Management of the Mons Pubis and Labia Majora in the Massive

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Aesthetic Surgery Journal
http://aes.sagepub.com/
Management of the Mons Pubis and Labia Majora in the Massive Weight Loss Patient
Gary J. Alter
Aesthetic Surgery Journal 2009 29: 432
DOI: 10.1016/j.asj.2009.08.015
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http://aes.sagepub.com/content/29/5/432
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Featured Operative Technique
Management of the Mons Pubis
and Labia Majora in the
Massive Weight Loss Patient
Gary J. Alter, MD
The high incidence of female obesity and weight loss has resulted in common complaints of a large, protuberant mons pubis and labia majora (outer labial lips) related to unsightly fat deposits and skin ptosis. The
author presents a technique to correct the protuberant mons and pubic descent by performing a pubic lift, fat
excision, and liposuction, and then tacking the superficial fibrofatty tissue to the rectus fascia. The labia majora enlargement is treated by fat excision and/or liposuction and skin excision. These techniques eliminate difficulties with sexual intercourse, poor hygiene, and discomfort, while also improving self-esteem. (Aesthet Surg
J;29:432-442)
he high incidence of female obesity has resulted in
common complaints of a large mons pubis and
labia majora (outer labial lips) related to unsightly
fat deposits. The mons and labia majora enlarge, protrude, descend, and hang. Even with dramatic weight
loss, these areas remain descended and bulky, with
excess fat and skin. The affected majora can cause difficulty with sexual intercourse and maintenance of
hygiene, and result in discomfort when wearing pants
and swimsuits. These unnatural fat deposits can also
severely affect self-esteem.
The surgical treatment of the enlarged mons pubis and
labia majora has been poorly understood and therefore
often neglected. Traditionally, the mons has been treated
by fat reduction, whether by liposuction or open excision, along with a pubic skin lift. However, skin elevation
is usually unsatisfactory, because the mons will descend
again upon standing. Many of these unsuccessful lifts
present after a simultaneous abdominoplasty. Oftentimes,
a surgeon will then perform a second unsuccessful pubic
lift, resulting in an unsightly reduction of the normal
escutcheon. Alternatively, some surgeons excise the
excess pubic skin and fat in the midline, which causes an
unsightly vertical mons scar, oftentimes a T scar.
Surgeons also avoid labia majora reduction because of a
lack of literature detailing operative techniques coupled
with a fear of creating sexual dysfunction.
T
Dr. Alter is Assistant Clinical Professor of Plastic Surgery at the
University of California, Los Angeles, CA.
432 • Volume 29 • Number 5 • September/October 2009
In many ways, the treatment of the mons pubis correlates with the treatment of the hidden penis in the obese
or formerly obese male.1-3 Excess suprapubic skin and
mons fat removal—along with tacking of the fibrofatty
tissue of the pubic skin flap to the rectus fascia—are
mandatory to achieve a lasting, successful mons pubis
lift.4 Labia majora reduction depends on the surgically
appropriate removal of fat and/or skin.
SURGICAL PLANNING
The patient is first evaluated while in a standing position. An abdominoplasty or panniculectomy can be performed at the same time as the pubic lift, but it may
result in increased postoperative labia majora swelling.
Therefore, the author suggests that it not be performed
at the same time as open labia majora reduction. The
amount of pubic descent is evaluated. If present, the
panniculus or abdominal skin is manually elevated and
the pubic area is raised to determine the amount of
excess skin above the pubic hairline that needs to be
transversely excised. The amount of lift necessary can be
estimated by placing the anterior labial commissure over
the pubic symphysis. Only a few centimeters of skin
excision is usually necessary, because the skin will modestly contract when fat is removed. The skin to be
excised is marked as a transverse crescent excision and
placed just below the panniculus fold or in a previous
abdominoplasty scar (Figure 1, A). The crescent incision
may extend laterally to each anterior superior spine, but
an incision that is so extensive is usually unnecessary.
The labia majora are also elevated upon raising the
A
A
B
Figure 2. A, The incision is made just below and parallel to the panniculus line or at an abdominoplasty scarline. B, The upper incision is
made to the rectus fascia. The flap is undermined to the pubic symphysis and laterally to the inguinal canals and external rings. ASIS,
anterior-superior iliac spine.
