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M. Brambilla
31.7 Injection Technique
In early lichen sclerosus stages, with moderate tissue sclerosis, a blunt 21 gauge cannula is used for microfatgraft spreading of the fat into the tissues with fan, multilevel technique.
a
A 27 gauge needle is used to inject nanofatgraft or prp
into the dermis (Fig.31.3).
In later stages when vulvar stenosis appears, microfatgraft
is performed with an 18 gauge sharp needle. The needle is
inserted at least 2cm away from the area to be treated and is
bcd
Fig. 31.3 Multilevel micro and nanofatgraft: a diagram of injection. Microfatgraft (yellow), nanofatgraft (orange) (b) microfatgraft with 21 gauge
blunt cannula c intradermal nanofatgraft with 27 gauge needle (d) nanofat preparation
ab
ab
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used as a cutter, with its tip performing small and multiplanar cuts. The needle moves with small fan multilevel movements in order to avoid wide dead spaces and simultaneous
fat injection is performed. The needle may delicately subcise
the dermis creating a subcisional net (Fig.31.4).
In case of severe stenosis, the procedure can be performed
at the same time of the surgical posterior wall amplication
and tissue reconstruction with perineal island tunneled aps
[51, 52].
The procedure can be performed “open wound” before
suturing the medial margins of the aps (Fig.31.5) together
or after the suture. Severe amplications may be covered
with full-thickness skin grafts. The skin graft will be treated
after 3months with a microfatgraft and a nanofatgraft, reducing retraction and gaining elasticity. This procedure can be
performed during the additional fat graft sessions planned
for the treatment of stenosis.
Fig. 31.4 Microfatgraft+ percutaneous scar release (rigottomy): a tension lines b scheme of tension line fragmentation with interposition of
microfatgraft clusters (orange)
Fig. 31.5 Lichen sclerosus:
micro+nanofatgraft. (a)
Preoperative image, (b)
postoperative image at 1year,
superior web release
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M. Brambilla
31.7.1 Immediate Postoperative Care
Polydine ointment is applied to the vulva, and a Kemicetine
(chloramphenicol) egg is inserted into the vagina. A cold pad
is applied to the vulva, the catheter is removed (if inserted),
and the patient may be discharged on the same day of the
procedure or after one night of observation.
Postoperative pain can be controlled easily with nonmorphinic analgesics (Paracetamol [acetaminophen]), and oral
antiedema (Bromelain) and hydrating genital creams are prescribed for 1 month. Blood uidifying medication is prescribed for 15 days. Patients must avoid sexual activity,
cycling, and riding horses for 30days. Pelvic oor rehabilitation is an essential part of the treatment and starts 1 week
after the procedure with nger massage only, followed by
2weeks after the operation with tissue expansion with inatable dilators.
31.8 Number ofProcedures andFinal
Results
In early stages, a single treatment of 5–15cc of microfatgraft
with blunt 21 gauge cannula injection +2/4cc of nanofatgraft
or PRP can achieve a good result, in elasticity and trophism
and a second treatment may be necessary 4–6months after
the rst treatment. Rarely, a third treatment is needed. Results
are stable and long lasting in the majority of the cases
(Figs.31.5, 31.6, 31.7, and 31.8).
Lichen sclerosus stenosis requires percutaneous microfatgraft+nanofatgraft or PRP treatment, followed if necessary
at 4 months by posterior commissure amplication with
transposition of the perineal aps plus fat grafting (Fig.31.9).
Severe vulvar stenosis that are considered urgent procedures will need rst a surgical amplication with the
interposition of tunneled labia majora aps (Fig.31.10),
ab
Fig. 31.6 Lichen sclerosus: microfatgraft+rigottomy +nanofatgraft. (a) Preoperative image, (b) postoperative image at 1year, superior web
release, (c) preoperative histology, (d) postoperative histology
ab
31 Fat Grafting toTreat Genital Lichen Sclerosus
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ab c
Fig. 31.7 Lichen sclerosus: microfatgraft+rigottomy+nanofatgraft. (a) Preoperative image, (b) postoperative image at 1year, (c) postoperative
image at 4years after second treatment
Fig. 31.8 Lichen sclerosus:
micro+nanofatgraft. (a)
Preoperative image, (b)
postoperative image at 4year,
superior web release
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M. Brambilla
Fig. 31.9 Lichen sclerosus: (a) preoperative image, (b) immediate post operative (c) postoperative image at 2years, after rigottomy micro/nano-
fatgraft followed at 3months by double perineal island aps transposition+rigottomy micro/nanofatgraft followed at 6months by nanofatgraft
Fig. 31.10 Lichen sclerosus:
(a) preoperative image, (b)
postoperative image at
2years, after rigottomy
micro/nanofatgraft followed
at 3months by double labia
majora island ap+rigottomy
micro/nanofatgraft followed
at 6months by nanofatgraft
or full thickness skin graft (Fig.31.11), or a combination
of both procedure if needed (Fig. 31.12). Simultaneous
open-wound microfatgrafts are advisable in order to
amplify and promote regeneration (Fig.31.13). In order to
enhance vulvar skin grafts elasticity after 3–6 months
from surgery, it is advisable to perform two procedures of
supercial microfatgraft and nanofatgraft at 4-month
intervals.
