Body image is an important factor which aids in building healthy self-esteem and confidence . It is important that a person is comfortable with their appearance in order to have a satisfactory sexual life. The mons pubis is triangular area of feminine fatty tissues located at the level of pubic symphysis and is considered one of the important aesthetic features of the feminine physique. . Laxity and ptosis of the mons pubis is a troubling finding in many females who are obese or have lost a significant amount of weight . The Ptosis of the mons pubis can be considered an important factor of dissatisfaction in a sexual relationship; . Some patients who suffer from ptosis in the pubic region may feel embarrassed and, in some cases, the deformity is so apparent that it cannot even be hidden by clothing.
Ptosis of the mons pubis can easily be corrected during an abdominoplasty procedure .
Aside from having a poor cosmetic appearance, pubic functionality can also be compromised, with difficulty in maintaining hygiene and altered sexual functions. Neglecting to treat the mons area during abdominal contouring may leave the patient with residual contour irregularities, ultimately affecting the aesthetic or functional result. We investigated whether there were significant improvements in patient satisfaction, functional outcomes, and aesthetic results in women who underwent abdominal
contouring surgery with monsplasty.
Mons ptosis is defined as:
An increase in length of the mons pubis greater than 2 cm when gently stretched compared to its relaxed state length. This distance is measured from the commissure to the infraabdominal crease , (Figure 1).
We did a prospective study of 80 patients over a period of 32 months. The study group consisted of patients who were admitted to our plastic surgery unit for abdominoplasty between the 1st of March 2015 and the 31st of December 2017. Patients were required to have a stable weight for more than 6 months, and normal laboratory test results, including complete blood count, electrolytes, and coagulation studies.
All patients included in the study had mild to severe laxity of the mons pubis. All female patients with BMI of 27.5 to 35 were included in the study. It was found that most patients with BMI less than 27.5 had a natural appearing, smooth, mons pubis and therefore were excluded from the study.
All patients included in the study were in the age group of 30-50 years and had active sexual life with a BMI of 27.5 to 35 and mons ptosis of greater than 2 cms.
Patients with diabetes or a history of chronic smoking were excluded, due to, possible neuropathy and the increased risk of necrosis of the flaps respectively. Monsplasty was offered to all 80 participants.
Demographic information such as age, parity, weight loss sexual relationship and hormonal status were obtained from the patients.
Patients giving consent for surgery after consultation, were separated into two groups to undergo abdominal contouring procedures with monsplasty or without monsplasty..
Out of 80 patients, 46 accepted to undergo Monsplasty and were categorized as group 1. The other 34 patients preferred abdominoplasty alone and were categorized as group 2. The patients refusing to undergo monsplasty were scared to add another procedure and not able take the decision Patients in both the groups completed a preoperative and follow-up questionnaire six months after surgery. The questions on the survey assessed patients' preoperative and postoperative satisfaction with the aesthetic appearance of their mons region.
At the 6-month post-operative follow up, a questionnaire about sexual satisfaction postoperatively was filled out by the patients in both groups (Figure 2)
Standard Abdominoplasty was performed for all patients followed by Monsplasty in the group 1 alone. For the Monsplasty; an inferior abdominal wall marking of 5 to 7 cm above the commissure was done. The pubis was then raised 2-3 cm above its original position, and fixed to the aponeurosis of the rectus abdominis muscles. The thickness of mons pubis fat was then measured. If it was found to be more than 2.5 cm, de-bulking was one from the lower portion to achieve a subcutaneous thickness of 2.5 cm. Deep sutures were taken in the tissue of the pubis, and it was fixed to the abdominal fascia in order to sustain a smooth, natural looking mons pubis. The aim was to elevate the pubis, correct the shape, and to resect the excess adipocutaneous tissues.
This was achieved in all 46 patients. Meticulous hemostasis was done to ensure the results were not compromised by a hematoma or bleeding. All other significant complication, which might have compromised the final result, were also avoided. The patients from group 1 and 2 followed up in an outpatient setting at 1 week, 3 weeks, 3 months, and 6 months after discharge (Figure3).
At the 6 months follow up, a final questionnaire targeting the patient's postoperative sexual satisfaction was filled out by the patients in both groups. The results for the 2 groups, patients who had undergone Monsplasty with abdominoplasty (group1), and patients who opted for standard abdominoplasty without Monsplasty (group 2), were as follows:
All patients in group 1 were extremely satisfied with the results of their surgery. There was no residual or recurrent deformity at the 6 months follow up, and the results of the surgery seemed to be long-lasting (Table 1).
It can be inferred from the results of the study that there is a significant benefit to adding Monsplasty to the standard abdominoplasty procedure, if indicated by ptosis of the mons pubis. Improving the appearance of the mons pubis plays a role in raising the self-confidence of patients, which in turn, significantly improves their sexual life and performance [3-5].
Our study is limited by the subjective nature of the responses from our surveyed patients. However, the opinions expressed by our patients in this study consistently displayed improvements in both aesthetic and functional properties after monsplasty.
Another limitation is that we were unable to identify which factors influenced satisfaction scores. The analysis assessing the influence of body mass indices, pannus resection weight, and change in BMI, on satisfaction scores were not considered. Perhaps by increasing our patient population and other influenciong factors we could have achieved a more robust statistical analysis, which might have helped us to determine the factors influencing satisfaction or dissatisfaction. Future long-term follow-up is warranted to examine the durability of the monsplasty technique.
We have developed simple modifications during the surgical planning of abdominoplasty, which may help achieve better patient satisfaction in regards to their appearance. The main changes to the procedure include: anchoring of the abdominal flap, fixation of the pubis at a higher position in the rectus abdominis sheath, and de-bulking of the mons pubis flap.
With proper incisional design, monsplasty can be performed safely during abdominal contouring with a high rate of patient satisfaction to improve both form and function of the pubic region. With regards to pubic deformity after massive weight loss, the results obtained in this study are proof that the adaptations to the well-known procedure are safe, easily reproducible, offer a high level of cosmetic and functional outcome, and have long lasting results (Table 2).