Clitoral Reconstruction: A Surgical Procedure Explained

Clitoral reconstruction is a surgical procedure that restores clitoral anatomy and, in many cases, sensation after the organ has been partially or fully removed. The most common reason people seek it is reversal of female genital mutilation/cutting (FGM/C), though the same principles now apply to women treated for vulvar cancer, people born with certain congenital conditions, and transgender men undergoing genital-affirming surgery. The procedure has been refined considerably since its formal introduction in the early 2000s, and the evidence on functional outcomes is encouraging, if still limited by the quality of available studies.

Why People Seek This Surgery

The World Health Organization classifies FGM/C into four types, ranging from partial removal of the clitoris and its hood (Type I) to the most invasive form, infibulation, which removes the clitoris, labia minora, and most of the labia majora (Type III). A fourth category captures other harmful practices such as stretching, piercing, and cauterization.¹ Worldwide, an estimated 200 million women and girls have undergone some form of FGM/C. Many experience chronic pain, difficulty with sexual function, and psychological distress that persists for years or decades. Clitoral reconstruction emerged as a way to address all three.

Beyond FGM/C, vulvar cancer surgery sometimes requires partial or complete removal of the clitoris. A growing number of surgical teams are now applying reconstruction techniques at the time of cancer treatment or afterward. Similarly, women born with congenital adrenal hyperplasia (CAH) who underwent aggressive childhood surgery may seek later reconstruction to improve sensation and cosmetic appearance. And in gender-affirming surgery for transgender men, the clitoris is the starting tissue for metoidioplasty, a procedure that shares some of the same dissection steps in reverse.

Why the Clitoris Can Often Be Rebuilt

A common misconception is that FGM/C removes the entire clitoris. In most cases, what is excised is the visible portion, the glans, along with part of the shaft. But a large portion of the clitoral body extends internally, anchored to the pubic bone by a suspensory ligament. That internal tissue retains its nerve and blood supply. The key anatomical insight behind reconstruction is that this buried remnant can be mobilized, brought forward, and reshaped into a new glans.

The clitoris is densely innervated. Research using fiber counting in cadaveric specimens found roughly 3,100 nerve fibers (axons) in each half of the clitoral body, about 71 percent of which are myelinated, meaning they carry fast sensory signals. While the clitoris receives only about a third as many total axons as the penis, its much smaller surface area gives it an innervation density roughly six times greater.² That density is what makes sensory recovery possible even after significant tissue loss: if the internal structures and their nerve pathways are intact, restoring exposure of the tissue to the surface can restore touch perception.

The nerve supply itself is not a single cable but a collection of loose bundles. About 12 such bundles run through each crus (the leg-like root of the clitoris), increasing to around 32 bundles in the body. This dispersed arrangement means there is no single nerve trunk a surgeon can accidentally sever; it also means that careful dissection is essential, because the fibers are woven into the surrounding connective tissue.² The dorsal clitoral nerve, the main sensory branch, runs along the top surface of the clitoral body and communicates with deeper autonomic fibers (the cavernous nerve) that control blood flow during arousal.³

The Foldès Technique and Its Variations

The most widely described approach is the technique developed by the French urologist Pierre Foldès. In broad terms, the surgeon first removes the scar tissue that has formed over the clitoral stump. The surrounding tissue is then carefully dissected to isolate the suspensory ligament while preserving the neurovascular pedicle, the bundle of nerves and blood vessels enclosed within the tough outer sheath (tunica albuginea) of the clitoris.⁴ The ligament is cut close to the pubic bone, which frees the clitoral stump to move forward and downward. A wedge-shaped trimming creates a rounded neo-glans, which is then fixed in a normal anatomical position.⁵

The exposed neo-glans is either left to re-epithelialize on its own (the raw surface gradually develops a skin-like covering) or is covered with a reconstructed clitoral hood fashioned from a local skin flap.⁴ Variations on the technique exist. A systematic review identified eight published studies, four using the original Foldès approach and four using modified versions, all based on the same principle of downward mobilization of the stump but differing in how the glans and prepuce are rebuilt.⁶

What Preoperative Imaging Adds

One challenge surgeons face is figuring out, before cutting, exactly how much clitoral tissue remains and where it sits relative to scar tissue and any cysts that may have formed. Ultrasound, including Doppler imaging to assess blood flow, has been used to map the anatomy before and during the procedure. In cases where a periclitoral inclusion cyst sits close to the clitoral stump, Doppler can help the surgeon distinguish cyst tissue from vascularized clitoral tissue, reducing the risk of accidental nerve or vessel injury during excision.⁷ Preoperative ultrasound also helps set realistic expectations: if imaging reveals very little residual tissue, the surgeon can counsel the patient accordingly.

