Mons Rejuvenation in the Massive Weight Loss Patient Using Superficial Fascial System Suspension

Abstract

Sir: Significant ptosis and fullness of the mons region often creates an additional skin roll in massive weight loss patients. Traditional abdominoplasty techniques may leave these patients with a ptotic mons and an unsatisfactory aesthetic result. Treating the mons region as a distinct aesthetic unit and incorporating correction into abdominal contouring procedures will lead to greater satisfaction. There are few references that address the mons region. Liposuction and wedge dermolipectomy have been advocated by some authors.1,2 We describe a technique of mons rejuvenation that involves direct excision of sub-Scarpa fat and suspension of the mons using the superficial fascial system. Over 400 massive weight loss patients have undergone mons rejuvenation at our center between 2002 and 2009. The severity of the mons deformity was either grade 2 or 3, as based on the Pittsburgh Rating Scale.3 Two considerations are necessary to adequately rejuvenate the mons region: does the mons need to be resuspended to the abdominal fascia? Does the mons thickness need to be reduced? After fascial plication and resection, the thickness of the remaining upper abdominal flap is compared with the mons region. If the thickness is comparable, defatting of the mons is not necessary. In patients with a thicker mons region, we directly excise a wedge resection of the deep, sub-Scarpa adipose tissue down to the level of the anterior abdominal wall overlying the pubic symphysis. Care is taken to uniformly thin the mons and to avoid entering the vaginal vault. To elevate the mons to a rejuvenated position and minimize recurrent ptosis, the deep surface of the mons superficial fascial system is suspended to the abdominal wall fascia with three to five 0 braided nylon sutures. Layered closure of the abdominal incision is then performed. Over 400 patients have undergone mons rejuvenation using this technique. Average follow-up is 6 months. There was significant improvement in the mons contour, with a smooth transition to the upper abdominal flap. The mons was suspended to a more youthful position (Fig. 1). Complications included self-limited edema and mons fullness secondary to conservative defatting. We had one case of suture granuloma from the permanent suture requiring excision. Temporary change in the angle of urinary stream may be encountered. There were no incidences of dyspareunia. Patient satisfaction with the rejuvenated mons contour was very high.Fig. 1.: (Above) Preoperative anteroposterior view of a 48-year-old woman after 137-lb weight loss. (Below) Postoperative view 1 year after fleur-de-lis abdominoplasty.Massive weight loss patients often present with severe ptosis and fullness of the mons region. Traditional cosmetic abdominoplasty techniques do not specifically address the mons regions. Failure to address the pubic region in the massive weight loss patient will result in fullness of the pubic area, ptosis, and an appreciable step-off between the mons and the upper abdominal flap. Suspension of the superficial fascial system in the mons region to the abdominal wall fascia minimizes recurrent ptosis, providing a durable result. Mons rejuvenation may be a source of patient embarrassment, but correction leads to high patient satisfaction and is necessary to obtain an acceptable aesthetic result. This technique can easily be incorporated during abdominal recontouring in the massive weight loss patient. DISCLOSURE The authors have no commercial interests or financial disclosures that might pose or create a conflict of interest with the information presented in this article. Joseph Michaels V, M.D. Tali Friedman, M.D. Devin Coon, B.A. J. Peter Rubin, M.D. Division of Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, Pa.