B
Figure 1. A, Preoperative markings to correct asymmetry on a 23year-old woman with a protruding mons fat pad. She had undergone
a 160-lb weight loss, an abdominoplasty, and a medial thigh lift. She
underwent a second unsuccessful attempt to eliminate the mons fat
pad with a pubic lift, which caused a short escutcheon. She did not
complain of excess majora skin. B, The same patient as seen in (A)
has labia majora that were enlarged but not hanging. She has a protuberant mons fat pad and labia majora; the excess labial fat was primarily anterior. (Note that medial thigh markings were made for
Z-plasties to eliminate restrictive medial thigh bands.)
mons, so this change should be noted along with the
amount of inferior labial protrusion.
The patient is then examined while in the lithotomy position. A decision is made as to whether the
patient needs labia majora skin and/or fat excision
(Figure 1, B). Labia majora fat can be excised from
above through the pubic incision or with the use of
liposuction, but these approaches are not as effective
or precise as resections directly through the labial
incisions. Labial markings are made in the lithotomy
position and checked while the patient is standing.
The amount of skin excision should be determined
with the patient’s legs widely abducted to prevent
over-resection. A medial crescent of labial skin to be
removed on each side is marked from the anterior to
the posterior labial commissures. The medial incision
line is usually placed just within the hairline in an
attempt to give a good color and tissue match upon
wound closure. Sometimes, the anterior crescent
needs to be extended slightly above the anterior commissure to eliminate a dog-ear. Because the anterior
incisions from each side should not meet in the midline, the most anterior markings may need to be
angled more vertically in a fusiform pattern. Care
should be taken not to remove too much skin, which
would cause the vaginal introitus to gape, especially
when the legs are abducted. Adjustments for asymmetry are made, which is common. With the patient first
lying down and then standing up, the marked skin
crescents are pushed in longitudinally with cotton
swabs to evaluate the probable appearance after
resection. If the patient has long, protuberant labia
minora (inner lips), she should be informed that they
will be more protuberant after surgery.
TECHNIQUE
In the operating room, the patient is placed in the lithotomy position, and the abdomen and genitalia are
prepped. The pubic lift is performed first. Through the
upper incision of the skin crescent, the skin and subcu-
Management of the Mons Pubis and Labia Majora
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Volume 29 • Number 5 • September/October 2009 • 433
A
B
C
D
E
F
Figure 3. Operative technique. A, The lower part of the crescent incision is removed. B, Fat is elevated off of the rectus fascia. C, Fat and skin are removed.
D, Fat excision is illustrated. It is tapered to the pubic symphysis. The thickness cephalad matches the abdominal side. E, Liposuction of the pubic flap and
labia majora, especially anterior labia, is performed. F, Liposuction of the pubic flap, labia majora, and inguinal regions is illustrated. This procedure provides
a uniform flap without a pubic concavity.
taneous tissue are incised to the rectus fascia (Figure 2,
A, B). The fat is elevated off the rectus to the level of the
pubic symphysis (Figure 3, A, B, D). The lower crescent
incision is made and a modest amount of underlying fat
is excised and tapered toward the pubic symphysis
(Figure 3, C). Liposuction of the fat of the pubis, upper
labia majora, and inguinal areas is performed after
tumescent fluid infusion (Figure 3, E and F). Enough fat
is removed to leave about 1 to 2 cm of fibrous subcutaneous tissue on the skin flap. If liposuction does not
eliminate enough fat under the flap, further conservative
open fat excision is needed, but care should be taken to
leave enough fibrous tissue under the skin flap for
suture placement. The lateral areas should be contoured
with liposuction or open excision to prevent an unsightly
pubic concavity. Overly aggressive inguinal fat excision
is unnecessary and can theoretically cause genital lymphedema. If a labial incision is not going to be performed, then liposuction of the labia majora or majora
fat excision from above is performed at this time. Closed
suction drains are placed in each labium if open excision
with fat removal was performed.
