Essentials of Aesthetic Surgery

872
Body Contouring

when patients approach their IBW.
• Aesthetic outcomes are better for patients near their IBW.
Most patients will settle at a
2 after bariatric surgery.
• Consider motivated patients in this category for an initial panniculectomy or breast
reduction to improve comfort during exercise.
• This may facilitate lifestyle changes that will result in further weight loss and provide
better aesthetic outcomes with subsequent surgery.


2
SENIOR AUTHOR TIP: Massive-weight-loss patients can be considered either
“complete” or “incomplete,” based on residual subcutaneous fat. Most massive-weight-
loss patients fall in the “incomplete” category, requiring reduction of subcutaneous
tissue in addition to skin resection.
PREOPERATIVE EVALUATION
Record greatest and presenting BMI.
Assess stability of medical comorbidities and psychiatric problems.
of bariatric patients are treated for psychiatric diagnoses.
Determine smoking history.


• Vitamin B12
• Calcium
• Potassium

• Fat-soluble vitamins (A, D, E, K)

Preoperative laboratory tests should include complete blood cell count (CBC),
electrolytes, blood urea nitrogen (BUN), creatinine, uric acid, liver function tests,
glucose, calcium, ferritin, total protein, albumin/prealbumin, B12/folate, prothrombin/
partial thromboplastin time (PT/PTT), fat-soluble vitamins.
SENIOR AUTHOR TIP: “Complete” weight-loss patients are more likely to have had

Preoperative evaluation and treatment is imperative for proper wound healing.

873
Chapter 62
SURGICAL STRATEGY
The goals of surgery are to alleviate the functional, aesthetic, and psychological
impairments from skin redundancy.
Determine the priorities of the patient. However, general sequence should be:
1. Trunk, abdomen, buttocks, lower thighs
2. Upper thorax/breasts, arms
3. Medial thighs
4. Facial rejuvenation
STAGING CONSIDERATIONS
Body contouring surgery in patients requiring several areas of correction is
to best minimize complications, pain, and need for blood transfusions.
Solo surgeon versus team approach
• The team approach can accomplish more in one stage.


anemia, thromboembolism, and wound complications).



lower BMI.
Determine patient’s ability to tolerate long procedures.
Evaluate patient’s assistance at home for recovery process.
Patients should be back to their preoperative health status before returning to the
operating room. Recovery of at least is usually required before performing
additional stages.
SENIOR AUTHOR TIP: A sequence of three procedures is usually required to complete
body contouring following massive weight loss. This can often require 1 year or more.
PHYSICAL EXAMINATION
Assess body habitus of patient.
Evaluate regional fat deposition.
Evaluate laxity of the skin envelope.

Estimate extent of tissue resection using a pinch test.

region of resection.
Evaluate for old scars.
Anticipate location of scars and expect scar migration.

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Body Contouring
TISSUE CHARACTERISTICS AND SURGICAL TECHNIQUES
TRUNK/ABDOMEN
The abdomen usually has the greatest
deformity in massive-weight-loss patients.
Most tissue descent is seen along the lateral
axillary lines.
The truncal tissues take on an appearance of
an inverted cone (Fig. 62-2).
The mons pubis will have varying degree of
ptosis.

• Flatten contour.
• Tighten abdominal wall with fascial
plication.
• Repair ventral hernia, if present.
• Elevate the mons pubis.


Identify locations of old scars on the
abdomen.
Determine the extent of the panniculus and
descent of abdomen onto lateral thighs.
Identify any presence of hernias.
Assess extent of mons ptosis.
Assess for presence/extent of midback or
lower back rolls.
Assess for buttock ptosis and contour.

buttock autoaugmentation.


techniques fail
to maximally improve body contour in this
patient population, because they do not
address the lateral tissue laxity.
Fleur-de-lis abdominoplasty (Fig. 62-3) can
be performed for patients without back and
lateral thigh ptosis.

(Fig. 62-4) addresses the circumferential
nature of the tissue ptosis seen in the trunk.
7
• Allows resection of the entire lower
section of the inverted-cone deformity
• Allows elevation of the buttocks and
lateral thighs to produce a comprehen-
sive additional lower body lift
Truncal body contour after
massive weight loss. The trunk takes
on the form of an inverted cone. The
soft tissue is narrow at the rib cage and
wider at the pelvic rim. A belt lipectomy
eliminates the inferior aspect of the cone.
A
B
C


abdominoplasty. Redundant vertical
tissue above the umbilicus is removed as a
triangle connected to the redundant skin
in the lower abdomen, which is marked as
a standard abdominoplasty. Points and
B will join as an inverted-T closure in the
midline at the pubic symphysis (point C).

point C is marked 4-6 cm below to resect
additional inferior redundancy and to
elevate the mons.

875
Chapter 62
Markings for a belt lipectomy. A, The midline is marked initially. The horizontal pubic
incision is marked below the natural hairline to allow elevation of the mons. The inferior midline of
the closure should be level with the pubic symphysis. The pannus is elevated superiorly and medially
in the direction of the arrows to allow marking of the lateral extension of the inferior incision to
just below the anterior superior iliac spine (ASIS). B, The superior markings are made anteriorly
using a pinch technique to determine the extent of resection. C, The midline of the back is marked
with the inferior point at the coccyx. D, The patient is slightly bent at the waist, and the pinch test
is used to estimate the superior extent of resection. E and F, The superior and inferior back marks
are made to meet the abdominal marks laterally.
A
B
C
D
E
F
Patients with have higher risks for complications after belt lipectomy/lower
body lift.1

• Mark patient as shown (see Fig. 62-4).

inferiorly.

maintain a layer of fat on the deep fascia. This will minimize seroma formation.
• Perform liposuction on lateral thighs to release zones of adherence, which allows
lateral thigh elevation.

crests). This will keep scars hidden under most undergarments and bikinis.
• Make inferior incision on the abdomen, similar to traditional abdominoplasty
technique.

876
Body Contouring

contoured abdominal skin, regardless of the contouring technique used.
• Prevent excess tension on the mons, which can elevate the clitoris and urethral
meatus.
• Widely drain anteriorly and posteriorly to prevent seroma formation.
TIP:
to prevent time delays on day of surgery.
Mark the anterior/inferior incision at the level of the pubic bone, generally 4-7 cm above
the introitus or base of the penis.
Minimize posterior skin resection to prevent competing anterior and posterior tension
forces.
Be more aggressive with lateral and anterior resections, because these are most visible
areas to the patient.
Contour the mons in two stages to prevent distortion of the clitoris and urethral meatus.
SENIOR AUTHOR TIP:
can be combined with an abdominoplasty or a body lift. Vertical resection is important

existing vertical scar which facilitates this. Mons hypertrophy and ptosis is often very

hygiene and appearance.
WAIST AND LATERAL THIGHS


Maximum vertical relaxation occurs along lateral body contours. Tissue excess descends
in an anteroposterior direction and spirals down the thigh.