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Fig. 31.11 Lichen sclerosus:
(a) preoperative image, (b)
postoperative image at
2years, after rigottomy
micro/nanofatgraft followed
at 3months by labia minora
skin graft
reconstruction+rigottomy
micro/nanofatgraft followed
at 6months by nanofatgraft
Fig. 31.12 Lichen sclerosus:
(a) preoperative image, (b)
postoperative image at
2years, after rigottomy
micro/nanofatgraft followed
at 3months by labia minora
skin graft reconstruction and
double perineal island
posterior commissure
reconstruction+rigottomy
micro/nanofatgraft followed
at 6months by nanofatgraft
ab
ab
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Fig. 31.13 Open wound rigottomy microfatgraft
31.9 Summary ofInstruments
andEquipment
– 14-gauge 140 mm multihole cannula to harvest the
microfatgraft
– 10cc Luer Lock syringes
– 27-gauge needle
– 18-gauge 5cm needle (for vulvar stenosis)
– 18-gauge 9cm needle (for vaginal stenosis)
– 5cc Luer Lock syringe
– 500cc of saline plus 40mL lidocaine plus 1mL 1:500.000
adrenaline for donor-site and recipient-site
hydrodissection
– 100cc saline for the fat washing procedure
– Centrifuge
– Nanofatgraft ltration system or prp kit
31.10 Complications
The immediate complications of fat grafting include infection, hematoma (will decrease efcacy of the treatment),
skin/mucosal necrosis due to overinjection or excessive
M. Brambilla
undermining, and edema. Painful calcications following
fat graft necrosis may occur due to excessive fat graft.
Pulmonary embolism and death have never been reported,
and thus to reduce this fatal complication, it is advisable to
avoid the treatment of patients affected by vulvar and vaginal varix.
31.11 Conclusions
If performed with a good knowledge of anatomy, instrumentation, and biological fat properties, the treatment of vulvar
LS is a safe and very successful procedure.
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Female Genital Mutilation: ASurgical
https://t.me/medicina_free
Approach toReshaping
AuroraAlmadori andStefaniade Fazio
Contents
32.1 Introduction 433
32.2 Surgical Management and Reconstruction 436
32.3 The Role of Plastic Surgeons in FGM and the Example of SICPRE (Italian Society of
Plastic Reconstructive-Regenerative and Aesthetic Surgery) 438
32.4 Conclusion 438
References 438
32
32.1 Introduction
Female genital mutilation (FGM) consists in multiple procedures involving the partial or total removal of the external
female genitalia or other injury to the female genital organs,
whether for cultural or any other nontherapeutic reasons. The
strong negative connotation of the word “mutilation” has
been suggested and adopted by WHO to emphasize the gravity of the practice and to underline that is a violation of girls’
and women’s human rights [1].
32.1.1 Prevalence
It is estimated that 100 to 140 million girls and women in the
world today have undergone some form of FGM, and two
million girls are at risk from the practice each year [2].
Although these gures are only estimate and the true incidence is difcult to assess, they do indicate the massive scale
of this human rights violation [3]. The majority of the
affected women live in Africa (Fig. 32.1), followed by
A. Almadori
Department of Plastic Surgery, Royal Free London NHS
Foundation Trust Hospital, London, UK
Centre for Nanotechnology and Regenerative Medicine, Division
of Surgery and Interventional Science, University College London,
London, UK
S. de Fazio (*)
Rome, Italy
Middle East and Asia. It has also been reported to be practiced in India by the Daudi Bohra Muslims. Nowadays
women with FGM are also found in Europe, Australia, New
Zealand, Canada, and the USA because of increased migration ows.
32.1.2 The Origins ofFGM
It is not known when or where the tradition of FGM originated. Multiple hypotheses have been formulated. It has
been proposed that FGM was common in ancient Egypt and
among the ancient peoples of the Arab world; that FGM
started with the arrival of Islam in some parts of sub-Saharan
Africa; that it commenced during the slave trade when black
slave women entered ancient Arab societies; and that the
practice developed independently among certain ethnic
groups in sub-Saharan Africa as part of puberty rites [2, 4].
32.1.3 Classication
Four types of FGMs have been described, namely: type I,
which consists of excision of the clitoris; type II, which
involves the excision of the clitoris with scraping or removal
of the labia minora; type III, which consists of excision of
part or all of the external genitalia and the stitching together
of the vaginal opening; and type IV, which encompasses all
other practices on female genitalia not covered in the
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. Di Giuseppe et al. (eds.), Fat Transfer in Plastic Surgery, https://doi.org/10.1007/978-3-031-10881-5_32
433
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