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Foldès Clitoral Reconstruction (± OD Preputial Flap)

The Foldès clitoral reconstruction is a widely reported technique for exposing and repositioning residual clitoral tissue after female genital mutilation/cutting (FGM/C). In a 2024 scoping review, 38 of 40 included studies described clitoral reconstruction, mostly using Foldès' method or variations; this is a proportion of studies, not of all patients or procedures worldwide.[1] First described by Pierre Foldès in France in 2004 (with an earlier description by Thabet and Thabet in Egypt), the operation relies on residual clitoral body and a preserved dorsal neurovascular supply, while the remaining anatomy varies between patients.[2][3][4]

For the broader treatment menu see the Vulvar Reconstruction Atlas. For the overarching genital reconstructive framework see Genital Reconstruction Principles.

The 2025 WHO guideline conditionally suggests clitoral reconstruction for selected women living with FGM/C (very-low-certainty evidence). It does not endorse a specific technique or guarantee individual benefit; WHO emphasizes a skilled multidisciplinary service and sexual-health counseling before or alongside surgery.[15]

Anatomical Basis​

The clitoris is a largely internal organ. The visible glans represents only a small portion; the clitoral body extends 3–4 cm deep, anchored by the suspensory ligament to the pubic symphysis, with paired crura extending posterolaterally. After many forms of FGM/C, a clitoral stump persists beneath the scar, although residual tissue and scar patterns vary. The dorsal neurovascular bundle (branches of the pudendal nerve and dorsal clitoral artery) runs along the dorsal surface of the body and is the critical structure to preserve during reconstruction.[2][6]

WHO classification of FGM/C types guides surgical planning across the procedure.

Surgical Technique (Foldès Method)​

Foldès' 2012 cohort used general anesthesia via laryngeal mask. The operative report describes the following sequence; later variants are not interchangeable with its original steps.[3]

  1. Scar excision and exposure — circular "buttonhole" skin incision over the clitoral shaft stump; the skin over its distal portion is sharply resected. Defibulation or pseudocyst removal was performed first when needed.
  2. Suspensory ligament transection — gradually transected close to the pubic bone, as deeply as needed to allow sufficient downward mobilization of the clitoral stump. Critical step permitting the retracted clitoris to be brought to its anatomical position.
  3. Neurovascular bundle preservation — dorsal neurovascular bundle carefully identified and preserved throughout dissection. Essential for maintaining sensation in the reconstructed neoglans.
  4. Neoglans exposure — residual scar is removed from the mobilized distal stump and the exposed clitoral tissue brought toward its anatomical position. The 2012 report does not specify wedge plasty or a ≥5-mm projection target as universal requirements.[3]
  5. Anti-retraction fixation — an initial layer holds the neoclitoral shaft; running or interrupted Monocryl sutures inferiorly pass from the residual fibrous layer surrounding the tunica to vestibular mucosa and skin. The report does not describe bilateral bulbocavernosus anchoring.[3]
  6. Closure and analgesia — superior vestibular skin is closed with interrupted polyglactin through bilateral subcutaneous connective tissue and midline periosteum; dissected spaces receive local anesthetic. Specific drug/dose choices require their own protocol review.[3]

For a separate surgical-teaching discussion of FGM/C, see Karim's chapter; it is not the source for the 2012 cohort's operative sequence or outcomes.[5]

The O'Dey Preputial Flap (OD Preputial Flap) Modification​

O'Dey described a complementary set of techniques that can be combined with or used alongside the Foldès approach.[7]

TechniqueFrequency in O'Dey cohortPurpose
Omega-domed (OD) flap85%Preputial reconstruction — recreating the clitoral hood (typically destroyed in FGM/C)
Neurotizing and molding of the clitoral stump (NMCS)82%Refinement of the clitoral stump itself
Anterior obturator artery perforator flap36%More extensive vulvovestibular reconstruction (labia minora, vestibule)

In O'Dey's cohort of 119 women, these combined techniques yielded significant postoperative improvement in clitoral sensation, orgasm, and reduction in dysmenorrhea, dysuria, and dyspareunia (all p < 0.05).[7]

Indications and Patient Selection​

  • Anatomy and goals, not type alone, guide suitability. The 2012 Foldès cohort specifically included type II or type III with clitoral excision and excluded type III without clitoral excision; reports of other types do not expand that cohort's eligibility.[1][3]
  • Primary indications: chronic clitoral / vulvar pain, sexual dysfunction (anorgasmia, reduced desire / arousal), negative body image, desire for anatomical restoration / identity recovery.[3][6]
  • Discuss nonsurgical care, including sexual-health counseling, as part of shared decision-making; WHO does not require a failed counseling trial as a universal prerequisite.[15]
  • Preoperative assessment should include psychosexual evaluation, anatomical education, and management of expectations.[8][9]
  • Foldès' landmark cohort reported patient expectations as: identity recovery 99%, improved sex life 81%, pain reduction 29%.[3]

Outcomes​

Foldès prospective cohort (n = 2,938)[3]​

At 1-year follow-up (866 of 2,938 patients; 29%): the substantial loss to follow-up and lack of a comparator limit inference. The following outcomes describe available respondents, not all 2,938 women.

Anatomic resultFrequency
Hoodless visible glans42%
Normal-appearing clitoris28%
Visible projection24%
Palpable projection6%
No change0.4%
  • 430 of 841 respondents (51%) reported orgasms at 1 year; this is not 51% of the 2,938 operated women, nor proof of a surgery-attributable gain.
  • Most patients reported improvement or no worsening in pain (821/840) and clitoral pleasure (815/834).