• Narrow waist as much as possible, especially in women.
• Create a smooth, natural curve from rib cage through waist and down onto hips.


thighs is not possible if the trunk remains lax.

waist and lateral hips in a single-stage procedure.
TIP: Use independent leg extensions on the OR table that will allow hip abduction
while patients are prone and supine. This eliminates tension on the lateral thigh
advancement.
-
tion to the deep fascia with permanent suture to maintain elevation of the lateral thigh,

877
Chapter 62
BUTTOCKS

to blend together. This gives the appearance
of a long vertical buttock height.
The central buttock crease descends, leaving
minimal soft tissue coverage over the coccyx.
The lateral inferior buttock creases lie in a
more horizontal direction without a shapely
curve.


of demarcation from the back to the

the superior gluteal curve in a central
gull-wing pattern.
• Elevate the buttocks, including the central
crease.
• Cover coccyx with additional soft tissue if

• Develop an upward curve of the inferior
buttock crease.


achieved with the circumferential belt
lipectomy/lower body lift.
However, consider autologous gluteal
augmentation to enhance buttock contour,
especially with central buttock projection.
Autologous gluteal augmentation can be




central or inferiorly based (Fig. 62-5).
BACK
Massive weight loss can lead to upper and lower back rolls.
Upper back rolls are typically singular and may be an extension of the lateral breast.

sweeping direction.

• Resect as many rolls as possible.



back rolls.
The upper back roll requires liposuction and/or direct excision in a separate staged
procedure from the belt lipectomy (Fig. 62-6).
Incise down to
level of underlying
muscle fascia
Elevate inferior pocket
at gluteal muscle
fascia level down to
gluteal crease
Rotate deepithelialized
flap into inferior
pocket and suture to
underlying gluteus
muscle fascia
Flap elevation
proceeds medially
based on vascularity
Inferior pocket
The design and inset of a

878
Body Contouring
and B, C and D, Upper back folds may
require direct excision.
A
B
C
D
TIP: Align transverse and posterior scars along the bra line in women.
MEDIAL THIGHS
Most massive- weight-loss
patients have more
skin excess of thighs relative to
vertical excess of thighs.
Vertical medial thigh lift is

medial thigh lift in these
patients (Fig. 62-7).
Most patients will require
vertical excision with some
horizontal component.


Medial thigh lift should be performed in a separate staged procedure after addressing
the lateral thighs.
This can be combined with liposuction of the medial, anterior, and posterior thigh as an
adjunct for mild contour irregularities.

• Preexisting lymphedema
• History of lower extremity deep vein thrombosis (DVT)
• Presence of varicose veins. Obliterate varicosities prior to medial thigh lipectomy.


• Minimize labial spreading.
Medial thigh markings.

879
Chapter 62

Mark the perineal crease on the inner thigh as the superior extent of the vertical ellipse.
Perform a pinch test in a superior-to-inferior direction to estimate the extent of
resection.
during resection.
To reduce potential for labial spreading,
Superior dog-ear can be worked out along the posterior inferior buttock crease or
anterior inguinal crease as a horizontal component.
Carry excisions below the knee if skin redundancy extends inferior to the knee.
TIP: Wait 6-12 months after lower body lift to minimize tension on the medial thigh
procedure.
To preserve inguinal lymphatics, resect only skin if the incision is taken anteriorly.
Suture the SFS of the thigh to the Colles fascia with nonabsorbable sutures if a horizontal
medial thigh lift performed.
A sequential resection and closure technique prevents overresection and excess tension
on the skin closure.
SENIOR AUTHOR TIP: Inner or medial thigh lift is usually an inadequate procedure
for the massive-weight-loss patient. Vertical thigh lift is almost always necessary to

is based on the deformity and patient desires. The vertical excision can extend down
to the calf if indicated. Following bimanual palpation, aggressive, thorough, complete
liposuction of the intervening area will eliminate all residual subcutaneous tissue
volume and allow for an incision and avulsion method of the skin, which completely
preserves and protects all neurovascular and lymphatic structures. This has reduced the
complication of lymphocele commonly seen in the knee region following traditional
methods of vertical thigh lift.
BREASTS
The volume and characteristics of breast tissue will be highly variable after massive
weight loss.
Critically evaluate amount of breast parenchyma, and location of the inframammary fold.


Reduction mammaplasty is indicated for patients with persistent macromastia.
No single reduction technique is superior in this patient population.
Mastopexy or augmentation is indicated for patients with grade I/II ptosis.
Mastopexy with or without augmentation is indicated for patients with grade III ptosis.

implants for volume restoration.
Revisions are usually required to optimize results.

880
Body Contouring
SENIOR AUTHOR TIP:
a very medialized nipple which should not be used to identify the breast meridian. The
breast meridian should be based on the center of the breast extending superiorly to a
point somewhere between 6 cm and the midline of the clavicle.


pole fullness
Patients may require an to restore upper pole fullness.
Scars are often long.
(Fig. 62-8)
• Poor shape, projection, and skin elasticity
• Severe ptosis and volume loss
• Flattening of breast
• Distorted, ptotic nipples, often inferomedially translocated
Breast appearance after massive weight loss.

• Correct nipple position.
• Reshape skin envelope.


• Tailored based on breast shape, volume loss, and degree of ptosis

(ptosis grade I or II or macromastia)



(ptosis grade III, moderate volume loss or constricted breast)


(severe lateral roll and/or severe volume loss with excess skin)

881
Chapter 62

Wise-pattern markings. indicates areas to be deepithelialized. B, Medial and
lateral areas of breast are rotated to create the appropriate shape. C, The breast is anchored to rib
periosteum, and gland is reshaped.

extensions depend
on amount of skin roll
and/or size of lateral

Extent of deepithelialization
depends on size of lateral

augmentation and need not
include entire Wise pattern
A


and mobilized
Pectoralis major
fascia
Central dermal
extension
Medial dermal

and mobilized
Second rib
Central dermal extension
suspended to rib
periosteum
B
Dashed lines
indicate areas to
be plicated
Fourth rib


periosteum
Central dermal
extension suspended
to rib periosteum

rib periosteum and
plication initiated
2
3
C



1. Mark a Wise pattern, including the lateral roll of tissue.

2. Deepithelialize the Wise pattern.

3. Deglove the parenchyma.





6. Plicate dermis to shape the breast.



8. Redrape the skin.

9. Release any skin tethering.
10. Close the skin.




surgery.
Most men with greater weight loss will require excisional techniques.
Scars are extensive and visible.

