Skip to main content

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

Autologous fat grafting for FGM/C-related vulvar scars is an emerging approach to symptomatic scarring and volume loss. Its proposed tissue-remodeling effects are drawn largely from non-FGM scar research, not demonstrated by tissue sampling in FGM/C. The Almadori, Hansen, Butler & Salgarello (2025) pilot is an uncontrolled 13-patient series reporting improved clinician-rated vulvar architecture (VASS), sexual function (FSFI), genital self-image (FGSIS), and psychological scores (HADS) at a mean 12.23-month follow-up. These before–after findings do not establish comparative efficacy.[1]

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 an important long-term consequence of FGM/C, though prevalence and severity vary by cutting type and population.[1] Clitoral reconstruction excises scar to expose the stump but does not specifically study treatment of diffuse surrounding vulvar fibrosis, which can cause pain, dyspareunia and distress. The AAP notes that FGM/C-related scarring can include unintended labial fusions, inclusion cysts, and obstructive infibulation scars.[3]

Fat grafting has been studied for scarring and fibrosis in other body regions (3,033 patients across 45 studies in a 2020 meta-analysis). That literature supplies indirect rationale, not proof of a standard of care or treatment effect for FGM/C scars.[1][4]

Mechanism of Action​

The following mechanical and biological mechanisms are proposed from general scar, cell and animal research. The FGM/C pilot measured clinical scores, not tissue histology or pathway activity; none of the molecular effects below was established in its vulvar grafts.[1][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.
  • May release scar tethering and improve pliability; the relative contribution of release versus graft biology is unknown.[4][7]

Biological / regenerative (ADSC-mediated)​

Adipose tissue contains stromal cells that show anti-fibrotic, pro-angiogenic and immunomodulatory activity in experimental settings:[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 uncontrolled cohort, Level of Evidence IV. Improvement from baseline cannot distinguish the procedure’s effect from other care, selection, or time.

Population: 13 FGM/C survivors with vulvar scars; types I (2), II (5) and III (6). Eligibility included ages 18–70, no pregnancy, active infection or cancer.[1]

Technique: Centrifuged macro-fat was placed subcutaneously for volume, and micro-fat more superficially at the dermal junction or in scars. The mean injected volume was 9.8 mL. Patients received sedation or general anesthesia and left the same day.[1]

Follow-up: Mean 12.23 ± 3.03 months (range 6–18). One patient had self-resolving donor-site bruising; the authors reported no other complications in this small series.[1]

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]

VASS was used as a clinician-rated outcome in the FGM/C study. Its validation in lichen sclerosus does not itself establish validity or a meaningful-change threshold in FGM/C.

Surgical Technique​

The steps distinguish what the FGM/C pilot used from variants in general scar literature. They are technical descriptions, not proof that one preparation or injection plane is superior.[1][4][7][15]

Step 1 — Fat harvest​

  • The pilot's illustrated donor sites were abdomen or thigh. Macro-fat was harvested with a 3-mm cannula with two 1-mm ports; micro-fat with a 2-mm, eight-port cannula.[1]
  • Other donor sites and low-pressure harvest systems are general fat-grafting options, not tested comparisons in this series.[7]

Step 2 — Fat processing​

  • Lipoaspirate processed to separate viable fat from blood, oil, and tumescent fluid.
  • The FGM/C series used centrifugation for both macro- and micro-fat; it did not compare processing methods or use nanofat or lipoconcentrate. The report does not provide a centrifuge speed/time protocol.[1]
  • Decanting, filtration, nanofat and lipoconcentrate are other described scar-treatment preparations, not studied FGM/C regimens here. Emulsification/filtration does not by itself establish cell enrichment or superior clinical effect.[15][16]

Step 3 — Fat injection​

  • In the pilot, macro-fat was placed subcutaneously with a 1.5-mm cannula; micro-fat was placed more superficially at the dermal junction or in scar with a 21-gauge cannula.[1]
  • Small aliquots and multiple passes are general graft-handling principles; the paper does not establish a specific fan pattern or compare these choices in FGM/C.[7][15]

Step 4 — Postoperative care​

  • The 13 patients were discharged the same day after sedation or general anesthesia.[1]
  • The pilot does not establish a standard return-to-activity interval; use individualized postoperative instructions.

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.
  • The study reported improved sexual-function scores; its non-FGM population provides indirect context for FGM/C counseling.
  • 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 graftingScar/volume treatmentVulvar scar tissueSmaller incisionsSedation or general in pilotTargets scarring and contour; may be repeatedSingle uncontrolled study (n = 13); no comparative cost or access data; does not reconstruct clitoris[1]
Foldès clitoral reconstructionSurgicalClitoral stump/scarModerateGeneral in original cohortLargest reported cohort (n = 2,938); exposes and repositions residual clitoral tissueDoes not study diffuse surrounding scar remodeling[19][20][21]
aOAP combined techniques (O'Dey)Surgical (flaps)Clitoris + prepuce + vulvovestibularModerate-highGeneralComprehensive anatomic reconstructionSingle-surgeon experience; complex[22]
A-PRPProposed adjunctNeoclitoral surfaceAdditional intraoperative stepApplied intraoperativelyHealing/pain benefit hypothesizedAdjunct only; 5-patient pilot cannot establish comparative benefit[23][24]

Potential as Adjunct or Standalone Therapy​

Almadori et al. propose several potential advantages. Their 13-patient pilot did not compare cost, access, anesthesia options or combination regimens with other reconstructions.[1]

AdvantageDetail
Less extensive tissue rearrangementDonor harvest and vulvar injection rather than a large local flap; the pilot used sedation or general anesthesia and same-day discharge
Possible lower-resource useSyringes/cannulas and processing equipment may be less complex than microsurgical transfer, but no comparative cost or implementation study was performed
Addresses a distinct problemVulvar scarring/volume loss may coexist with clitoral or anatomic concerns; treatment choice depends on the patient's findings and goals
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 selectionIncluded types I, II and III; the small cohort does not identify which patients benefit most, and individual cases included prior reconstruction or defibulation
StandardizationThe report describes centrifuged macro-/micro-fat and injection volumes but provides no comparative processing protocol or validated repeat-session schedule
Future trials warrantedAuthors explicitly state results warrant further testing in clinical trials[1][2]

Emerging Adjuncts and Combinations​

ApproachDetail
Hybrid fractional laser + lipofillingDelia 2025 addresses scars outside this FGM/C cohort; any combination benefit for FGM/C vulvar scars remains untested.[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 fat described in other scar and genital-aesthetic contexts; not used or compared in the FGM/C pilot, and superior efficacy in thin vulvar scars is unestablished.[15][16]

Key Takeaways​

  1. Autologous fat grafting is an emerging option directed at symptomatic vulvar scarring and volume loss after FGM/C.[1]
  2. Mechanical scar release and adipose-cell signaling are plausible mechanisms drawn largely from other scar settings; the FGM/C pilot did not test molecular mechanisms.[1][4][5][6][12]
  3. Almadori 2025 — n = 13 with improved mean 12-month VASS, FGSIS, FSFI and HADS scores (all p ≤ 0.019), without a comparator.[1]
  4. Same-day discharge followed sedation or general anesthesia in this pilot. Lower cost, scalability and low-resource feasibility remain hypotheses, not measured outcomes.[1]
  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