Sensory Outcomes After Surgery

The most meaningful question for many patients is whether sensation returns. In a study that tested clitoral sensitivity with standardized monofilament touch testing, patients who had undergone Type IIb mutilation (removal of the clitoris and partial excision of the labia minora) showed a significant improvement in sensitivity after reconstruction. Postoperatively, about 96 percent of patients could detect the finest monofilament used, and no patient’s sensitivity worsened compared to baseline.⁸ The post-surgical sensitivity levels were not statistically different from those of women with an intact clitoris, a striking result given the severity of the original injury.

Orgasmic function, which depends on more than just touch sensitivity, has also improved in published cohorts, though the numbers are more variable. In the largest reported series, about half of women described experiencing orgasms at one year after surgery, including roughly 175 who described normal orgasms and 255 who described occasional or restricted ones.⁹ A systematic review covering multiple cohorts found consistent evidence of improvement in clitoral pleasure, with roughly 43 to 51 percent of women reporting restricted or normal orgasms after surgery, compared to rates as low as 2 percent before.¹⁰ Individual case reports have described outcomes ranging from complete resolution of vulvar pain and improved orgasm to improved desire and lubrication that the patient attributed more to better body image than to the physical change alone.¹¹

These numbers should be read carefully. The systematic review that compiled them flagged a high risk of bias across studies, noted that most did not use validated sexual function questionnaires, and pointed out that a large proportion of patients were lost to follow-up.⁶ Still, the direction of the evidence is consistent: reconstruction appears to improve both measurable sensitivity and self-reported sexual experience for many women.

Psychological Benefits and the Case for Multidisciplinary Care

Surgery alone does not address the full scope of what FGM/C does to a person. Many women carry trauma, anxiety about their bodies, and deeply internalized beliefs about sexuality. Research comparing women who received clitoral reconstruction combined with psychosexual therapy against those who received psychosexual therapy alone found that the combined group reported higher overall satisfaction, greater psychological well-being, better sexual response scores, and a more positive genital self-image.¹² A narrative review reached a similar conclusion: reconstruction could be beneficial in terms of both enhanced sexual function and body image, but the psychological dimension mattered enormously.¹³

This is why most centers with experience in the procedure now embed it in a multidisciplinary program that includes counseling before and after surgery, sexual health education, and sometimes pelvic floor physiotherapy. The surgical procedure addresses anatomy. The therapy addresses the meaning a woman attaches to her body and her expectations for recovery.

Pain Management and the Neuroma Problem

Some women who have undergone FGM/C develop neuromas, painful tangles of nerve tissue that form at the cut end of severed nerves. These can cause chronic clitoral pain that persists for years. Clitoral reconstruction, by removing scar tissue and the neuroma along with it, has been shown to relieve this pain. In a published case series, women who underwent both psychosexual therapy and reconstruction experienced resolution of clitoral pain within three months of surgery, the time frame in which the neo-glans typically completes re-epithelialization and surgical pain subsides.¹⁴

Postoperative pain from the reconstruction itself, however, has been underaddressed. A survey of care providers found that screening for neuropathic pain after surgery was rare, performed in only about 3 percent of cases, and that pudendal nerve blocks were used by just 8 percent of providers.¹⁵ More recent work has tested bilateral pudendal nerve blocks performed at the end of the procedure and found them effective for reducing immediate postoperative pain.¹⁶ One complication worth noting: in the multidisciplinary care study mentioned earlier, the main surgical complications were minor postoperative bleeding and one wound infection that triggered a relapse of post-traumatic stress disorder, a reminder that for trauma survivors, even routine surgical pain can carry outsized psychological weight.¹²

Complication Rates

Across published studies, the overall postoperative complication rate for clitoral reconstruction after FGM/C has been reported at about 5 percent.⁶ Complications tend to be minor: wound infection, bleeding, and transient swelling. Serious adverse events, such as significant nerve damage causing permanent sensory loss, have not been prominently reported, though the limited follow-up in most studies makes it hard to know the true long-term rate. No deaths have been attributed to the procedure in the published literature. Still, incomplete follow-up is itself a limitation. When half or more of enrolled patients drop out of a study before the final visit, the complication rate among those lost is unknown.