Consider free-nipple grafting in cases with severe nipple malposition or nipple ptosis.

882
Body Contouring
UPPER ARMS
Severely ptotic skin of the upper arm develops that extends from the olecranon across
the axilla onto the chest wall.
The excess arm skin is contiguous with the posterior axillary fold on the lateral chest.

residual fat.

• Eliminate horizontal upper arm excess.
• Eliminate lateral thoracic skin excess.
• Create a smooth transition from the lateral chest onto the upper arm.
• Minimize scar visibility and contracture.


Brachioplasty techniques that place the incisions
are less noticeable to patients and less visible to others when viewed from the front.
However, there is varied opinion and literature on this.
Scars placed along the bicipital groove tend to widen and take longer to mature.
Resect the entire subcutaneous tissue down to the muscular aponeurosis.
Identify and prevent injury to the ulnar nerve during resection.

and to restore a more natural dome shape to the axilla.
TIP:
a staged procedure before excisional lipectomy.
A sequential resection and closure technique prevents overresection and excess tension
on the skin closure.
SENIOR AUTHOR TIP: Following bimanual palpation, the intervening area of tissue
of the arm can be infiltrated and very thoroughly liposuctioned to eliminate all
subcutaneous fat. The skin pattern can be rechecked, incised, and avulsed immediately
at the subdermal level. This protects all important neurovascular and lymphatic
structures, in particular the medial antibrachial cutaneous sensory nerve that resides
in the bicipital groove.
FACE AND NECK

laxity after massive weight loss.
An appearance of develops.
More volume loss occurs in the midface relative to nonmassive-weight-loss patients.
An “aged” facial appearance may be more displeasing to a young patient than redun-

clothing.

• Redrape the skin over the face and neck to restore a normal-appearing jaw and
neckline.
• Harmonize facial appearance with the contouring of the rest of the body.

883
Chapter 62

Correction of facial skin redundancy requires more skin undermining to produce a
smooth contour relative to a typical rhytidectomy.
More aggressive skin resection is required.
Fig. 62-10 demonstrates vectors for facial rejuvenation for varying portions of the face.
Consider midline skin excision of neck if redundancy is too severe for lateral pull.

problem. Normal SMAS plication is performed.
Perform platysmaplasty if platysmal banding is
present.
Perform suction-assisted or direct lipectomy of
remaining fat deposits of jowls and submental triangle.
The skin incision can enter the temporal hairline above
the helical root if the planned vector of facial elevation
is posterior and superior.
Carry the incision around the earlobe and onto the
conchal bowl posteriorly.
• The vector of elevation on the neck can be mostly
superior, which prevents an incision across the
occipital hairline.
• Use a traditional postauricular incision with
occipital hairline extension if skin laxity of the neck
is severe.
Consider volume replacement to the midface with fat

SAFETY CONCERNS IN BODY CONTOURING SURGERY
ANESTHESIA ISSUES see C

• Anatomic variability. Fiberoptic intubation may be helpful.
• Many patients have
• Patients who have had manipulation of the gastroesophageal junction may be at
increased risk for and aspiration.

• Body temperatures can fall rapidly because of large, exposed areas during surgery
and long operative times.
º

• Warming blankets

• Warming preparatory solutions
• Covering patients during position changes
• Keeping room temperatures elevated

is essential in large-volume excisional surgeries (e.g., belt lipectomy).


continued IVF resuscitation as needed.
Vectors of facial
rejuvenation.

884
Body Contouring
ANEMIA
of massive-weight-loss patients are anemic.8
Recognize and treat anemia preoperatively.
Transfuse intraoperatively and postoperatively as necessary.
THROMBOEMBOLISM see C
Obesity is a risk factor for DVT/PE and pulmonary embolism (PE).
Risk of DVT/PE is <0.1%.
Higher risk during truncal lipectomies. Increased intraabdominal pressure leads to
decreased venous return from lower extremities.

• Heparin or low-molecular-weight heparin before surgery and during hospitalization
may reduce risk.
• Epidural analgesia decreases incidence of DVT/PE, according to orthopedic
literature.
15
• Sequential compression devices are placed before induction of general anesthesia
and maintained postoperatively.
• Patients should start ambulating with assistance starting the day of surgery.
• Incentive spirometry
COMPLICATIONS OF BODY CONTOURING SURGERY
HEMATOMA
Typically occurs in the immediate postoperative period
Requires operative evacuation and exploration
SEROMA

lower body lift
Maintain drains until output <30 ml over 24 hours.
Drain seromas early before capsule formation.


Inject cavity with doxycycline to sclerose walls. Wait at least 4-7 days after surgery to
minimize pain associated with earlier infusion.
TIP: Obliterate dead space with progressive tension sutures and three-point sutures
at the level of the skin closure.
The preservation of a thin layer of fat on the deep fascia may diminish the risk of seroma
by maintaining some lymphatic drainage.
Fibrin sealants may help to reduce the incidence of seromas.
LYMPHOCELE

Seen primarily in the inguinal region from aggressive resection into femoral triangle
Perform serial aspiration.
Percutaneous drainage with placement of closed suction drain

885
Chapter 62
Doxycycline injection
Requires operative exploration and ligation of leaking lymphatic channels if
nonoperative management fails
SENIOR AUTHOR TIP: Direct resection of the tissues of the medial thigh in a vertical
thigh lift is commonly associated with a lymphocele formation in the area of the knee.

and then removing the skin using an avulsion technique will protect all neurovascular
and lymphatic structures, dramatically reducing the incidence of lymphocele.
Eliminating a lymphocele commonly requires excision and space-obliterating sutures.
WOUND COMPLICATIONS
Dehiscence (22%-30%)

• Early dehiscence from excess tension or movement, often seen in the posterior
closure of the body lift

(6%-10%)
(1%-7%)


• Tobacco use. Wait at least 1 month after cessation of smoking to perform surgery.
• Diabetes
• Active systemic steroid use

2
TIP:

Ensure that patients are awake and alert before postoperative movement. Cooperative
patients can determine which movements place excess tension on their incisions.
Have caregivers assist with postoperative activities, such as showering and removal of
compression garments, that can cause orthostasis and fainting, resulting in falls.
TOP TAKEAWAYS


performed today.