Meremikwu 2026 SR / meta-analysis (13 studies, nearly all Foldès)[9]​

  • A before–after pooled pain comparison (six studies, 1,116 participants) reported OR 79.67 (95% CI 41.67–152.33; I² = 82%) for reduced vulval/clitoral/intercourse pain. It is not an odds ratio versus no surgery or another technique.
  • Improvement in body image, self-esteem, and clitoral sexual function.
  • However, certainty of evidence was very low (GRADE) across all outcomes.

Almadori 2024 scoping review (40 studies, 7,274 women)[1]​

These heterogeneous aggregate findings span the included FGM/C reconstructive studies; they are not a Foldès-specific probability of improvement or complications. More than half of the reported improvements lacked a specified outcome domain, and only 14 of 40 studies reported complications.[1]

  • 6,858/7,274 (94%) reported as improved across differing definitions and follow-up completeness.
  • 207 reported complications across the review's surgical cohorts (about 3% by its summary); incomplete adverse-event reporting makes this an unreliable individual risk estimate.

Complications​

Published series report the following adverse events; incomplete follow-up and very-low-certainty evidence limit precise estimates of benefit and harm:[1][3][9][10]

TypeDetail
Immediate (5% in Foldès cohort)Hematoma, suture failure, moderate fever; 4% required brief re-admission
Other reportedInfection, edema, prolonged postoperative pain, mild inflammation, necrosis
Chronic painRare; associated with a history of physical abuse
Clitoral burial (retraction beneath the skin)Recognized complication, more common in younger patients

Adjuncts and Modifications​

ModificationAuthor / yearDetail
Sensate labial flapsWilson & Zaki 2022[11]Innervated flaps from the labia minora to cover the neoclitoris; FSFI 11.6 → 29.1 postoperatively
Vaginal mucosal graftMañero & Labanca 2018[12]Alternative coverage technique; FSFI 16 → 29
Autologous PRP (A-PRP)Manin 2022[13]Applied intraoperatively to potentially reduce pain and accelerate healing

Ethical and Counseling Considerations​

Clitoral reconstruction should be considered within a multidisciplinary framework with sexual-health counseling before or alongside surgery. The 2024 scoping review found counseling offered in only 15/40 studies (37.5%); this is a reporting proportion, not proof that counseling was absent for all other patients.[1][8][15]

  • Patients must be informed about the limited certainty of evidence regarding benefits, the realistic range of outcomes, and the risks.[6][9]
  • The American Academy of Pediatrics notes that for adolescents, there is still inadequate data assuring successful outcomes.[14]
  • Reconstruction should not be the sole therapeutic solution; it should complement comprehensive care addressing the physical, psychological, and sexual health needs of FGM/C survivors.[2][6]

Key Takeaways​

  1. Foldès-style reconstruction predominated among studies in a 2024 scoping review; 95% must not be read as a worldwide patient share.[1]
  2. Anatomic premise: FGM/C typically removes only the external glans / hood; the clitoral body and dorsal neurovascular bundle remain intact and can be liberated and repositioned.[2]
  3. The original operative sequence is scar exposure → graded suspensory-ligament release while protecting dorsal neurovasculature → repositioning/fixation → closure. Fixed projection measurements and muscle anchoring are not established by the 2012 report.[3]
  4. O'Dey’s OD, NMCS, and aOAP procedures form a separate combined reconstructive program; its reported improvements cannot be assigned to Foldès or to one component alone.[7]
  5. Outcomes — Foldès enrolled 2,938, but only 866 (29%) returned at 1 year; 430/841 respondents reported orgasm. Meremikwu's large pain OR is a heterogeneous before–after comparison, not treatment versus control. Review-wide improvement and complication percentages have inconsistent definitions/reporting; certainty is very low.[1][3][9]
  6. WHO 2025 conditionally suggests surgery for selected women, with very-low-certainty evidence and counseling/multidisciplinary care; adolescents have insufficient outcome data.[6][14][15]

References​

1. Almadori A, Palmieri S, Coho C, et al. Reconstructive surgery for women with female genital mutilation: a scoping review. BJOG. 2024;131(12):1604–1619. doi:10.1111/1471-0528.17886

2. 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

3. 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

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

5. Karim R. Female genital mutilation. Chapter 46.

6. Sharif Mohamed F, Wild V, Earp BD, Johnson-Agbakwu C, Abdulcadir J. Clitoral reconstruction after female genital mutilation/cutting: a review of surgical techniques and ethical debate. J Sex Med. 2020;17(3):531–542. doi:10.1016/j.jsxm.2019.12.004

7. 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

8. Abdulcadir J, Rodriguez MI, Petignat P, Say L. Clitoral reconstruction after female genital mutilation/cutting: case studies. J Sex Med. 2015;12(1):274–281. doi:10.1111/jsm.12737

9. Meremikwu C, Oringanje C, Moses C, et al. Clitoral reconstructive surgery in women and girls living with female genital mutilation: a systematic review. Int J Gynaecol Obstet. 2026;172 Suppl 1:81–94. doi:10.1002/ijgo.70760

10. Gnofam M, Crequit S, Renevier B, Abramowicz S. Prognostic factors of poor surgical outcome after clitoral reconstruction in women with female genital mutilation/cutting. J Sex Med. 2023;21(1):59–66. doi:10.1093/jsxmed/qdad150

11. Wilson AM, Zaki AA. Novel clitoral reconstruction and coverage with sensate labial flaps: potential remedy for female genital mutilation. Aesthet Surg J. 2022;42(2):183–192. doi:10.1093/asj/sjab218

12. Mañero I, Labanca T. Clitoral reconstruction using a vaginal graft after female genital mutilation. Obstet Gynecol. 2018;131(4):701–706. doi:10.1097/AOG.0000000000002511

13. 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

14. 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

15. World Health Organization. WHO guideline on the prevention of female genital mutilation and clinical management of complications. 2025. Recommendation 8 and implementation remarks.