In order to maintain the lifted position of the mons,
rows of transverse tacking sutures of no. 1 polyester
(Ethibond [Ethicon, Somerville, NJ], Ticron [Tyco,
Waltham, MA], or Mersilene [Ethicon]) are placed with a
large tapered needle (CTX; Ethicon; Figure 3, G). The first
row of three sutures is placed from the fibrous fatty tis-
G
H
I
J
K
L
Figure 3. G, The first tacking suture is placed from the subcutaneous tissue of the pubic flap to the rectus fascia. H, Placement of tacking sutures is shown.
The first row is placed 1-2 cm cephalad to the anterior labia commissure from the fibrofatty tissue of the flap to the rectus fascia just cephalad to the pubic
symphysis and medial to the external rings. I, The first row of the tacking sutures has been placed. J, Three rows of tacking sutures are usually placed. Care
should be taken to prevent significant dimpling insofar as possible. The labia majora and anterior labial commissure are pulled up. A closed suction drain is
placed from the pubic symphysis around the right side, then under the deep closure. K, Results after tacking sutures are tied and the mons is lifted. L, The
incision closure is shown. The pubic flap underwent liposuction after the initial flap elevation. The anterior labial commissure is elevated.
sue several centimeters superior to the anterior labial
commissure, to the rectus fascia just cephalad to the
pubic symphysis and medial to the external rings (Figure
3, H–J). Placement of these sutures usually requires several attempts in order to prevent an abnormal “pulled”
appearance of the majora, to minimize pubic dimpling,
and to achieve symmetry. At least two more transverse
rows of three sutures are usually placed from the flap to
the rectus fascia. A closed suction drain is placed from
the symphysis around one side of the wound and then
under the skin closure (Figure 3, J, K).
If labia majora skin and fat excision is to be performed, the medial crescents are excised, followed by
precise excision of underlying fatty tissue. If no skin is
to be removed, fat alone can be removed through
medial labial incisions. Care should be taken not to
over-resect the fat, and symmetry should be respected.
Meticulous hemostasis is mandatory, because large
vessels are present. Bilateral closed suction drains are
inserted and brought out through the lateral pubic
areas with significant fat removal. The subcutaneous
tissue is closed in several layers and a subcuticular
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A
B
C
D
E
F
Figure 4. The 23-year-old woman described in Figure 1 is shown preoperatively (A, C, E) and four months after (B, D, F) pubic lift and labia majora
liposuction with Z-plasties to eliminate restrictive medial thigh bands.
Figure 5. A 34-year-old woman who lost 200 lbs. had previously undergone an abdominoplasty with an attempt to decrease the mons fat pad at
the same time. Preoperative markings indicate the amount of pubic skin to be excised, which includes the previous abdominoplasty scar.
Symmetric marking for excision of labia majora are shown.
A
B
C
Figure 6. A, B, The patient in Figure 5 is shown with preoperative markings for labia majora skin excision. The pubic lift has been completed. The
medial excision was placed just lateral to the hairline. The anterior excisions do not cross the midline. Care was taken to maintain enough labia
majora skin to allow for full leg abduction without opening the vagina. C, The patient is shown after reduction of the labia majora and pubic lift.
A
B
Figure 7. A, Again, the patient in Figure 5 is shown preoperatively in the lithotomy position with mons fat pad and excess labia majora skin and fat. B, Ten
months after pubic lift. Ideally, the patient could probably benefit from more mons liposuction, but is pleased with the postoperative results.
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A
B
C
D
E
F
Figure 8. The 34-year-old woman shown in Figures 5, 6, and 7 is shown preoperatively (A, C, E). These images show her protuberant mons fat
pad and enlarged, hanging labia majora. B, D, F, Ten months after pubic lift. The patient could still benefit from more mons liposuction.
A
B
C
D
E
F
Figure 9. A, C, E, Preoperative views of a 58-year-old woman who had undergone previous abdominoplasty and unsuccessful mons lift with liposuction. She presented with a massive mons fat pad and labia majora. She had a previous medial thigh lift, so labia majora skin excision was not
performed at the same time as the mons lift. B, D, F, One year after pubic tacking with mons and labia majora fat removal. The labia majora are
still too large, so the patient later underwent labia majora skin and secondary fat removal one year later (see Figure 11).