Start body contouring surgery when patients have stabilized their weight for at
least 6 months.

The best aesthetic outcomes with the least perioperative risks will occur with
patients near their IBW or with a BMI of 25-30 kg/m 2 after bariatric surgery.

The abdomen demonstrates the greatest deformity, and most tissue ptosis is
appreciated along the lateral axillary lines.



Treat the trunk, lateral thigh, and buttocks as a single aesthetic unit.
Continued

886
Body Contouring

Circumferential belt lipectomy/lower body lift provides resection of excess
truncal tissue and elevates the buttocks and lateral thighs.

Perform liposuction on the lateral thighs during a belt lipectomy to release the


Massive-weight-loss patients may require breast reduction or mastopexy,
depending on the amount of breast volume loss.

Patients develop premature facial aging because of skin redundancy rather than
SMAS laxity.




Complication rates increase with higher BMI.
REFERENCES

2. Rubin JP, Nguyen V, Schwentker A. Perioperative management of the post-gastric-bypass pa-
tient presenting for body contouring surgery. Clin Plast Surg 31:601, 2004.
3. Taylor J, Shermak M. Body contouring following massive weight loss. Obes Surg 14:1080, 2004.
4. Hamad GG. The state of the art in bariatric surgery for weight loss in the morbidly obese
patient. Clin Plast Surg 31:591, 2004.

Reconstr Surg 130:948, 2012.
6. Kenkel J. Marking and operative techniques. Plast Reconstr Surg 117(1 Suppl):45S; discussion
82S, 2006.
7. Aly AS, Cram AE, Heddens C. Truncal body contouring surgery in the massive weight loss
patient. Clin Plast Surg 31:611, 2004.
8. Kenkel J. The physiological impact of bariatric surgery on the massive weight loss patient. Plast
Reconstr Surg 117(1 Suppl):14S; discussion 82S, 2006.
9. Kenkel J. Safety considerations and avoiding complications in the massive weight loss patient.
Plast Reconstr Surg 117(1 Suppl):74S; discussion 82S, 2006.


2004.


2007.
-
tion. Plast Reconstr Surg 129:766, 2012.
13. Rubin JP, Toy J. Mastopexy and breast reduction in massive-weight-loss patients. In Nahai F, ed.
The Art of Aesthetic Surgery: Principles and Techniques, ed 2. New York: Thieme Publishers,
2011.
14. Sclafani AP. Restoration of the jawline and the neck after bariatric surgery. Facial Plast Surg
21:28, 2005.

vein thrombosis following total hip arthroplasty. J Arthroplasty 10:405, 1995.

887
Incidence of female genital aesthetic surgery has increased as the quest for the
aesthetic “ideal” becomes more popular.
• Fivefold increase in the number of patients seeking cosmetic surgery of the vaginal
region.
1
Often, the balance of aesthetic beauty and functional optimization, particularly in
terms of sexual intercourse, has played hand in hand.
Genital beauty is 2 (Table 63-1)

• In Western society, protruding inner labia are considered less desirable.
• In part of Africa, in a ritual known as Kudenga, the inner labia are stretched from a
young age in the belief it optimizes sexual intercourse.



Vulvovaginal plastic surgery

below
Vaginal rejuvenation
Not recommended for use as a proprietary term for
medical terminology

Reduction of the labia minora
Clitoral hood reduction
Reduction of the clitoral hood

Reduction of the labia majora
Vaginoplasty
Repair of the vagina to correct vaginal relaxation
Perineoplasty
Excision of excess introital and perineal tissue and repair
of the perineal musculature
Vaginal tightening
(colpoperineoplasty)
Both perineoplasty and some degree of posterior vaginal
repair for vaginal restoration
Hymenoplasty
Repair/reconstruction of the hymen so as to mimic the
virginal state

• Aesthetic and functional concerns drive this trend.
• Reasons in Westernized women
3:

888
Body Contouring
4
• Small, hardly visible, symmetrical labia minora have become the norm, with
commercial images being altered to reduce the size.4,5
• Growing habit of shaving the genital area, and even the availability of pornography,
4
A series from Alter6 revealed the following reasons for surgery:
• 85.5% aesthetic reasons, with some discomfort with clothing, exercise, or sexual
intercourse
• 13.3% aesthetic reasons alone
• 1.2% medical reasons
2,7:

standing
• Full labia majora that conceals the labia minora completely with minimal bulkiness in
tight clothing
• Inconspicuous clitoral hood
• Mons fat pad that does not protrude in clothing
LABIA MINORA ENLARGEMENT
8
Felicio
Type

I

<2
II

2-4
III

4-6
IV


CONDITIONS AND CAUSES
Enlargement or hypertrophy in both length and width9-16 (Box 63-1)
• Most feel that 5 cm in length, measured from the base of the minora to the labial
edge, is the upper limit of normal.
4
• Some have suggested that those seeking reduction have a mean labial width of
3.52 ± 0.71 cm8,9
8 (see Table 63-2)

889
Chapter 63 Female Genital Aesthetic Surgery
Box CAUSES OF LABIA MINORA ENLARGEMENT

Most common

Pregnancy, birth control pills, aging, exogenous hormones7,11
Topical estrogen12
Stretching or weight attachment of the labia13
Dermatitis secondary to urinary incontinence14
14
Myelodysplastic disease15
Repetitive stretching from pregnancy, sexual intercourse, chronic masturbation16
Atrophy or hypoplasia




• Interference with intercourse
• Chronic local irritation
• Hygiene problems

local hygiene
10

CLITORIS AND CLITORAL HOOD
NOTE:

Excessive, unattractive skin from preputial fold hypertrophy
• Can occur in the horizontal and vertical dimension
• Parallel folds lateral to the clitoral hood
• Drape-like folds that separate the anterior vulvar commissure on standing
1
• May protrude to give the appearance of a small penis
• Apparent hypertrophy of hood after aggressive edge trim labiaplasty17
• “Buries” the clitoris
NOTE:

Hood redundancy is the most common reason patients seek revision surgery.18

890
Body Contouring
• Phimotic clitoral hood over the clitoris
• Clitoral glans hypertrophy



and is
19

commissure to the distal clitoral prepuce



fascia)

LABIA MAJORA
Primary hypertrophy2
• Volume excess
20
Secondary hypertrophy
• Volume loss, creating excess skin
Fat and skin excess
• Creates overhang and droop, often with a central crease from the introitus
• Protuberance




• Same as those for labia minora reduction
• Aesthetic concern
• Functional concern

irritation
• Weight-related issues are key concerns.



