Clitoral Hood Reduction Techniques

CHAPTER 7

Clitoral Hood Reduction Techniques

Otto J. Placik

Key Points

• Clitoral hood reduction (CHR) is rarely performed as an isolated procedure.

• CHR is most commonly performed in combination with labia minora reduction.

• Functional outcomes of CHR are poorly understood, and the effect on sexual function has not been established.

• CHR is typically more of an aesthetic procedure.

• CHR should be distinguished from clitoral procedures.

• The procedure is not female genital mutilation, infibulation, cultural/ritualistic female circumcision, or genital piercing.

Indications and Contraindications

General Considerations

CHR is a procedure that is often confounded with clitoral hood removal, clitoroplasty, clitoral unhooding, clitoral hoodectomy, clitoropexy, hoodoplasty, dorsal slit surgery, lysis of adhesions, and unhooding. Understanding the difference between the glans/corpora clitoris and the prepuce is essential for distinguishing procedures. In the context of this chapter, the hood is the prepuce of the clitoris and is analogous to the penile foreskin. I intentionally do not use the term circumcision, because it has negative connotations and is often confused with clitoral amputation. The hood is distinctly different from the clitoris, and I will refer to CHR exclusively without focusing on clitoral surgery. Information on the surgery and its sequelae is sparce; a literature search on CHR yielded only 13 results. Part of the difficulty is that CHR is rarely performed as an isolated procedure and in most instances is performed in combination with labia minora reduction. CHR is predominantly performed for aesthetic indications and is limited to skin resection. Other procedures performed on the clitoris proper include the following:

• Clitoropexy to retract or suspend the clitoris

• Clitoral reduction (reduction clitoroplasty) to reduce the size of the clitoris, which most commonly occurs with congenital adrenal hyperplasia, ambiguous genitalia, female pseudohermaphroditism, clitoromegaly, clitoral hypertrophy, and genital virilism

• Clitoral lysis of adhesions, usually resulting from lichen sclerosus

In these operations, portions of the clitoral hood may be removed as an integral part of the reconstructive procedure, as discussed by Graves et al 1 for clitoral reduction and Ostrzenski² for buried clitoris. CHR should be further differentiated from female genital mutilation procedures, including infibulation and cultural or ritualistic female circumcision. Although genital piercing is often performed on the clitoral hood, it does not reduce the bulk of soft tissue.

Anatomic Issues

Although practitioners of aesthetic female genital surgery have an innate appreciation for the boundaries and extent of the clitoral hood, it is poorly defined in the literature. Some authors have referred to the hood (preputium clitoridis) as the superior portion or division of the labia minora.³ The clitoral hood varies greatly among individuals, with either a smooth or irregularly folded/pleated surface, and is commonly asymmetrical.⁴ Most anatomists refer to the free edge of the prepuce as the clitoral hood. Aesthetic surgeons consider the hood as extending anteriorly and superiorly to the anterior labial commissure (apex of the intervulvar cleft). The inferior border is the free edge of the prepuce and extends down to the junction with the labia minora. This serves as the defining point of the clitoral frenulum, the portion of the labia minora that extends to the clitoris and begins medial to the attachment with the clitoral hood. Some authors think the clitoral frenulum anchors and stabilizes the inferior attachment of the clitoral hood, and failure to respect this landmark may produce a clitoral hood deformity when a labiaplasty is performed.⁵

Laterally, the hood is bounded by the interlabial sulcus (Fig. 7-1). The length of the hood is measured from the anterior labial commissure to the distal prepuce, in the midline, and ranges from 2 to 6 cm.⁴ Protrusion of the hood beyond the labia majora is not consistent and will vary with the size of the clitoris, with some resembling a small penis. The thickness is a function of the skin quality and the underlying subcutaneous tissue and dartos fascia. The layers of the midportion of the hood from superficial to deep are the skin, subcutaneous tissue, dartos fascia, Buck fascia and suspensory ligament, neurovascular bundle, tunica albuginea, and clitoris (Fig. 7-2).

Fig. 7-1 A, The clitoral hood skin is retracted, exposing the clitoris and clitoral frenulum. B, The typical extent of the clitoral hood (red). C, The same patient is shown in a lithotomy position without the clitoral hood skin retracted. D, The area addressed with CHR is outlined in red.

Fig. 7-2 A transverse section through the body of the clitoris.

