Correction of Clitoral Phimosis
Severe clitoral phimosis is an end result of long-standing and suboptimally managed lichen sclerosus (Fig. 74–1A, B). In this circumstance, the skin of the frenulum and the clitoral hood fuse as a result of inflammation and subsequent scar formation (Fig. 74–1C). This creates persistent, severe itching, as well as outright pain. Because drainage is poor, smegma builds up, which may lead to abscess formation. The goal of surgery is to remove the scarred tissue and preserve the clitoris. Removal of the clitoris is unnecessary and should not be done.
Examination with an operating microscope (colposcope) will reveal a tiny opening in the sheath or complete incarceration of the glans (Fig. 74–1D). Identifying an opening gives the surgeon the advantage of being able to insert a probe in close proximity to the clitoris (Fig. 74–2). The entire operation should be performed with use of the microscope. With a 27-gauge needle, a 1 : 100 vasopressin solution is injected on either side of the clitoris through the mass of tissue that was once the clitoral hood (Fig. 74–3). A knife incision is made to one side of the palpated clitoris. The incision should be made on the side with the least amount of scar tissue (Fig. 74–4A).
Dissection proceeds from lateral to medial (Fig. 74–4B). The skin edges are retracted with Allis clamps. Stevens tenotomy scissors are ideal for sharply dissecting and separating the clitoral body from the scar tissue (Fig. 74–5). The scar is dissected anteriorly and posteriorly to completely mobilize the clitoris (Fig. 74–6). Next, the sheath and the remains of the frenulum are cut away from the glans clitoris (Fig. 74–7). The junction of the frenulum to the glans is highly vascular and must be clamped, cut, and suture-ligated with 4-0 or 5-0 Vicryl (Fig. 74–8
