Restoring patients’ dignity with reconstructive surgery of the genitals

There is no doctor who best describes flamboyance better than Dr Francis Were. If there was an award for the most colourfully dressed gynaecologist, he would win this hands down every single time.

His area of sub-specialisation completely fits his profile; or so many thought, before they actually understood what cosmetic gynaecology is truly about. As a more recent development in the world of gynaecology, cosmetic gynaecology has faced plenty of resistance. This is just like how plastic surgery did in the past; resulting in the adaptation of the specialty into plastic and reconstructive surgery to bring out the often overlooked aspect of reconstruction.

Just about two decades ago, the term plastic surgery evoked images of huge breasts and pouty lips worn by celebrities who couldn’t seem to get enough of going under the knife to alter what nature bestowed upon them. To the medical world, plastic surgery simply looked like a specialty that would get one rich very fast; a fact that has never been synonymous with medical practice as we know it.

It has taken time to make known the less glamorous aspect of plastic surgery; the reconstructive surgery. Kenya has been training plastic surgeons locally for the past decade now. This has resulted in a number of plastic surgery clinics around town; serving a fairly elite population of men and women seeking to enhance their looks.

The less known side is about the clients they serve, who need reconstructive surgery to improve their quality of life. These are women with gygantomastia (abnormally large breasts) who need breast reduction to cure their chronic back pain or cervical spine dislocation. These are persons who have undergone severe scarring from burns, trauma or accidents, who need reconstruction to improve their general aesthetics and function. These are children born with congenital lesions that are unsightly, needing to be removed, with additional reconstruction, to bring about a semblance of normalcy.

How has this translated into gynaecological endocrinology? The advent of all-out aesthetic procedures around the vulva and penis has resulted in questionable hypes that have made us all question where to draw the line between aesthetics and genital mutilation. What started as penile and vulval piercings evolved over time to need vulval reconstruction to achieve the perfect vulva. This drew a lot of debate, with hesitation among the professionals to embrace the idea.

However, Dr Were and colleagues have gone on to learn and perfect skills that are now bringing relief to many women across board. A few months ago, our colleague colourfully took us through what his work looks like with respect to the populations we serve.

He presented case studies of women living with anatomical variations of clitoris and labia minora that are way too prominent for comfort. For these patients, discomfort did not mean that they looked different. It meant that the large labia would make it uncomfortable to wear underwear and jeans.

Walking would induce chaffing of the extremely sensitive region, causing untold pain. Their only option is to wear long dresses, with no underwear. This may be possible most times, but not during menses when pads and panties are non-negotiable. Let’s not talk about those in the service industry who must wear staff uniform and spend all day on their feet walking around.

Surgery to reduce the excessive tissue is the only option they have, to give them a semblance of a normal life. The delicate surgery takes into consideration the minimisation of blood loss (the vulva may be small but is terrible bloody during surgery); reduction of scar formation during healing; and the maintenance of sensation as a key factor in retaining full function.

But the biggest beneficiaries of this craft are women who have undergone female genital mutilation (FGM). For many of these women, they were children when it happened. They did not have a say and did not choose this. In their adult age, the only form of justice they can truly have is an attempt at giving them back what they were robbed of.

The reconstructive surgery for FGM is a multi-step process that requires repeat surgeries and plenty of rehabilitative procedures in order to have a reasonable outcome. It takes patience from both the doctor and the patient, time and commitment. A support network is key for the patient to manage not just the physical aspect but also the psychological issues that she lives with.

The aim of surgery is to actually dig into the pelvis and attempt to bring out the residual clitoral tissue that escapes injury during the FGM process. The new clitoris requires refashioning tissue to provide cover, rebuild the shape and size to look as close as possible to the anatomic normal, and most importantly, to give a chance at restoring some level of sensitivity that the clitoris is known for.

Just like a patient with a broken bone who undergoes surgery to fix it, it requires physiotherapy to restore function. The refashioned clitoris requires its own special physiotherapy to restore function as much as possible. Herein comes the therapeutic use of sex toys to stimulate the refashioned nerves in an attempt to restore sensitivity. The patient is required to self-stimulate with a dildo for months in order to train the nerves in the refashioned clitoris to gain the unique sensitivity required.

Newer technologies such as platelet-rich plasma injections have been shown to demonstrate benefits in the healing process after surgery, thereby improving overall outcomes for these patients. Research findings with regard to outcomes of these procedures demonstrate marked improvement in the patient’s satisfaction index with regard to the physical, functional and psychological aspects. Surgical techniques continue to improve, as well as technologies to make the procedures safer and with better outcomes. In these uncharted territories, Dr Were and colleagues are pioneers. Their biggest challenge is not in the work they are doing; but in the quest to improve the outcomes of these procedures.

The efforts to eradicate FGM must continue full steam ahead. However, those unfortunate enough to suffer this injustice still make up a significant portion of the population. They shouldn’t have to live with the consequences of the practice, suffering the silent pain. Kudos to the flamboyant doctor for demystifying his craft, and for domiciling these solutions right here at home. Now, over to the Social Health Insurance Find to ensure these important procedures are included in the list of benefits accessible to all!

Dr Bosire is a gynaecologist/ obstetrician