An “ideal” configuration and relation of the glans clitoris to the prepuce has not been established. Typically, the glans clitoris will protrude slightly beyond the clitoral hood with varying degrees of visibility. Excessive prominence of the clitoral hood either in untreated or iatrogenic cases after isolated labiaplasty has been described as a “micropenis.”⁶ The innervation of the clitoris and hood is generally attributed to the dorsal nerve of the clitoris, which crosses the perineal membrane 2.4 to 3.0 cm lateral to the urethral meatus (Fig. 7-3). It passes along the perineal membrane for 1.8 to 2.2 cm to the ischiopubic ramus, where it transitions to the anterolateral surface of the clitoral body, deep to the Buck fascia, for 2.0 to 2.5 cm.⁷ Surgeons must use caution when dissecting deep to the Buck fascia and lateral to the midline over the clitoral hood and minimize surgery in the depths of the interlabial sulcus at the level of the meatus. Although anatomic studies in humans are limited, we know that the undersurface of the prepuce has many sensory nerves; any surgery on these tissues is discouraged unless indicated for such conditions as lichen sclerosus.⁸

Fig. 7-3 A, Clitoral structures and relationship to pubic bones with pudendal nerve and sensory branches of the clitoris. B, Sensory nerves of the vulva and relationship to pelvic floor muscles.

The function of the prepuce is unknown but is purported to protect the clitoris and the eccrine glands, which, unique to females, keep the glandopreputial sulcus moistened.⁹

Indications

The goals of surgery are to debulk and reduce the excess or redundant clitoral prepuce. However, the specific indications are less clear. Hodgkinson and Hait 10 reported that “aesthetic external genital surgery may be requested by females who feel that their sexual enjoyment will be enhanced by exposing the clitoris … or a reduction in size of the clitoris may be aesthetically more appealing.”¹⁰ However, their described procedure accomplished neither of these goals. Alter¹¹ later modified their description, stating that the “aesthetic ideal is labia minora and a clitoral hood that do not protrude past the labia majora.” He referred to the elective nature of the procedure when noting that the surgery is “to excise redundant lateral labium and excess lateral clitoral hood (if desired by the patient).” Elsewhere he stated that the “excision allows for elimination of much of the unsightly lateral hood, which is a major aesthetic and often functional concern” but did not specify the initial functional impairment for which correction was sought or achieved.¹² Gress¹³ reported that “the aim of the surgical procedures is to achieve a result that best fulfills the wishes and expectations of the patients” and is “as balanced as possible.” Goodman¹⁴ noted that CHR is intended “to produce more ‘exposure’ of the clitoral body, theoretically providing improved sexual stimulation” but did not substantiate this claim; he restated the aesthetic indications. de Alencar Felicio⁶ stated that with CHR “the clitoris is exposed”; in a letter to the editor, Hunter¹⁵ expressed his disagreement with this and stated that surgeons should “never expose/further expose the clitoris.” Hamori¹⁶ reported that findings that respond to CHR include projection beyond the labia majora or sufficient hood bulkiness that “exceeds the width of either surrounding labium majus” or “widening of the intervulvar commissure [anterior vulvar commissure].” She discussed patients’ requests for a “petite labia minora and clitoral hood,” but she also cautioned that “care must be taken … as this may cause exposure of the glans clitoris.”⁵

Ostrzenski¹⁷ distinguished between an elongated hood and a thickened hood. An elongated hood is treated to result in 3 to 5 mm of glans exposure using his earlier “hydrodissection with reverse V-plasty.”² Patients were initially managed with a V-plasty for reasons of embarrassment: “feeling different and unhappy in an intimate relationship” and “noticeable overgrowing”; hygiene issues: “offensive odor,” discomfort, elongation, a negative body image perception “responsible for her deterioration of social and emotional well-being”; and aesthetic correction of a “significantly protruding clitoral prepuce.”¹⁷

The degree of exposure of the glans clitoris (3 to 5 mm) and the ability to improve sexual stimulation by diminishing tissue interference are controversial.¹⁷ Benson¹⁸ discussed the patients he thought would be happy with the procedure (Table 7-1). The issues of improved cosmetic appearance, contour, and folds are less debated.¹⁴

Table 7-1 Patients Likely To Be Satisfied With a Clitoral Hood Reduction Procedure

Will Likely Be Satisfied

Will Likely Not Be Satisfied

Anorgasmic Patients

These patients will be happier with coitus even if no climax is achieved, if emotionally stable.

Surgery is avoided if untreated emotional issues are evident.

Patients With These Characteristics

These patients desire orgasm in the missionary position.

These patients desire orgasm with no other stimulation except intercourse.

Orgasm Is Slow or Weak

These patients are usually the most likely to be pleased with the result of the procedure; as intensity increases, speed to climax is variable.

Currently Happy and Normal

Surgery is avoided unless a physical examination supports correction.

Orgasmic but Requires Manual/Oral/Vibrator/Positioning

Patients will be pleased with increased sensation but will likely require extra stimulation.

Low Sex Drive

If the condition has a psychological or hormonal basis, surgery will not help; the underlying condition must first be treated.

