Skip to main content

Foldès Clitoral Reconstruction (± OD Preputial Flap)

The Foldès clitoral reconstruction is the most widely performed surgical technique for restoring clitoral anatomy and function in women who have undergone female genital mutilation/cutting (FGM/C) — used in approximately 95% of published reconstructive cases worldwide.[1] First described by Pierre Foldès in France in 2004 (with a parallel earlier description by Thabet and Thabet in Egypt), the procedure is based on the anatomical principle that FGM/C typically removes only the external glans and hood, while the deeper clitoral body and neurovascular bundle remain intact beneath scar tissue and can be surgically liberated and repositioned.[2][3][4]

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

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. Even after FGM/C Types I–III, a substantial clitoral stump typically persists beneath the scar, retracted superiorly by the suspensory ligament. 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)​

The procedure is performed under general anesthesia (typically via laryngeal mask) and follows six key steps:[2][3]

  1. Scar excision and exposure — circular or longitudinal "buttonhole" skin incision over the clitoral stump; overlying scar tissue and fibrosis sharply excised to expose the residual clitoral body. If infibulation (Type III) is present, defibulation and pseudocyst removal are performed first.
  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 creation — distal end of the exposed clitoral body fashioned into a neoglans by wedge plasty. Goal: ≥ 5 mm projection beyond the skin surface to compensate for expected postoperative retraction.[5]
  5. Fixation and anti-retraction sutures — first layer of sutures anchors the neoclitoral shaft to surrounding tissue (bulbocavernosus muscles bilaterally) to prevent retraction. Running or interrupted monocryl sutures pass from the residual fibrous tunica to vestibular mucosa and skin.[3]
  6. Closure — vestibular skin closed superiorly with interrupted polyglactin sutures through subcutaneous tissue and periosteum. All dissected spaces are infiltrated with local anesthetic (e.g., ropivacaine).[3]

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​

  • FGM/C Types I, II, and III (WHO classification) — the Foldès technique has been applied across all types.[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]
  • Indicated when symptoms have not responded to more conservative measures (e.g., psychosexual counseling alone).[6]
  • 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 patients, 29% follow-up rate):

Anatomic resultFrequency
Hoodless visible glans42%
Normal-appearing clitoris28%
Visible projection24%
Palpable projection6%
No change0.4%
  • 51% of women reported orgasms at 1 year.
  • 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]​

  • Significant reduction in vulval pain, clitoral pain, and dyspareunia — OR 79.67 (95% CI 41.67–152.33).
  • 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]​

  • 94% post-surgery improvement.
  • 3% complication rate.

Complications​

The procedure has a favorable safety profile. Reported adverse events:[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 offered within a multidisciplinary framework including psychosexual counseling (offered in only ~38% of published studies).[1][8]

  • 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 clitoral reconstruction is the most widely performed FGM/C-restoration technique (~95% of published cases).[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. Six-step Foldès technique: scar excision → suspensory ligament transection → NVB preservation → neoglans creation (≥ 5 mm projection) → anti-retraction fixation → closure.[2][3]
  4. O'Dey OD preputial flap, NMCS, and aOAP flap complement Foldès for hood / stump / vulvovestibular reconstruction with significant improvement in sensation, orgasm, and dysmenorrhea / dysuria / dyspareunia.[7]
  5. Outcomes — Foldès n = 2,938: 51% orgasm at 1 year; Meremikwu 2026 SR: significant pain / dyspareunia reduction (OR 79.67); Almadori 2024 scoping: 94% improvement, 3% complication rate — but evidence certainty is very low.[1][3][9]
  6. Should be offered within a multidisciplinary framework with psychosexual counseling; adolescents have insufficient data.[6][14]

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