MONS PUBIS

Descent of tissue
• Massive weight loss
Excess skin
• Massive weight loss
NOTE:
21

891
Chapter 63 Female Genital Aesthetic Surgery


GOALS OF TREATMENT
Varies across cultures, particularly in relation to the labia minora
Aesthetically desirable result, addressing any functional issues
Preserving sensory innervation and physiology is critical.
LABIA MINORA
Create an aesthetically pleasing labia minora while addressing functional concerns4,6
Reduction of the hypertrophic labia minora
• Thin and straight labia

• Nonredundant edges
• Symmetry
NOTE:

8
• Preservation of the introitus
• Maintenance of neurovascular supply
• Preservation of sensitivity to the labium and labial edge

23
sexual sensitivity with labial hypertrophy
Improve volume of the atrophic or hypoplastic labia minora8
• Aesthetic
• Some point out a functional aspect


CLITORIS AND CLITORAL HOOD
Reduce excess skin
Release entrapment
Resuspend to the pubic symphysis
LABIA MAJORA
Reduce excess skin redundancy and tissue descent
Reduce fat volume
Enhance contour
Augment atrophy
MONS PUBIS

• Decrease protuberance of excess fat

• Contour excess or ptotic skin
• Smooth transition from the lower abdomen to pubic area

892




3,7,24,25

Pubic symphysis
Anterior labial commissure
Posterior labial commissure
Glans of clitoris
Frenulum of clitoris
Vaginal orifice
Urethral orifice
Labium minus
Ischium
Labium majus
Prepuce of clitoris
Hood of clitoris
Pubic symphysis
Glans of clitoris
Vaginal orifice
Urethral orifice
Ischium
Crus of clitoris
Vestibular bulb
Corpora cavernosa
of clitoris
Anal orifice
Dorsal neurovascular
bundle of the clitoris

C

893
Chapter 63 Female Genital Aesthetic Surgery
• Body

laterally to attach bilaterally to the ischium

• Glans


apocrine, or sweat glands

fascia.
Dorsal neurovascular bundle travels at the 11 o’clock and 1 o’clock positions at the
junction of the glans and body.
• Travels within the deep Buck fascia directly on the tunica albuginea

Covers the glans
Formed from folds of the labia minora that pass dorsal (anterior) to the glans

Extends from ventral (posterior or deeper) glans bilaterally
Meets with an extension of the hood to form the labia minora

Appearance varies and is frequently 19

• Smooth or corrugated
• Parallel folds
• Variable thickness
• Protrusive if hood is thickened or clitoris enlarged
LABIA MINORA
Other names include or pudenda.
Two longitudinal, hairless cutaneous folds
• Varying in size and devoid of fat
• Internally situated between the labia majora
• Paired folds surrounding the vestibule of the vagina
Skin is smooth, pigmented, and mildly rugose at the edges.
• The dermis has a comparatively thick connective tissue component.

tissue
• The dermis is similar in thickness to eyelid dermis. This varies patient to patient.
Some patients have very thick dermis of the labia minora.
16
Core of spongy connective tissue
• Contain erectile tissue and many small blood vessels and sensory nerve endings

Inner surfaces of each labium have numerous sebaceous and eccrine glands, along with
sensory nerve endings.
• Pink color of mucus membranes

894
Body Contouring
The posterior ends may be joined across the midline by a fold of skin (frenulum
labiorum pudendi, fourchette, or posterior commissure of the labia minora).
Anteriorly
• Each labium divides into upper (anterior or dorsal) and lower (posterior or ventral)
parts

(prepuce)


frenulum of the clitoris.
Notable sensibility
• Highly innervated for the entire edge, which is notable for sexual response10,26-30
• Genital corpuscles for erogenous sensibility, as well as Pacinian and Meissner
corpuscles26,31
LABIA MAJORA
Prominent folds of skin surrounding the pudendal cleft
Each contains:

• The termination of the round ligament of the uterus

Externally, covered with pigmented skin (variable), sebaceous glands, crisp pubic hair
Internally, pink and hairless
MONS PUBIS
Rounded, fatty prominence anterior to the pubic symphysis, pubic tubercle, and
superior pubic rami
Mass of fatty subcutaneous tissue
• Typically increases at puberty, decreases at menopause
Surface continuous with the anterior abdominal wall
VESTIBULE
Space between the labia minora containing openings of the urethra, vagina, and ducts
of the greater and lesser vestibular glands


• Paired masses of elongated erectile tissue (~ 3 cm in length) along the sides of the

• Covered by the bulbospongiosus muscles
• Homologous to the bulb of the penis and corpus spongiosum

are partially overlapped posteriorly by the vestibular
bulbs.

895
Chapter 63 Female Genital Aesthetic Surgery





• Ischiocavernosus


compression of deep dorsal veins, contributing to clitoral engorgement
(erection).
26
• Bulbospongiosus




SENSORY INNERVATION

• Ilioinguinal nerve
• Genital branch of the genitofemoral nerve
• Perineal branch of the posterior cutaneous nerve of the thigh

• Run posterior to anterior toward the mons
• Pudendal nerve


• Terminal branches of the posterior cutaneous nerve of the thigh

• Increases vaginal secretion
• Erection of the clitoris
• Engorgement of erectile tissue in the bulbs of the vestibule
Malinovsky et al23
hypertrophy of the labia minora involved in sexual sensitivity.
VASCULAR SUPPLY
Extensive collaterals


(branch of the internal pudendal artery)


• Internal pudendal artery branches

896
Body Contouring
PREOPERATIVE EVALUATION
A thorough discussion regarding patient’s aesthetic and functional goals is essential.
Examine in both and positions.
Evaluate area as a unit comprising the mons, pubic area, labia minora and majora,
clitoral hood and clitoris, introitus.
NOTE:

LABIA MINORA
Protrusion


Thickness
Symmetry
Skin quality
Skin color
Relationship of the introitus


LABIA MAJORA
Excess of loose skin
Excess or lack of fat
Projection in the anteroposterior direction
Anterior labial commissure in relation to the pubic symphysis
• This is a guide point, particularly in procedures with a planned pubic lift
Must evaluate alongside mons pubis descent and pubic lipodystrophy
NOTE:



CLITORIS AND CLITORAL HOOD
• Evaluate patients while they are in standing and lithotomy position.
• Note protrusion, symmetry, hyperkeratotic or darkened skin, extra folds (horizontal
and vertical), clitoral gland size, and degree of clitoral exposure.
• Hood deformities are best noted with patient standing.
NOTE:

897
Chapter 63 Female Genital Aesthetic Surgery
MONS PUBIS
Mons descent
Observe the related enlargement, descent, or protrusion of the labia majora.
• Assess the labia majora with simulated elevation of the pubic fat pad, noting the
amount of inferior labial protrusion.
• Examine the majora with the mons lifted.
Panniculus
• Determine the amount of pubic skin above the hairline that will need to be excised
transversely.
• Simulating a possible lift, note the position of the anterior labial commissure.


excised
NOTE:
INFORMED CONSENT
Postoperative course and complications


Change in position of the anterior labial commissure
Inadequate reduction
Pain
Color change
• Suture line may create a contrast between lighter and darker tissue or between

• Seen in all forms of labia minora and labia majora reduction
Reduction of one area of the total complex may result in prominence of other areas.
• Reduction of the labia majora alone may result in more prominence of the labia
minora or clitoral hood.
Sexual dysfunction
Change in position, sensation, or even tethering of the vaginal introitus
Exposure of the clitoral glans
Vaginal dryness
Changes in sexual sensation
Scarring—widened, hypertrophic, painful
Hematoma
Infection
Transient dyspareunia
Fistula or major wound dehiscence

898
Body Contouring
TECHNIQUES
All techniques are performed with patients in the lithotomy position. Markings are made,
and local anesthesia is injected.
LABIA MINORA

A
B
C
D
A, Deepithelialization; central portion of labial mucosa deepithelialized
and reapproximated. B, Direct excision; full-thickness excision using contoured excision parallel
to each labia minora, sparing the fourchette. C, Central wedge resection; central wedge of excess
tissue excised and labium reapproximated. D,
wedge of tissue is resected and labium reapproximated.

899
Chapter 63 Female Genital Aesthetic Surgery
E
F
G
H
W-plasty excision (zigzag technique); complementary, running, W-shaped
resections along medial and lateral aspects of each labium minus, sparing clitoris and fourchette.
Interdigitating reapproximation of tissue. F,
central wedge of tissue with approximation of each labium minus. G, Composite reduction; curved

of tissue below clitoris removed to an extent to which the clitoris will move caudally. Central,
rectangular skin segment cranial to the clitoris excised and reapproximated. H,
used to excise tissue similar to direct excision and wedge resection.

• Edge trim (most common) 3
• Wedge resection patterns, as originally described by Alter6,18-20 or a variant of such
techniques
• Bilateral deepithelialization technique
• Composite reduction
33
9,34

900
Body Contouring

12,13,17,35,36 (Box 63-2)
Box LABIA MINORA REDUCTION TECHNIQUES–ELLIPTICAL EXCISION: PROS AND CONS

Edge irregularities are reduced.
Techniques are powerful for those
with extreme hypertrophy.35
Removal of pigmented edge.
Debulks thick leading edge of labia
minora.
Cons

and scar retraction remains.
Potential for excess tissue resection, especially if
minora retracted laterally during marking and
subsequent excision.
Some pigmentation may remain depending upon
location and amount of labial hypertrophy.
The transition zone between the labium,
frenulum, and clitoral hood may become
distorted, resulting in an abrupt-ending clitoral
frenulum and large, noticeable, overhanging
clitoral hood.



clitoral hood and does not include the frenulum.
of the
posterior fourchette.

distortion.



on suture line to avoid suture track scarring.
(Maas and Hage
37) (Box 63-3)
Box ZIGZAG TECHNIQUE: PROS AND CONS

Preservation of natural border
Elimination of the labia minora edge
scar, thus creating a more rounded
lateral edge.
Cons
Color mismatch or asymmetry.
Pigmentation is lost along the labial edge.3
35

901
Chapter 63 Female Genital Aesthetic Surgery
(Fig. 63-3)


pattern.





interdigitating fashion with interrupted 6-0 absorbable suture.
Lateral incision
Medial incision

W-shaped incision on the medial aspect, and the interrupted line indicates the complementary
marking on the lateral aspect of each labium minus.
• Felicio8 described free edge amputation technique with the use of an S-type incision
to decrease the chance of scar contracture.


excision (Alter
6) (Box 63-4)
Box WEDGE EXCISIONS: PROS AND CONS

Versatile and allows lateral clitoral hood
reduction by extension of dog-ears
superiorly.
Debulks most protuberant portion of labia.8
Applying posterior tension minimizes
projection of the clitoral hood anteriorly.2
Cons
A scar runs from the base to the edge.
May oppose dark pigmentation with light
at wedge closure site.37
Posterior tension may cover more of the
clitoral hood, potentially decreasing
sensation.3

902
Body Contouring


removal of excess lateral clitoral hooding or dog-ears.
(Fig. 63-4)
Medial
incisions
Lateral
incision
Markings for a V-shaped wedge excision and extended central wedge excision described
by Alter.

labia minora. This point varies and is key element in resection pattern.
– Anterior portion of the incision line is at or posterior to this convergence
point.

create a straight line without causing a tightened introitus or undue tension
on the incision.
– The wedge point must end just outside of the hymenal ring.

– Markings are carried in a “hockey-stick” manner anteriorly to incorporate
lateral clitoral hood or lateral hood folds.

introitus to prevent tightening.

overtightening.
NOTE:

903
Chapter 63 Female Genital Aesthetic Surgery
8 (Figs. 63-5 and 63-6)

the mucosa, preserving the important subcutaneous tissue. A knife is used to remove the mucosa
to the point of the traction suture. B, Completed excision of medial and lateral tissue, noting the
preservation of the important subcutaneous tissue.
A
B
A
B
C
D
Subcutaneous tissue is approximated using 5-0 Monocryl suture. Any excess,
protruding medial or lateral subcutaneous tissue is removed. B, Completed approximation of
subcutaneous tissue. Note the smooth transition of subcutaneous tissue following excess removal,
to avoid dog-ears and thickened labia on closure. C, Skin closure from distal to proximal in vertical
mattress fashion. The deep portions medially may be performed in a running fashion. D, Completed
lateral incision line.

904
Body Contouring

may exist.