Reconstruction After Vulvar Cancer

The Foldès technique was designed for FGM/C reversal, but oncologic surgeons have adapted its principles for women who lose clitoral tissue to cancer surgery. In a small case series of 18 women who underwent clitoral reconstruction at the time of vulvar cancer treatment, the procedure added roughly 15 minutes of operative time. Postoperatively, about 89 percent of the women reported the ability to achieve clitoral orgasm, and the complication rate specific to the reconstruction was about 11 percent.¹⁷ That orgasm rate is noteworthy for a cancer population, where the primary surgical goal is oncologic clearance and functional preservation is secondary.

A qualitative study of 12 vulvar cancer patients who underwent reconstruction found that 10 experienced at least partial restoration of clitoral sensation. The two who did not regain sensitivity had both received full-thickness skin grafts for hood reconstruction, suggesting that graft choice may influence outcomes.¹⁸ Another team used a perforator-based island flap (the Singapore flap) to reconstruct both the vulva and the clitoris after anterior vulvectomy. The flap approach maintained its own cutaneous innervation and blood supply, with minimal donor site problems.¹⁹

The evidence here is thin, consisting of single-center case series, but the fact that reconstruction can be integrated into cancer surgery without substantially lengthening the procedure or increasing major complications has prompted calls for wider adoption.

Congenital Conditions and Clitoral Surgery

Women born with congenital adrenal hyperplasia sometimes develop significant clitoral enlargement due to excess androgen exposure in utero. Historically, many underwent clitoral reduction surgery in infancy, procedures that sometimes sacrificed sensation. Modern approaches emphasize neurovascular-sparing techniques. A case report of an adult CAH patient who underwent multidisciplinary reconstruction, including clitoroplasty, urethrovaginal separation, vaginoplasty, and labial reconstruction, demonstrated preserved clitoral sensation and normal urinary and menstrual function postoperatively, without complications.²⁰ The broader shift in this field has been away from early, irreversible surgery on infants and toward patient-centered decision-making in adolescence or adulthood, when the person can participate in choosing what, if anything, is done.

Gender-Affirming Applications

For transgender men and some nonbinary people, the clitoris is the starting point for metoidioplasty, a procedure that converts a hormonally enlarged clitoris into a small phallus. Testosterone therapy typically increases clitoral size over months to years before surgery. The operative steps share familiar ground with FGM/C reconstruction: the clitoris is degloved, the suspensory ligament is divided near the pubic bone, and the tissue is mobilized forward.²¹ Additional steps include urethral lengthening, scrotoplasty with testicular implants, and sometimes vaginectomy. Newer techniques have added corpora mobilization and local flap interposition to improve neophallus length and girth.²² Although the goals of metoidioplasty are different from those of FGM/C reconstruction, the underlying anatomical knowledge and nerve-sparing dissection principles overlap substantially.

Access, Cost, and Ethical Tensions

Availability of clitoral reconstruction varies wildly by country and even by province or state. A qualitative study in Canada found that women with FGM/C felt excluded from the healthcare system because reconstructive surgery was not covered under Ontario’s universal health insurance, even as cosmetic genital surgeries sought by other women and gender-affirming procedures were funded. Obstetricians and gynecologists reported facing ethical dilemmas: it was legal to perform elective cosmetic genital surgery on Western-born patients, but not legal to perform reinfibulation requested by some immigrant patients, and clitoral reconstruction fell into a grey zone of inaccessibility.²³

There is also a risk of overselling the procedure. Reviews have cautioned that women must be informed about the gaps in the evidence, disabused of myths about female sexual function, and assessed according to current best practices before being offered surgery.²⁴ A woman who expects surgery alone to resolve complex psychosexual trauma is likely to be disappointed. Similarly, marketing reconstruction as a guaranteed “cure” for FGM/C misrepresents both the limits of surgery and the nature of the harm. The strongest outcomes in the literature come from programs that combine surgery with sustained psychological support, and preoperative counseling that sets honest expectations appears to be one of the most important factors in postoperative satisfaction.

