Mañero Vaginal Mucosal Graft — Clitorolabial Reconstruction After FGM/C
The Mañero vaginal mucosal graft technique is a novel approach to clitorolabial reconstruction after FGM/C described by Iván Mañero and Trinidad Labanca (Barcelona, Spain) in 2018. It is the only published alternative to the Foldès technique that uses a free vaginal mucosal graft to provide soft-tissue coverage of the neoclitoris and reconstruct the labia, rather than relying solely on local skin closure or pedicled flaps.[1][2] In a prospective cohort of 32 women, the technique produced significant improvements in both sexual function (FSFI 16 → 29, p < 0.001) and quality of life.[1]
For the broader treatment menu see the Vulvar Reconstruction Atlas. For the workhorse FGM/C reconstruction technique see Foldès Clitoral Reconstruction; for the aOAP-flap variant used for FGM/C vulvovestibular and LSA reconstruction see aOAP Flap.
Background and Rationale
A key limitation of the standard Foldès technique is that after scar excision, suspensory-ligament transection, and clitoral-stump mobilization, the neoglans is typically covered by closing the surrounding vulvar skin directly over it. In women with extensive FGM/C (particularly Types II and III), there may be insufficient local tissue to provide adequate soft-tissue coverage, reconstruct a clitoral hood, or recreate the labia minora.[1][3] The Mañero technique addresses this by harvesting a free mucosal graft from the lateral vaginal wall to serve as both neoclitoral coverage and labial reconstruction material.[1]
Rationale for using vaginal mucosa specifically:
| Property | Detail |
|---|---|
| Tissue similarity | Vaginal mucosa is histologically similar to the inner surface of the native clitoral prepuce and labia minora (non-keratinized or minimally keratinized stratified squamous epithelium) — a more physiologic tissue match than keratinized skin grafts[1] |
| Moisture and pliability | Mucosal tissue maintains a moist, supple surface that more closely mimics the natural vulvar environment |
| Concealed donor site | Vaginal harvest site heals by secondary intention without visible external scarring |
| Availability | Even in women with extensive external genital mutilation, the vaginal canal is typically intact and provides an accessible donor site[1] |
Surgical Technique
The Mañero procedure combines the core principles of clitoral-stump mobilization (similar to Foldès) with the addition of a vaginal mucosal free graft.[1][3]
Step 1 — Clitoral stump exposure and mobilization
- General anesthesia; vulvar scar tissue overlying the clitoral stump is excised.
- Residual clitoral body identified and dissected free from surrounding fibrosis.
- Suspensory ligament transected to allow downward mobilization of the clitoral stump (as in Foldès).
- Dorsal neurovascular bundle carefully preserved throughout.
Step 2 — Neoglans fashioning
- Distal end of the mobilized clitoral body shaped into a neoglans.
- Neoclitoris sutured into anatomical position with anti-retraction fixation sutures.
Step 3 — Vaginal mucosal graft harvest
- Rectangular or elliptical mucosal graft harvested from the lateral vaginal wall.
- Taken as a partial-thickness or full-thickness mucosal specimen depending on the tissue needed.
- Vaginal donor site left to heal by secondary intention (or closed primarily if feasible).
Step 4 — Graft placement for clitoral and labial reconstruction
- Vaginal mucosal graft trimmed and tailored to the recipient site.
- Used to provide soft-tissue coverage over the neoclitoris (recreating a neo-prepuce / clitoral hood) and / or to reconstruct the labia minora.
- Graft sutured into position with fine absorbable sutures.
- Single-stage clitorolabial reconstruction.
Step 5 — Closure and postoperative care
- All wounds closed in layers.
- Local anesthetic infiltration for postoperative analgesia.
Published Outcomes — Mañero & Labanca 2018 (n = 32)[1]
Original and only published cohort — 32 consecutive women treated at the Iván Mañero Clinic in Barcelona, Spain, with prospective follow-up:
| Outcome | Result |
|---|---|
| FSFI | 16 → 29 (p < 0.001) |
| Improvement | Significant gains in body image, self-esteem, and quality of life |
Comparison with Other Coverage Techniques
| Technique | Tissue source | Key advantage | Key limitation | FSFI change |
|---|---|---|---|---|
| Mañero vaginal mucosal graft | Lateral vaginal wall (free graft) | Mucosal tissue match; concealed donor site; single-stage clitorolabial reconstruction | Free graft (no intrinsic blood supply); single-center evidence (n = 32) | 16 → 29[1] |
| Wilson & Zaki sensate labial flaps | Labia minora remnant (pedicled flap) | Innervated; maintains own blood supply; improved sensation | Requires sufficient labial remnant; not feasible in severe Type III | 11.6 → 29.1[5] |
| O'Dey OD flap | Local vulvar tissue (pedicled flap) | Preputial reconstruction; combined with NMCS and aOAP | Multi-flap technique; 8.4% revision rate | Significant improvement (p < 0.001)[6] |
| Standard Foldès (skin closure) | Local vulvar skin | Simplest; largest evidence base (n = 2,938) | No dedicated coverage tissue; no labial reconstruction | Orgasm in 51% at 1 y[7] |
Position in the Literature
The Mañero vaginal mucosal graft technique is notable as the only non-Foldès technique included in the 2026 Meremikwu SR of FGM/C clitoral reconstruction (13 studies — 12 Foldès, 1 Mañero).[2] The 2024 Almadori scoping review similarly noted that the Foldès technique was used in 95% of published studies, with Mañero representing one of the few described alternatives.[4]
The technique has been recognized in multiple reviews as an important innovation that addresses the soft-tissue-coverage gap after clitoral mobilization, particularly in women with extensive mutilation where local tissue is insufficient.[3][8] However, it remains supported by only a single-center, single-cohort study (Level of Evidence IV); no comparative trials exist.[2][4]
Limitations and Considerations
| Limitation | Detail |
|---|---|
| Limited evidence | One published cohort (n = 32) from a single center; no randomized or comparative studies[1][2] |
| Free-graft biology | Unlike pedicled flaps (Wilson & Zaki sensate labial; O'Dey OD), a free mucosal graft depends entirely on revascularization from the recipient bed — inherent risk of partial / complete graft loss[5][6] |
| Donor-site morbidity | Vaginal donor site is concealed; potential complications include vaginal scarring, stenosis, or discomfort (not prominently reported in the original series)[1] |
| Sensation | Vaginal mucosal graft is not innervated at the time of transfer (unlike Wilson & Zaki sensate labial flap); sensation in the reconstructed tissue depends on reinnervation from the recipient bed over time[5] |
| Multidisciplinary care | Psychosexual counseling should be offered as part of comprehensive FGM/C care; included in only ~38% of published studies[4][8] |
Key Takeaways
- The Mañero vaginal mucosal graft is the only published alternative to standard Foldès that uses a free vaginal mucosal graft for neoclitoral coverage and labial reconstruction.[1][2]
- Rationale — physiologic tissue match (mucosa similar to native clitoral prepuce / labia-minora epithelium), concealed donor site, accessible even in extensive FGM/C.[1]
- Outcomes — n = 32, FSFI 16 → 29 (p < 0.001) with significant QOL gains.[1]
- Evidence base is single-center, single-cohort (Level IV); no comparative trials.[2][4]
- Trade-off vs sensate labial flaps (Wilson & Zaki) — Mañero is feasible even when labial remnant is absent, but the free graft has no intrinsic blood supply or innervation at the time of transfer.[5]
References
1. 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
2. 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
3. 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
4. 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
5. 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
6. 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
7. 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
8. 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