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

Kevin Jovanovic, MD

Mons pubis liposuction would seem to be an easy proce- paramount to maintain natural smooth transition supe- dure, but procedures in this small area, hidden by clothing riorly from the abdomen and inferiorly to the most of the time, have generated a great deal of controversy majora and then lateral in a tapered triangle to the and misconceptions. The goal of this review is to examine inguinal . A literature review about the aes- the current evidence in the literature and try to dispel some thetics of the mons pubis revealed one article that tried of the mryths sutounding this seemingly simple procedure. 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 l\ fions pubis is the Latin for '.pubic mound." The volunteers aged26 to 53 years with a body mass index IVIu."u'is also known as the as the mons veneris (BMD between 18 and 26 and no prior altering opera- (Latin, mound of Venus). The anatomy of the mons tions in the mons area were evaluated. In addition, pubis, that is the area that is included when measuring measurements were performed for 13 female cadavers and defining the aesthetically correct mons pubis, is aged 60 to 95 years. The following lines and angles the lying above the pubic bone of adult were measured: (1) umbilicus/pubic is the mea- females, anterior to the symphysis pubis. The mons surement equivalent to the top of mons pubis, (2) top pubis forms the anterior portion of the . The of the mons pubis to the end of the , (3) margins are as follows: the inferior border divides the lengths of the side segment lines (end of the labia labia majora, thelateral border encompasses the ingui- majora along the inguinal crease up to the lateral hair- nal ligaments, and the superior border is the anterior line at the femoral vessels, (4) length of the base of the abdominal wall (Figure 1). mons triangle, (5) inguinal crease/pubic hairline angle, Mons pubis liposuction would seem to be an easy and (6) inguinal crease/labia majora angle. Means, procedure. Although this small area is hidden by medians, and standard deviations were calculated for clothing most of the time, surgical procedures in this each measurement (Table). area have generated a gteat deal of controversy and misconceptions.la The goal of this review is to exam- Recommendations for Performing a Safe and ine the current evidence in the literature and to try to Effective Liposculpturing of the Mons Pubis dispel some of the myths surrounding this seemingly Recommendations for the performance of liposculp- simple procedure. turing of the mons pubis include the technique that is commonly described as a criss-cross liposuction from What Are the Goals of Liposuction both sides of triangle. Focus is on the central portion of the Mons Pubis? to allow the edges to be tapered to the surrounding tis- The aesthetic goal for liposuction of the mons sues (Figure 2). Carc must be taken to stay to deeper pubis is to remove an unsightly bulge in clothing. It is planes to allow for debulking without complete loss of subdermal fat. Special attention should be taken along publication April 25,2oll. Received for inguinal areas to avoid injury to the inguinal liga- From the LVRI of New York City, New York, NY. the Conesponding author: Kevin Jovanovic, MD, LVRI of New York City, ments and its contents. Occasionally, scar revision or 930 Fifth Ave, Suite 3, New York, NY 10021 (e-mail: drjovanovic@ undermining of scars is needed in conjunction with hotmail.com). DOI: 10.5992/AJCS-D- I 1-00020. I liposuction to achieve the desired result. 'uoDer^ep pJupuBts seFJrpur cs * V'E 9L 9L 9'9 9L 9L (seer8ep) (fl = e13uer4 suoruJo dr1) e13ue uroluur elqel 01 esuerc leurn8ul vz9 v9 g'9 v9 99 (seer8ep) (e = ey8uerrl suoruJo reutoc) ey?uu euqrrcq crlqndTeseerc leurn8ul 9'Z 8I 6I E'Z 9I 9I (tuc) c = eISu€lJt suour Jo oseq Jo sqfue'I (ruc) (eulpreq I€relel o1 dn eseerc L'I VI VI I'Z T,I EI leurn8ur eqi 3uo1u eroluru BIqBI Jo pue) q = Seurl lueur8es eprs Jo sq13uel v'r I E9 (,(, v I (urc) (urqel Jo pue o1 gelc) u.rofuur ulq€l Jo {t8ue1

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Figure 3. Liposuction of mons pubis and scar lift with Pelosi lipo scissors.

Figure 2. Common liposuction technique. of wound cellulitis and acute and chronic lymphedema was significantly lower.ro Only one patient in this repofted case of a self-inflicted vibrator burn after series with saphenous vein preservation developed suction-assisted lipectomy.8 chronic lymphedema, a patient who received postop- erative radiation therapy. The article changes surgical the radical dissection used from the Is Lymphedema of the Leg Possible staging from 1900s to the new staging procedures that are being as Result of Liposuction? used today for the past 10 years since 2000. Chronic One of the common vulvar medical procedures that lymphedema has been reported in l0-20%o of women has a high incidence of lymphedema of the leg is sur- after groin node dissection. This can be a disabling gical staging of . Cancer of the vulva is problem and is more common if radiation is required the fourth most common malignancy of the female after groin dissection. Limiting groin node dissection genital tract. The American Cancer Society estimates women with early cancers and preserving the that 3580 women were diagnosed with vulvar cancer in saphenous vein decreases the incidence of this in 2009.e Currently, approximately 757o of patients problem. A theoretical cause of lymphedema of the with vulvar carcinomas will be cured, making vulvar leg with aggressive liposuction of the inguinal area carcinoma responsible for approximately 900 deaths would result from sacrificing the saphenous veins or annually in the United States. suctioning the lymph nodes below cribriform . Since the early part of the 20th century, the tradi- tional surgery has been a radical dissection of the primary lesion with a bilateral groin node dissection Is Dyspareunia Possible as a Result of performed through a single incision. The femoral tri- Liposuction of the Mons Pubis? angle is bounded by the inguinal superiorly, It is important to understand there many different the adductor longus medially, and the sartorius laterally. medical conditions underlie the diagnosis of dyspareu- The superficial groin nodes lie above the cribriform nia. The causes of dyspareunia fall into two broad fascia in the femoral triangle. Careful dissection gen- categories: physical causes and psychological causes. erally reveals 5 vessels in the femoral triangle above Physical causes of dyspareunia are further catego- the cribriform fascia, the largest of which is the saphe- rized as dyspareunia on entry or deep dyspareunia. nous vein. The other vessels include the superficial Dyspareunia on entry can result from lubrication circumflex, the superficial epigastric, and the external (hormones, medication), trauma (circumcision, pelvic pudendal. surgeryftrysterectomy), inflammation (sexually trans- Below the cribriform fascia are the deep inguinal mitted disease, eczema), allergic reaction (to lubricants, nodes. The most superior of these is the sentinel node to toys), and vaginismus. Deep dyspareunia can result the pelvic lymphatics, which is known as the node of from illness (pelvic inflammatory disease, endometri- Cloquet. The saphenous vein is key, and a review of osis, fibroids, cystitis, irritable bowel syndrome), 139 cases of groin node dissection demonstrated that infection (sexually transmitted disease), and surgery when the saphenous vein was preserved, the incidence (pelvic surgery, radiation). 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