What the Clitoral Hood Adds

Several newer techniques focus not only on the neo-glans but on reconstructing a clitoral hood to protect it. After the Foldès procedure, the exposed neo-glans goes through a period of re-epithelialization that can be uncomfortable. A reconstructed hood, built from a thin local skin flap, provides coverage and may help preserve the sensitivity of the newly exposed tissue over time by shielding it from chronic friction against clothing. In vulvar cancer reconstruction, the choice between a full-thickness graft and a buccal mucosal graft for hood formation may affect sensory outcomes, as noted in the qualitative study where the two patients who did not recover sensation had both received full-thickness grafts.¹⁸ This is an area where surgical refinements are still evolving, and head-to-head comparisons of graft types have not yet been published.

1
PubMed Central. Reconstructive Surgery After Female Genital Mutilation: A Multidisciplinary Approach
2
PubMed Central. Innervation pattern and fiber counts of the human dorsal nerve of clitoris
3
The Journal of Sexual Medicine. Neural Supply to the Clitoris: Immunohistochemical Study with Three‐Dimensional Reconstruction of Cavernous Nerve, Spongious Nerve, and Dorsal Clitoris Nerve in Human Fetus
4
Sexual Medicine Reviews. Clitoral reconstructive surgery in patients with vulvar (pre)malignancies: what can we learn from female genital mutilation/cutting? A scoping review
5
PubMed. Reconstructive surgery of the clitoris after sexual mutilation
6
Sex Reproduction & Healthcare. Clitoral reconstructive surgery after female genital mutilation: A systematic review
7
PubMed. Ultrasound-guided staging and reversal of female genital mutilation
8
PubMed Central. Sensitivity after Clitoral Reconstruction in Patients with Female Genital Mutilation
9
The Lancet. Effect of surgical reconstruction of female genital mutilation on morphological outcome and sexual function: a prospective cohort study
10
PubMed Central. A systematic review of the evidence on clitoral reconstruction after female genital mutilation/cutting
11
PubMed. Clitoral reconstruction after female genital mutilation/cutting: case studies
12
PubMed Central. Clitoral reconstruction and psychosexual care after female genital mutilation/cutting: Assessment of multidisciplinary care
13
PubMed Central. Psychosexual Consequences of Female Genital Mutilation and the Impact of Reconstructive Surgery: A Narrative Review
14
PubMed Central. Management of painful clitoral neuroma after female genital mutilation/cutting
15
PubMed. Postoperative pain after clitoral reconstruction in women with female genital mutilation: An evaluation of practices
16
The Journal of Sexual Medicine. Bilateral pudendal nerve block reduces postoperative pain after clitoral reconstructive surgery: a prospective comparative study
17
PubMed. Clitoral reconstructive surgery for patients with vulvar carcinoma
18
The Journal of Sexual Medicine. Clitoral reconstructive surgery in vulvar cancer patients: a qualitative study about motives, experiences, and outcomes
19
International Journal of Gynecological Cancer. Vulvar and clitoral reconstruction using bilateral Singapore island perforator flap after anterior vulvectomy
20
Urology Case Reports. Functional Urology Adult congenital adrenal hyperplasia presenting with severe clitoromegaly and distal vaginal stenosis: A reconstructive surgical case report
21
PubMed Central. Metoidioplasty in Gender Affirmation: A Review
22
PubMed. A New Combined Technique for Neophallus Elongation and Girth Enhancement for Metoidioplasty (Barroso Procedure): Total Corpora Mobilization with Martius Flap
23
PubMed Central. How Canadian Law Shapes the Health Care Experiences of Women with Female Genital Mutilation/Cutting/Circumcision and Their Providers: A Disjuncture Between Expectation and Actuality
24
PubMed. Clitoral Reconstruction After Female Genital Mutilation/Cutting: A Review of Surgical Techniques and Ethical Debate