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Archive for the ‘pubic lift’ Category

Case Study – The Triple Roll Tummy Tuck with Pubic Lift

Sunday, December 3rd, 2017


Background: Large amounts of weight loss cause an expected amount of abdominal skin looseness and overhang. The deflation of the abdominal and waistline fat causes a resultant skin excess that hands down. This most commonly results in a single roll of tissue that hangs over the waistline known as an abdominal pannus. In patients with a lot of remaining intra-addominal fat or a thick upper abdominal subcutaneous fat layer, the deletion of weight loss causes a tissue roll above the umbilicus as well as below it. (double roll abdominal deformity)

But a third roll in weight loss patients is also possible but it does not involve the abdomen per se. If one has a large pubic region initially it will partially deflate and sag. This smaller tissue roll is pushed down by the larger tissue roll above it, creating the third roll or the triple roll abdominal deformity.

A large and low hanging pubic ‘pannus’ complicates the tummy tuck design for these larger excisional patients. Should the central part of the lower tummy tuck incision go lower to remove the upper third of the sagging pubic mound or should the tummy tuck markings be done in the standard fashion above the pubic mound and just do liposuction of the pubic mound to further deflate it? Or should some combination of both pubic mound management strategies be done?

Case Study: This 45 year-old female lost over 60lbs on her own but developed the triple roll abdominal deformity. She has a large and full pubic mound that hung down between her inner thighs.

Under general anesthesia she underwent a tummy tuck that included excision of the complete middle abdominal roll, a portion the lower end of the upper abdominal roll and the upper third of the pubic mound or lower pubic roll. Her postoperative result shows substantial improvement although not completely flattening of the entire front torso.

The pubic mound shows a significant lift but not a complete flattening of its profile. The abdominal wall above it is also much better but is similarly not flat. Ideally a second stage procedure is needed primarily focusing on liposuction of the abdomen and pubic mound for further flattening. Some additional skin above and below the tummy tuck scar may also be needed.

The triple roll abdominal deformity is a difficult problem to ideally correct in a one-stage procedure. It often takes a second procedure to improve the results of the first tummy tuck with additional fat and skin removal.


1) The ‘triple roll’ abdominal deformity can happen after a lot of weight loss in certain women.

2) The third roll in this type of abdominal lipodystrophy is the pubic ‘pannus’.

3) The low hanging and full pubic pannus must be factored into the design of the tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Maximal Buried Penis Repair Technique

Thursday, November 5th, 2015


buried penisThe buried penis problem is adult men is almost seen with pubic and abdominal tissue redundancies. Obesity to some degree is a frequent accompaniment to the hidden penis. But even in weight loss patients the tissue redundancies are not completely solved and only the subcutaneous fat layer gets thinner. The skin overhang and loss of penile show remains.

The buried penis poses multiple problems which are completely predictable. The urinary stream is obstructed and this poses obvious hygiene issues. This is compounded by the moist skin folds underneath the tissue excesses.  This creates the potential for irreversible skin change on the shaft such as lichen planus and scarring. Sexual activity is usually limited or impossible to perform due to both physical limitations and embarrassment.

In the November 2015 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Limited Panniculectomy for Adult Buried Penis Repair’. In this paper, the authors describe a procedure which includes a combination of a mons panniculectomy, fixation of adjacent skin to the base of the penis, removing abnormal penile skin at its base and skin grafting the residual penile shaft defect.

While an overhanging abdominal pannus creates its own contribution to the buried penis, a large mons mound has a more direct influence on it in some men. This is a tissue excess that is situated between the visible waistline superiorly and the penis inferiorly and drapes over it. This leaves only an inverted hole or funnel where the penis is ‘hidden’. While mons liposuction in some male patients may be adequate to create increased penile exposure, a large mons mound with excess skin requires skin removal as well. This is where the mons panniculectomy is useful. This directly removes a large of tissue just above the base of the penis but also allows access to secure the skin around the penis toi be sutured down to the pubic symphysis.

Fortunately addressing poor penile shaft skin is not often needed. But if the penile skin is of poor quality due to chronic irritation or is restricting the penis from coming forward, it need to be released and removed. Skin grafting can be done directly to Dartos fascia which is best to allow the skin graft to stretch during erection. Split-thickness skin grafting is best to allow for quick and complete take in most cases.

The mons panniculectomy and penile release with skin grafting is the most aggressive approach to the treatment of the adult buried penis repair. But in some men with a large pubic mound this may be the only effective approach.

Dr. Barry Eppley

Indianapolis, Indiana

Fascial Suspension for Pubic Lifts

Tuesday, October 14th, 2014


While there are numerous body areas that can be changed through excisional lifts, particularly after large amounts of weight loss, the most common area treated is that of the waistline. Tummy tucks and body lifts (circumferential lipectomy) make up the most well known and largest surface area removal procedures. Often overlooked (but ultimately not by that of the patient) is the smaller pubic region which lies just below the waistline and may often be hidden by overlying abdominal tissues.