– Placing traction on the labia, the incision is carefully carried just into the
mucosa, preserving the thin, underlying subcutaneous tissue.
– The medial portion is removed carefully with a knife.

– On stretch, the lateral incision is made just through the dermis, preserving
the underlying subcutaneous tissue.

– 5-0 Monocryl suture on an atraumatic needle in two layers whenever
possible
NOTE:
8
– Any excess, protruding subcutaneous tissue may be removed here to
prevent dog-ears.
(see Fig. 63-6)
– Distal to proximal
– Interrupted vertical mattress sutures using 5-0 Monocryl
– The key point is the edge suture, bringing the medial and lateral edge

fashion for proper eversion of the tissue.
– A running suture may be used in the deepest portions of the medial
incision or occasionally on the lateral lines.

8
– Attention must be given to the vaginal introitus both before and after
resection.
A high posterior lip or overly tight introitus may lead to intercourse

The posterior lip may need to be incised and vaginal mucosa sutured to
the perineal skin.
– If vaginal tightening procedures are performed at the same time, they
must be done before the labiaplasty.

905
Chapter 63 Female Genital Aesthetic Surgery
(Munhoz et
al10) (Box 63-5)
Box INFERIOR WEDGE RESECTION AND SUPERIOR PEDICLE FLAP: PROS AND CONS

In correctly selected patients, the

with natural color and texture.
Cons

to a bulky labium.
• Should this occur, less lateral clitoral hood skin
is advanced posteriorly.
The inferior edge of the labial resection is the
thinnest and least protuberant portion of the
minora.35
• The transition sometimes results in a bulging

• An unnatural transition, with a pulled-down
appearance near the posterior fourchette, may
result.

less predictable result.

38



measured horizontally from the midline when placed on lateral traction with
minimal tension

redundancy of skin and mucosa of the region, along with the dense
network of perforating vessels near the midline of the perineum

Minimal hypertrophy or absence of skin laxity
Pinch test using small forceps
The middle portion of the labia minora is gently grasped and stretched
inferiorly to the posterior portion of the vaginal introitus.
– Simulates the amount of wedged tissue to be resected and the extension

906
Body Contouring
Tension is assessed.


more tissue.
A wedge-shaped area is designed between this midlabial point and the
posterior edge of the labia in the lithotomy position.

cutaneous/mucosal laxity.

located exclusively on the more posterior labia minora.

region, with more curved borders and convex design to include excess
tissue.
NOTE:


(Figs. 63-7 and 63-8)
90°
90°
120°
120°

hypertrophy, we prefer a small reduction with an angle between the two lines of 90 degrees. In the
presence of severe hypertrophy, and if the patient desires more aggressive reduction, the angle
can be 120 degrees.

907
Chapter 63 Female Genital Aesthetic Surgery
1
2
A
1
2
B
1
2
C
D
and B, The skin incision is carried down to the subcutaneous tissue on the medial
layer. The complementary incision is performed on the lateral layer, and the total wedge-shaped
area is resected. C, Point is approximated to point D, The medial and lateral incisions are closed.




of the labia minora supplies the vascularity.

labia.

908
Body Contouring
(Tepper et al4) (Box 63-6)
Box MODIFIED DOUBLE-WEDGE “STAR” LABIAPLASTY: PROS AND CONS

Flexibility is increased over the vertical technique
described by Alter and the inferior wedge
technique described by Munhoz.
An additional means of reduction is created,
without the risk of widening the central vertical
V excision.
Cons
Additional suture line and tissue
dissection is involved.



resection is provided without the risk of widening the vertical V.



alone



Alter technique.
6


(Fig. 63-9)
star
technique.
size or angle of the V and adding one or two horizontal wedge resections.

909
Chapter 63 Female Genital Aesthetic Surgery
(Kelishada et al26) (Box 63-7)
Box POSTERIOR WEDGE RESECTION: PROS AND CONS

The central wedge is an advantage,
because it can be arranged to remove
the most protuberant portion of each
labium.
The normal pigmentation of the outer
surface of the minora is preserved.
Cons
The most undesirable portion of the labium is

posteriorly.

labia minora


and outermost labia minora.
– Preserves the outermost edge or anterior edge, mainly at the most
superior and inferior boundaries
– Gives the results of a thinner-appearing superior pedicle by preserving the
outer edge and theoretically decreasing the distance required to close the





– Carried from posterior to anterior to end within 1 cm of the frenulum
– Extended to the base and then posteriorly to within 1 cm of the fourchette

(Fig. 63-10)
Lateral incision
Medial incision
A
B
C
D
The hypertrophic labia minora. B, Marks for posterior wedge resection. C, The red
arrows
resection and brought down toward the remaining labial base. D,
placement of sutures.

910
Body Contouring


patterns.




35
– Thinner lateral edges of the minora are preserved and suture lines placed
in natural creases.
– Base width of the minora is reduced by imbricating sutures to match the
thinner lateral edge widths of the minora.


(Giraldo et al
31) (Box 63-8)
Box CENTRAL WEDGE RESECTION WITH A NINETY-DEGREE Z-PLASTY: PROS AND CONS


decreasing the likelihood of scar contracture
and introital narrowing.39 Because of thin
labial mucosa, Alter18-20
be much of a problem.
The base is not violated, thus preserving the

nerve and its distal branches so vital for
sensation.39
Cons
The anterior and posterior surfaces
have mismatched color.39
The full-thickness resection pattern
may increase the chance of


to aid in closure

labia



is designed to end just ventral to the urinary meatus.
– This marking is drawn on the corresponding lateral cutaneous border as
well.
(Fig. 63-11)

911
Chapter 63 Female Genital Aesthetic Surgery
1
2
3

of tissue to be resected, converging toward the ventral portion of the urinary meatus ( Clitoris;
vagina; redundant tissue of the central third of the labia minora.)

9,34



shorter side
– Allows adjustment of the length of the two branches of the V resection at
the base of the minora
– Theoretically, reduces the tension on closure of the wound
– Similar to other wedge resections, preserves the outer edge of the labia,
reducing the color change
34

– Decreases bleeding

distortion from local anesthetic injection
(Choi and Kim 40) (Box 63-9)
Box BILATERAL DEEPITHELIALIZATION: PROS AND CONS

The entire edge of the labium is preserved.
Demucosalization avoids injury to neuro-
vascular supply.
Postoperative tightness or pulling at the
introitus may be less likely.
Cons
The anterior to posterior length of the
minora is not addressed.
A bulky labium with redundancy in the
anterior and posterior portions may
result.35
The retained central parenchyma may
create a bulge and increase the width at
the base.39

912
Body Contouring
• Central deepithelialization technique creating a vertical reduction

supply
• Delicate technique involving partial-thickness resection

35



protrusion past the introitus.
(Fig. 63-12)
Deepithelialization.

performed.


