control groupStudy lacks a comparator arm (sham injection / saline / no treatment)
Fat-graft survivalLong-term volumetric retention in the vulvar region is unknown; 30–70% resorption rates in other body regions often necessitate repeat procedures[4]
No histological confirmationUnlike Lai et al., the Almadori FGM/C study did not include tissue biopsies confirming the biological mechanisms in the vulvar context[1][13]
Patient selectionDoes not specify which FGM/C types were included or whether fat grafting was a standalone or combined procedure
StandardizationFat-processing techniques (centrifugation vs decanting vs filtration), injection volumes, and number of sessions are not standardized for vulvar scar treatment
Future trials warrantedAuthors explicitly state results warrant further testing in clinical trials[1][2]

Emerging Adjuncts and Combinations​

ApproachDetail
Hybrid fractional laser + lipofillingDelia 2025 — CO₂ / erbium laser + fat grafting produces superior scar remodeling vs laser alone; greater improvements in pigmentation, elasticity, pliability, and thickness[25]
SVF enrichmentIsolating and concentrating the stromal vascular fraction may enhance regenerative potency; preclinical data show SVF and purified ADSCs both reduce hypertrophic-scar parameters, though ADSCs may be more efficient[8][26]
MSC therapyHansen 2025 SR — beneficial effects on scar remodeling through anti-fibrotic / immunomodulatory mechanisms; standardized protocols and RCTs still needed[27]
NanofatEmulsified, filtered, ADSC-enriched but mature-adipocyte-depleted fat — particularly suited for intradermal injection into thin vulvar scar tissue where volumetric augmentation is not desired[15][16]

Key Takeaways​

  1. Autologous fat grafting addresses the most common long-term FGM/C sequela — vulvar hypertrophic scarring — which existing reconstructive techniques do not specifically treat.[1]
  2. Dual mechanism — mechanical (rigottomy / scar release) and biological (ADSC-mediated ECM remodeling, anti-fibrotic cytokines, decorin-mediated TGF-β1 trapping, M2 macrophage / regenerative immune shift, neoangiogenesis).[4][5][6][12]
  3. Almadori 2025 — n = 13 with significant 12-mo improvements in VASS, FGSIS, FSFI, and HADS (all p ≤ 0.019).[1]
  4. Minimally invasive, cost-effective, repeatable, and scalable — feasible in low-resource settings.[1][2]
  5. Potentially combinable with Foldès clitoral reconstruction (clitoral-stump-targeted) — addresses different anatomic problems — though this combination has not yet been studied.[1]
  6. Evidence base is very limited (single-center n = 13, Level IV) — RCTs and multi-center series are warranted.[1][2]

References​

1. Almadori A, Hansen E, Butler P, Salgarello M. A novel approach to female genital mutilation reconstruction with fat grafting and adipose stem cell therapies: a minimally invasive solution with a potential impact on millions of women worldwide. Aesthetic Plast Surg. 2025. doi:10.1007/s00266-025-04895-9

2. Almadori A, Hansen E, Butler P, Salgarello M. Response to letter: a novel approach to female genital mutilation reconstruction with fat grafting and adipose stem cell therapies. Aesthetic Plast Surg. 2026;50(7):2908–2909. doi:10.1007/s00266-026-05694-6

3. Young J, Nour NM, Macauley RC, Narang SK, Johnson-Agbakwu C. Diagnosis, management, and treatment of female genital mutilation or cutting in girls. Pediatrics. 2020;146(2):e20201012. doi:10.1542/peds.2020-1012

4. Krastev TK, Schop SJ, Hommes J, Piatkowski A, van der Hulst RRWJ. Autologous fat transfer to treat fibrosis and scar-related conditions: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2020;73(11):2033–2048. doi:10.1016/j.bjps.2020.08.023

5. Spiekman M, van Dongen JA, Willemsen JC, et al. The power of fat and its adipose-derived stromal cells: emerging concepts for fibrotic scar treatment. J Tissue Eng Regen Med. 2017;11(11):3220–3235. doi:10.1002/term.2213

6. Spiekman M, Francia DL, Mossel DM, et al. Autologous lipofilling improves clinical outcome in patients with symptomatic dermal scars through induction of a pro-regenerative immune response. Aesthet Surg J. 2022;42(4):NP244–NP256. doi:10.1093/asj/sjab280

7. Le JM, Bosworth JW, Honeywell B, Ananthasekar S, Collawn SS. Adipose grafting for volume and scar release. Ann Plast Surg. 2021;86(6S Suppl 5):S487–S490. doi:10.1097/SAP.0000000000002873

8. Domergue S, Bony C, Maumus M, et al. Comparison between stromal vascular fraction and adipose mesenchymal stem cells in remodeling hypertrophic scars. PLoS One. 2016;11(5):e0156161. doi:10.1371/journal.pone.0156161

