The American Journal of Cosmetic Surgery

Volume 29, Number 1,2012
AlurgRrcRx
Acnnrvv
OF COSMETIC SURGERY
The AmericanJournal
of Cosmetic Surgery
FEATURES,
Breast Capsulorrhaphy Revisiled' A Simple Technique
Utitizing a Gore-Tex Mesh
Use of Urinary Btadder Matrix, a Bioactive, Aceltutar
Scaffotd, in Transplant Donor Scars and Androgenetic
Alopecia, lnitiat Ctinical Experience
Long-Term Cosmetic Benefit of Wound Heating by
Betutine
The 1540-nm Nonablative Fractional Photothermolysis
for Faciat SurgicaI Scars
ln Vitro Comparison of Light-Emitting Diodes and
Carnosic Acid Effects on Keratinocyte Proliferalion and
Wound Healing
Temperature Monitoring During Laser-Assisted
Liposculpture in Males
The American Journal of Cosmetic
Surgery Yol.29, No. 1' 2012
TIPS AND TECHNIOUES
Technical Considerations Regarding Liposuction
of the Mons Pubis
Kevin Jovanovic, MD
Mons pubis liposuction would seem to be an easy procedure, but procedures in this small area, hidden by clothing
most of the time, have generated a great deal of controversy
and misconceptions. The goal of this review is to examine
the current evidence in the literature and try to dispel some
of the mryths sutounding this seemingly simple procedure.
paramount to maintain natural smooth transition supe-
l\
volunteers aged26 to 53 years with a body mass index
(BMD between 18 and 26 and no prior altering operations in the mons area were evaluated. In addition,
measurements were performed for 13 female cadavers
aged 60 to 95 years. The following lines and angles
were measured: (1) umbilicus/pubic hair is the measurement equivalent to the top of mons pubis, (2) top
of the mons pubis to the end of the labia majora, (3)
lengths of the side segment lines (end of the labia
majora along the inguinal crease up to the lateral hairline at the femoral vessels, (4) length of the base of the
mons triangle, (5) inguinal crease/pubic hairline angle,
and (6) inguinal crease/labia majora angle. Means,
medians, and standard deviations were calculated for
each measurement (Table).
fions pubis is the Latin for '.pubic mound." The
IVIu."u'is
also known as the as the mons veneris
(Latin, mound of Venus). The anatomy of the mons
pubis, that is the area that is included when measuring
and defining the aesthetically correct mons pubis, is
the adipose tissue lying above the pubic bone of adult
females, anterior to the symphysis pubis. The mons
pubis forms the anterior portion of the vulva. The
margins are as follows: the inferior border divides the
labia majora, thelateral border encompasses the inguinal ligaments, and the superior border is the anterior
abdominal wall (Figure 1).
Mons pubis liposuction would seem to be an easy
procedure. Although this small area is hidden by
clothing most of the time, surgical procedures in this
area have generated a gteat deal of controversy and
misconceptions.la The goal of this review is to examine the current evidence in the literature and to try to
dispel some of the myths surrounding this seemingly
simple procedure.
What Are the Goals of Liposuction
of the Mons Pubis?
The aesthetic goal for liposuction of the mons
pubis is to remove an unsightly bulge in clothing. It is
Received for publication April 25,2oll.
From the LVRI of New York City, New York, NY.
Conesponding author: Kevin Jovanovic, MD, LVRI of New York City,
930 Fifth Ave, Suite 3, New York, NY 10021 (e-mail: drjovanovic@
hotmail.com).
DOI: 10.5992/AJCS-D- I 1-00020. I
riorly from the abdomen and inferiorly to the labia
majora and then lateral in a tapered triangle to the
inguinal ligaments. A literature review about the aesthetics of the mons pubis revealed one article that tried
to define normal dimensions to aid in reconstruction
after abdominoplasty. In this study, the mons pubis
was measured in 28 female patients.5 Healthy female
Recommendations for Performing a Safe and
Effective Liposculpturing of the Mons Pubis
Recommendations for the performance of liposculpturing of the mons pubis include the technique that is
commonly described as a criss-cross liposuction from
both sides of triangle. Focus is on the central portion
to allow the edges to be tapered to the surrounding tissues (Figure 2). Carc must be taken to stay to deeper
planes to allow for debulking without complete loss of
subdermal fat. Special attention should be taken along
the inguinal areas to avoid injury to the inguinal ligaments and its contents. Occasionally, scar revision or
undermining of scars is needed in conjunction with
liposuction to achieve the desired result.
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Surgery Yol.29, No. 1' 2012
3.
Liposuction of mons pubis and scar lift with
Pelosi lipo scissors.
Figure
Figure
2.
repofted case
Common liposuction technique.
of a self-inflicted vibrator burn after
suction-assisted lipectomy.8
Is Lymphedema of the Leg Possible
as Result of Liposuction?
One of the common vulvar medical procedures that
has a high incidence of lymphedema of the leg is surgical staging of vulvar cancer. Cancer of the vulva is
the fourth most common malignancy of the female
genital tract. The American Cancer Society estimates
that 3580 women were diagnosed with vulvar cancer
in 2009.e Currently, approximately 757o of patients
with vulvar carcinomas will be cured, making vulvar
carcinoma responsible for approximately 900 deaths
annually in the United States.
Since the early part of the 20th century, the traditional surgery has been a radical dissection of the
primary lesion with a bilateral groin node dissection
performed through a single incision. The femoral triangle is bounded by the inguinal ligament superiorly,
the adductor longus medially, and the sartorius laterally.
The superficial groin nodes lie above the cribriform
fascia in the femoral triangle. Careful dissection generally reveals 5 vessels in the femoral triangle above
the cribriform fascia, the largest of which is the saphenous vein. The other vessels include the superficial
circumflex, the superficial epigastric, and the external
pudendal.
Below the cribriform fascia are the deep inguinal
nodes. The most superior of these is the sentinel node to
the pelvic lymphatics, which is known as the node of
Cloquet. The saphenous vein is key, and a review of
139 cases of groin node dissection demonstrated that
when the saphenous vein was preserved, the incidence
of wound cellulitis and acute and chronic lymphedema
was significantly lower.ro Only one patient in this
series with saphenous vein preservation developed
chronic lymphedema, a patient who received postoperative radiation therapy. The article changes surgical
staging from the radical dissection used from the
1900s to the new staging procedures that are being
used today for the past 10 years since 2000. Chronic
lymphedema has been reported in l0-20%o of women
after groin node dissection. This can be a disabling
problem and is more common if radiation is required
after groin dissection. Limiting groin node dissection
in women with early cancers and preserving the
saphenous vein decreases the incidence of this
problem. A theoretical cause of lymphedema of the
leg with aggressive liposuction of the inguinal area
would result from sacrificing the saphenous veins or
suctioning the lymph nodes below cribriform fascia.
Is Dyspareunia Possible as a Result of
Liposuction of the Mons Pubis?
It is important to understand there many different
medical conditions underlie the diagnosis of dyspareunia. The causes of dyspareunia fall into two broad
categories: physical causes and psychological causes.
Physical causes of dyspareunia are further categorized as dyspareunia on entry or deep dyspareunia.
Dyspareunia on entry can result from lubrication
(hormones, medication), trauma (circumcision, pelvic
surgeryftrysterectomy), inflammation (sexually transmitted disease, eczema), allergic reaction (to lubricants,
toys), and vaginismus. Deep dyspareunia can result
from illness (pelvic inflammatory disease, endometriosis, fibroids, cystitis, irritable bowel syndrome),
infection (sexually transmitted disease), and surgery
(pelvic surgery, radiation).
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