Abstract
BACKGROUND: Aesthetic alteration of the genitalia is increasingly sought by women who are unhappy about the size, shape or overall appearance of their vulva. Clitoral hypertrophy is usually seen in congenital malformations, specifically in intersexual stages of hormonal expression. A large clitoris has an appearance of a small penis, is psychologically disturbing and interferes in sexual activity. PURPOSE: Clitoral reduction surgery has evolved over the years. Total clitorectomy, clitoral recession and neuro-vascular pedicle sparing clitoroplasty can be considered as three major milestones in its evolution. In nerve sparing clitoroplasty, earlier dorso-lateral approach was challenged by ventral approach, which is establishing itself as the approach of choice by its own merits. Clitoral reduction surgery being not a very commonly performed surgery, demands refinements in its technique to improve its results and particularly the aesthetic outcome, which is gaining more importance in recent years. METHODS: An adult case of late onset congenital adrenal hyperplasia (CAH) with clitoromegaly underwent nerve sparing reduction clitoroplasty by ventral approach under moderate magnification. We present key points of the preoperative anatomic evaluation. Technical refinements planned and executed step wise during the procedure resulted in satisfactory outcome. RESULT: Patient now has normal appearing genitalia, a small clitoris nicely covered by skin hood and very well preserved sensation to light touch. CONCLUSIONS: Preservation of sensation in the glans clitoris is of paramount importance during clitoral reduction surgery. Knowledge of the anatomy of the neurovascular supply to the glans clitoris gives us freedom from not isolating it in order to preserve it. In fact a deliberate attempt to dissect it can prove detrimental particularly when operating on a smaller organ during childhood. A ventral approach with refined technique proves safe and gives satisfactory result. Moderate degree of magnification eases dissection. A component-based detailed preoperative planning improves the overall aesthetic appearance of the female genitalia.