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A
C
B
D
Figure 10. Intraoperative photos feature the patient described in Figure 9. A, The pubic flap and fat are dissected. B, The mons and majora fat are
removed from above. The fat to be excised extends into the labia majora. C, The pubic flap anterior, the rectus fascia posterior, and the tunnels in
the labia majora after lipectomy are shown. D, Excised skin and fat (left) and suctioned fat and fluid (right).
A
B
C
D
E
F
Figure 11. The patient in Figure 9 underwent a second procedure one year after the first. The labia majora were still enlarged despite the previous
fat excision through the pubic approach. A, Preoperative markings for skin and fat excision. B, Fat and skin are excised. The fat excised is from the
right labium. C, Illustration of the crescent of skin removed from the medial labium majora. The shape depends on the amount of excess skin. The
two incision lines should not meet in the midline. Fat is excised. D, Labia majora are shown at the end of the procedure, after the fat and skin
have been removed. E, Illustration of the closure, which is performed in layers. A subcuticular closure is performed on the skin and a deep drain
is placed if significant fat is removed. F, Bilateral closed suction drains have been inserted.
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skin closure is performed. Clinical examples and additional intraoperative details are shown for three
patients in Figures 4 through 11.
PRECAUTIONS
No change in sexual sensation will occur if the clitoris
is not injured. This will not occur if mons fat excision
is removed superior to the pubic symphysis, and if
labia majora fat excision is performed lateral to the
pubic symphysis and clitoral hood and superficial to
the ischium. The body and glans of the clitoris can be
palpated between your fingers for orientation.
The mons should not be overly elevated, because this
creates an abnormal escutcheon, with deformity of the
labia majora and clitoral hood. Over-resection of mons
fat can cause a pubic concavity or unnatural appearance.
Over-resection of labia majora fat can cause a significant
flattening deformity.
Labia majora skin excision should be measured carefully and with patient approval. A gaping introitus
caused by over-resection can be a disastrous complication, leading to discomfort in clothes and with exercise,
vaginal dryness, and an inability to completely abduct
the legs, therefore causing severe functional and emotional disabilities. Labia majora skin excision should be
conservative if a medial thigh lift is contemplated or was
recently performed, because later relaxation of the medial thigh Colles fascia tacking sutures can result in an
open introitus.
Labia majora skin excision probably should not be
done at the same time as a pubic lift with fat excision if
a medial thigh lift has previously been performed,
because the blood supply to the skin between the labial
incision and the previous medial thigh incision may be
compromised. Alternatively, superior fat excision or liposuction can be performed initially, followed by later skin
excision if necessary.
3. Alter GJ. Aesthetic surgery of the male genitalia. In: Ehrlich RM, Alter
GJ, editors. Reconstructive and Plastic Surgery of the External Genitalia.
Philadelphia: W. B. Saunders, 1999:460–470.
4. Alter GJ. Aesthetic genital surgery. In: Mathes SJ, Hentz VR, eds.
Plastic Surgery, 2nd ed, vol VI. Philadelphia: W. B. Saunders,
2008:389–410.
Accepted for publication August 6, 2009.
Reprint requests: Gary J. Alter, MD, 416 N. Bedford Dr., Ste. 400, Beverly
Hills, CA 90210. E-mail: [email protected].
Copyright © 2009 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$36.00
doi:10.1016/j.asj.2009.08.015
CONCLUSIONS
Obese patients or patients who have undergone massive
weight loss have significant deformities from protuberant mons pubis and labia majora. Excellent techniques
are available to treat this overlooked issue. Improvement
of this area can significantly improve patient comfort,
self-image, and self-esteem. ◗
DISCLOSURES
The author has no disclosures with respect to the contents of this
article.
REFERENCES
1. Alter GJ. Surgical techniques: surgery to correct hidden penis.
J Sex Med 2006;3:939–942.
2. Alter GJ, Ehrlich RM. A new technique for correction of the hidden
penis in adults and children. J Urol 1999;161:455–459.

Management of the Mons Pubis and Labia Majora in the Massive

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