Painful Clitoris

Pain may resolve when chronic infection or adhesions are treated.

Seeking Multiorgasmic Status

Surgery on these patients is avoided; this result may occur but cannot be promised or necessarily delivered.

Labiaplasty Patients

Patients will be pleased with a more contoured appearance.

Menopausal Agglutination

Problems will recur if hormonal status is not normalized.

Lichen Sclerosus Scarring

This condition almost always recurs within a few months.

Body Modifiers

Surgery is not performed on these patients; they may not be satisfied with the results, and procedures may be difficult to reverse.

Adapted from Benson R. Clitoral hood reduction. Presented at the Seventh Annual Congress for Aesthetic Vaginal Surgery, Tucson, AZ, Jan 2012.

Nearly anyone who presents with realistic expectations and has excess preputial tissue is a candidate for an elective procedure. Several authors have described an iatrogenic clitoral hood deformity after labiaplasty.”5,11,13 Hamori⁵ reported that the trim method of labia reduction may produce a relative reduction in the prominence of the labia minora in comparison to the residual clitoral hood with the excessive projection of the clitoral hood creating the illusion of a “small penis.” However, she did not comment on whether a clitoral hood reduction was performed as part of the initial procedure, as is typically routine in most instances of labia reduction (R. Alinsod, personal communication, 2013). This may also occur as the result of an isolated labia reduction with the wedge technique (also called with inferior wedge resection and superior pedicle flap reconstruction), leading Dr. Alter^11,12 to modify his technique and rename it the extended central wedge resection. He stated that the extension was required to “excise the … excess lateral clitoral hood (if desired by the patient).”¹² In his discussion, Alter commented that the trim technique may result in an “abrupt-ending clitoral frenulum and large overhanging clitoral hood.” The clitoral hood resection was described as either being continuous with the central wedge resection or, alternatively, as a discontinuous “separate elliptical excision.” See Fig. 10-18 in Chapter 10 (Complications of Female Cosmetic Genital Surgery) for more information about this condition.

Contraindications

Contraindications to CHR include a patient’s unrealistic expectations or comorbid untreated psychosexual conditions that may interfere with sexual function; patient confusion with hoodectomy procedures; active vulvovaginal infections; active vulvovaginal inflammatory diseases; coagulopathy; and smoking.

Patient Evaluation

Clinical Evaluation of the Deformity

Although screening methods for patients undergoing female genital plastic surgery have been recommended, including traditional assessments and sexual function surveys (particularly orgasmic dysfunction), no established tools for evaluating CHR candidates have been established. Because the surgery is rarely performed as an isolated procedure, evaluation typically proceeds as for a candidate for labia minora reduction. Hamori 5,16 suggested that clitoral hood redundancy is optimally assessed with the patient in the standing position, with attention to tissue thickness and bulk, redundant folds, symmetry, separation of the anterior vulvar commissure, and previous surgery (especially trim labiaplasty); the clitoris is also palpated to exclude clitoromegaly. Because Gress’s technique¹³ may affect the prominence of the clitoris, he suggested preoperative analysis of the clitoral glans and body to distinguish the hypertrophy of the glans from that of the hood, as well as the degree of “protrusion of the tip of the clitoris.” He advised measuring the distance from the glans clitoris to the urethral meatus and stated that this must be a minimum of 1.5 cm.

Freedom of the prepuce from the glans clitoris and the presence of adhesions, phimosis, scars, piercings, trauma, pain, and dysesthesias should be documented. Lichen sclerosus should be excluded. The clitoris and prepuce have no standard appearance, and a wide variety of anatomic variations have been described.¹⁹ Ostrzenski²⁰ proposed a clitoral hood classification that is not widely used but is most applicable to his described surgical approaches: occlusion as seen in lichen sclerosus (type 1), hypertrophy (type 2), and hypertrophy with subdermal asymmetry (type 3).

Preoperative Planning and Preparation

As with all surgical planning, a survey of patient motivations with counseling is an essential component of treatment.²¹ After a complete history is taken and a physical examination completed, including psychological, gynecologic, and sexual evaluations, some practitioners advise that patients be referred for counseling with appropriate specialist management, such as cognitive behavioral therapy.²² The assessment of sexual function is as important as the aesthetic and anatomic evaluation.²³ The Society of Obstetricians and Gynaecologists of Canada has suggested encouraging girls younger than 16 years of age to defer surgery until completion of mature genital development.²¹ Patients should be informed about the procedure with a thorough review of the risks, alternatives, and benefits, consistent with the principles of informed consent.

When discussing the role and goals of the procedure, physicians should inform patients that the normal physical appearance is highly variable, and repair probably has no direct medical benefit. Patients’ natural asymmetries and functional anatomy are reviewed.