CLITORIS AND CLITORAL HOOD

• Addresses vertical and/or horizontal skin redundancy of the clitoral hood

dimension preoperatively, is best addressed with the lateral hockey-stick
extension as a part of the Alter wedge resection (see Figs. 63-5 and 63-6).

913
Chapter 63 Female Genital Aesthetic Surgery

labia majora–clitoral hood sulci.

is marked.
– An inverted-V pattern is designed for this.
– May be incorporated into a V-Y plasty to resuspend the clitoral glans
6,16
NOTE:
NOTE:




patients with labia minora hypertrophy
16

addressed

normal anatomic position provides a means of tightening the labia minora in the
anteroposterior dimension.

providing access to the area of suspension.
16



16

16 discussed the importance of remaining midline to avoid disrupting
sensation from the deeper pudendal nerves, which are lateral.

16 followed by assessment of excess hood skin
and tissue. If needed, the Y may be extended to aid in movement of the glans.
CAUTION:



(an inverted-V).

marked.
(Fig. 63-13)

the Y extension.

expose the suspensory ligament of the clitoris and pubic symphysis.

914
Body Contouring
Pubis
Clitoris
Ligamentous
attachment
Clitoral hood
Placement of
3–0 PDS
Hypertrophic
labia minora
A
Clitoris
Y-shaped incision
Area of Choi
and Kim
resection
V-shaped suture
line (clitoris moved
in upward/anterior
direction)
Reduced labia
minora
B
C
Suture is placed in the midline, between the suspensory ligament of the clitoris
and pubis. B,
C, Postoperative appearance.
NOTE:


suspension in the midline is determined.

– Holds the potential V-Y clitoral hood reduction in place without tension
16

915
Chapter 63 Female Genital Aesthetic Surgery
LABIA MAJORA

• Skin
• Underlying fat
• Skin and underlying fat
NOTE:
20
Excision
• Excess skin excision
• Deeper fat excision






abdomen
• Some consider excision or liposuction performed from a superior position during

22

Box LABIA MAJORA DIRECT EXCISION: PROS AND CONS


by direct access to each component
of the labia majora (skin, fat).
Cons
Overresection of labia majora fat and skin may
cause a gaping introitus leading to vaginal
dryness, discomfort in clothing, discomfort
with activity, and an inability to completely
abduct the legs
May result in a perceived increased prominence
of the clitoral hood or labia minora
Contrast of skin color and hair pattern may
occur


• Mark medial thigh crease.

916
Body Contouring
• Mark the skin excess.

posterior labial commissures



in preoperative holding area by using a cotton-tipped applicator to imbricate the
tissue.
) is also a good option.
• Medial incision




the legs are fully abducted


NOTE:

• If patient has had a previous medial thigh lift
20,41

reduction through skin excision techniques, because the intervening vascular tissue


a gaping introitus secondary to:


pull on the labia majora
41
• Important note







tissue deep must be maintained to preserve lymphatics.
NOTE:

917
Chapter 63 Female Genital Aesthetic Surgery
(Fig. 63-14)
A, A crescent of skin is removed from the medial labium
majus. The shape depends on the amount of excess skin. The two incision lines should not meet
in the midline. Fat is excised. B, Closure is performed in layers. A subcuticular closure is performed

A
Proposed
incision
Excess fat
removed
B
Subcuticular
suture closes
skin

of Colles fascia
and subdermis
• Skin incision
• Fat excision (if needed)





• Tailor-tacking of the skin edges to adjust for symmetry
• Closure


deeper Colles fascia to eliminate dead space.

918
Body Contouring

Box LIPOSUCTION OF LABIA MAJORA: PROS AND CONS


protrusion
May be combined with other contouring
procedures such as mons liposuction/
lift, or during abdominoplasty
Cons


after the procedure.
Considered to be less precise than direct
excision

• Topographic marking of fat protrusion
• Access incisions





• Suction assistance using 3 mm Mercedes-tip cannula


issues.





• Firmness of the labia majora may persist for several months.
MONS AND MONS PUBIS
Mons remodeling to tighten and lift, addressing21,41:
• Subcutaneous fat and/or skin
• Volume reduction
• Correction of ptosis

919
Chapter 63 Female Genital Aesthetic Surgery

Box MONS PUBIS CONTOURING, COMBINED EXCISION, LIPOSUCTION, AND LIFT: PROS
AND CONS

Natural transition is created from the
abdomen and ptotic mons skin.
The anterior labial commissure is returned to a
more anatomic position.
Mons lift raises the ptotic labia majora;

the tissue
43

patients.43
Bladder incontinence is improved.43
Cons
Excessive resection of fat may lead to
concavity of the mons.
Aggressive removal of underlying fat
and/or skin can create an unnatural
anterior labial commissure position
and possible shortened escutcheon.7
Urinary stream may be altered.43

lymphedema.22,43
Vertical excision, if needed, can be used for tightening.21
• Midline skin excision may give an unsightly vertical scar.22

Inverted triangle of skin and subcutaneous tissue excised with minimal
undermining
35,42

triangle incision to include reduction of the labia majora.35,42
Results in an inverted-T incision on the skin

planning amount of skin to resect.
20

• Most often done in concert with abdominoplasty or pubic lift
• Isolated liposuction will probably not address the excess skin or subsequent ptosis.

• Perform direct undermining or liposuction of mons fat pad for optimal contour
• Secure into position to prevent pubic descent
21,22,43,44

• Patient is standing in front of a mirror and then in the lithotomy position.20
• While the patient is standing, have them assist in strongly elevating the skin to
determine the amount of pubic skin above the hairline that will need to be excised
with the lift.

step.

920
Body Contouring
NOTE:
7,21


subcutaneous tissue may be designed.
20
• If only mons is to be treated, this may be done with patient in the supine position,
otherwise lithotomy.


• Combination with existing abdominoplasty incision
(Figs. 63-15 and 63-16)
•
• A tumescent solution containing dilute lidocaine and epinephrine may also be
injected.
• Upper incision is made and carried down to the rectus fascia.

symphysis.

toward the pubic symphysis.
Upper incision
Predicted lower incision
Pubic symphysis

symphysis and laterally to the inguinal canals and external rings.