9. Wang M, Zhao J, Li J, Meng M, Zhu M. Insights into the role of adipose-derived stem cells and secretome: potential biology and clinical applications in hypertrophic scarring. Stem Cell Res Ther. 2024;15(1):137. doi:10.1186/s13287-024-03749-6

10. Deng J, Shi Y, Gao Z, et al. Inhibition of pathological phenotype of hypertrophic scar fibroblasts via coculture with adipose-derived stem cells. Tissue Eng Part A. 2018;24(5-6):382–393. doi:10.1089/ten.TEA.2016.0550

11. Ma J, Yan X, Lin Y, Tan Q. Hepatocyte growth factor secreted from human adipose-derived stem cells inhibits fibrosis in hypertrophic scar fibroblasts. Curr Mol Med. 2020;20(7):558–571. doi:10.2174/1566524020666200106095745

12. Kang L, Li Z, Li F, et al. Transcriptome and proteome analysis identify decorin as a principal antifibrotic component trapping TGF-β1 within adipose-derived stem cell secretome. Stem Cells Int. 2025;2025:1416567. doi:10.1155/sci/1416567

13. Lai YW, Wu SH, Chou PR, et al. Autologous fat grafting in female genital area improves sexual function by increasing collagenesis, angiogenesis, and estrogen receptors. Aesthet Surg J. 2023;43(8):872–884. doi:10.1093/asj/sjad040

14. Almadori A, Zenner N, Boyle D, et al. Development and validation of a clinical grading scale to assess the vulvar region: the Vulvar Architecture Severity Scale. Aesthet Surg J. 2020;40(12):1319–1326. doi:10.1093/asj/sjz342

15. Pallua N, Kim BS. Microfat and lipoconcentrate for the treatment of facial scars. Clin Plast Surg. 2020;47(1):139–145. doi:10.1016/j.cps.2019.08.010

16. Menkes S, SidAhmed-Mezi M, Meningaud JP, et al. Microfat and nanofat grafting in genital rejuvenation. Aesthet Surg J. 2021;41(9):1060–1067. doi:10.1093/asj/sjaa118

17. Al Qurashi AA, Siddiqi AK, Alghamdi AA, et al. Effectiveness of autologous fat transfer in the treatment of scar-related conditions: a systematic review and meta-analysis. Aesthetic Plast Surg. 2022;46(5):2564–2572. doi:10.1007/s00266-022-02869-9

18. Huang SH, Wu SH, Chang KP, et al. Alleviation of neuropathic scar pain using autologous fat grafting. Ann Plast Surg. 2015;74 Suppl 2:S99–S104. doi:10.1097/SAP.0000000000000462

19. Botter C, Sawan D, SidAhmed-Mezi M, et al. Clitoral reconstructive surgery after female genital mutilation/cutting: anatomy, technical innovations and updates of the initial technique. J Sex Med. 2021;18(5):996–1008. doi:10.1016/j.jsxm.2021.02.010

20. Foldès P, Cuzin B, Andro A. Reconstructive surgery after female genital mutilation: a prospective cohort study. Lancet. 2012;380(9837):134–141. doi:10.1016/S0140-6736(12)60400-0

21. Foldes P. Reconstructive plastic surgery of the clitoris after sexual mutilation. Prog Urol. 2004;14(1):47–50.

22. O'Dey DM, Kameh Khosh M, Boersch N. Anatomical reconstruction following female genital mutilation/cutting. Plast Reconstr Surg. 2024;154(2):426–438. doi:10.1097/PRS.0000000000011026

23. 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(3):340–350. doi:10.1093/asj/sjac265

24. Manin E, Taraschi G, Berndt S, Martinez de Tejada B, Abdulcadir J. Autologous platelet-rich plasma for clitoral reconstruction: a case study. Arch Sex Behav. 2022;51(1):673–678. doi:10.1007/s10508-021-02172-9

25. Delia G, Quattrocchi L, Micieli P, et al. Hybrid fractional laser and autologous lipofilling: a synergistic strategy for functional and aesthetic scar remodeling. J Clin Med. 2025;14(19):6708. doi:10.3390/jcm14196708

26. Stachura A, Paskal W, Pawlik W, Mazurek MJ, Jaworowski J. The use of adipose-derived stem cells (ADSCs) and stromal vascular fraction (SVF) in skin scar treatment — a systematic review of clinical studies. J Clin Med. 2021;10(16):3637. doi:10.3390/jcm10163637

27. Hansen L, Laustsen-Kiel CM, Rangatchew F, et al. Mesenchymal stromal cell therapy for scarring: a systematic review of clinical and preclinical studies. Stem Cells. 2025;sxaf070. doi:10.1093/stmcls/sxaf070