Pubic Lift in a Tummy Tuck oblique view Dr Barry Eppley IndianapolisThe mons pubis is  a skin and fat mound that is located directly above a woman’s pubic bone. This pad of tissue is thought to provide protection of the underlying bones during intercourse. With a predominantly fat composed mound, it is easy to see how it could act as a cushion. But with weight gain (and loss) the fatty pubic mound can sag and remain full of fat that can have a contour that becomes protrusive when what lies above it becomes flattened. It has been well described by patients of how a prominent mons pubis has become ‘unmasked’ by tummy tuck surgery. With a tight and flat horizontal scar line above it, the rounder and more convex pubic mound can stick out further than a flat stomach after tummy tuck surgery.  It is thus well known amongst plastic surgeons to check carefully for the pubic mound contour and incorporate it into the excisional design of the tummy tuck surgery

In the November 2014 issue of the Annals of Plastic Surgery journal, an article appeared entitled Using Superficial Fascial System Suspension for the Management of the Mons Pubis After Massive Weight Loss’. In this paper, fifty (50) patients who underwent a lower body lift had a simultaneous mons pubic lift using a superficial fascial suspension technique. After an average follow-up of nearly 18 months, they were evaluated by before and after pictures as well as a satisfaction survey. Satisfaction of their mons pubic appearance improved significantly. One-third of the patients described the look of their pubic region as very good while half of them described it as good. Eight patients developed prolonged swelling of  the mons pubis and a single patient developed an infected fascia suture which had to be removed.

In the extreme weight loss patient, an unshapely pubic mound always exists even in men. But unlike the fat and more convex mound shape in a more traditional tummy tuck patient, the weight loss patient’s pubic mound is deflated and has substantial skin sag. Thus a significant pubis lift is needed with their tummy tuck/lower body lift and fascial suspension along with skin excision is a logical and stable approach to doing it.

Dr. Barry Eppley

Indianapolis, Indiana

Tummy Tucks and the Pubic Lift Effect

Tuesday, January 15th, 2013


A tummy tuck can produce a dramatic change in the shape of one’s abdomen and frontal waistline. By removing a large horizontal ellipse of loose skin and fat, a tightening and flattening effect is seen when the remaining abdominal tissues are put back together. Such reapposition is known as a transposition of the remaining upper abdominal fasciocutaneous flap downward towards the pubis. The union of the abdominal flap downward towards the pubic area creates the location of the horizontal incision line.

While the downward movement of the abdominal flap over the area of removed tissues is often described as stretching down to meet the fixed pubic tissues, this is not entirely accurate. In reality, the abdominal flap does not provide 100% coverage of the excised abdominal area. The closure is accomplished because there is also some upward movement of the pubic tissues as well. While each patient is going to be different, a better understanding is that the downward movement of the abdominal flap covers approximately 80% of the distance while the upward movement of the pubic tissues is approximately 20%.

While how the wound is closed over the area excised in a tummy tuck may seem irrelevant, these tissue movements will make some anatomic changes in the shape of the pubis. The upward movement of the tissues below the abdominal cut out will create differing degrees of a pubic lift. With the lifting of the pubic also comes a change in the pubic hairline as well. It will move upward to meet the incision line creating lengthening and an elevated position of the pubic hairline.

While the lifting and flattening of the pubic mound will be a benefit to most tummy tuck patients, the elevation of the pubic hairline may be a nuisance. The pubic hairline will meet the incision and there will be no separation between the two. For some women this may necessitate hair removal methods to create a few centimeters of separation between the incision and the upper pubic hairline. Laser hair removal is the most common method used and can be particularly effective if one has a dark pubic hair color.

The incision line of a tummy tuck is usually the tightest and most constricted area along the newly created waistline. Despite getting a concurrent pubic lift during a tummy tuck the elevated pubis may appear as a bulge that sticks out further than the incision line. This can be aesthetically unflattering for some women in tight clothes. This can be secondarily corrected by liposuction which can make the pubic bulge completely flat and in better profile to the incision line. When such pubic bulging is recognized before undergoing a tummy tuck, it can be simultaneously treated by pubic liposuction during the tumm y tuck once the incision is closed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Tummy Tuck with Pubic Liposuction

Monday, January 9th, 2012

Background:Tummy tuck surgery, or abdominoplasty, provides an unparalleled amount of trunk reshaping. With excessive and loose abdominal skin caused by pregnancy or large amounts of weight loss, only cutting it out can really provide the desired amount of flattening and tightening improvement.

While a tummy tuck provides a great amount of abdominal tightening, the most significant location of its effect is around the waistline, directly where the closure/scar lies. This is exactly the area which shows the maximal effect of the tissue removal. It is very similar to that of wearing a belt and tightening it. This ‘banding’ effect creates the narrowest zone of abdominal circumference which may show fuller areas either above or below it.

One of the common areas of dissatisfaction in tummy tuck surgery is persistent fullness or tissue sag that remains below the scar line. The indentation caused by the tight abdominal scar line can make the pubic area stick out further than what lies above it. Or the pubic area may continue to have a sag because it was minimally lifted from the tummy tuck.

Evaluation of the pubic area prior to tummy tuck surgery is often overlooked, much to a patient’s dissatisfaction after surgery if fullness or sagging remain. Patients should not assume that a tummy tuck will always make the pubic area as lifted or as flat as the middle part of the abdomen.

Case Study: This 59 year-old female from Indianapolis wanted to finally do something about her expanding waistline. She never had much of a stomach until the past ten years where it has grown to the point of being uncomfortable in addition to also being aesthetically unpleasing. She thought about non-surgical methods of fat reduction and liposuction but came to the realization that only a tummy tuck will provide real improvement. In evaluating her for a tummy tuck, it was noted that she had a full or thicker pubis. As part of her tummy tuck, it was decided that liposuction of it should be done at the same time.

Under general anesthesia, she underwent a full tummy tuck where the excisional pattern was above the belly button. She has rectus fascial plication from the xiphoid process down to the pubis with permanent sutures. The upper abdominal skin flap was brought down to the lower one and closed. A new belly button hole was created and the original umbilical stalk brought through and shortened. The pubic area had tumescent infiltration and was then treated by liposuction, removing 55cc of aspirate. Her flanks and side of the waistline also underwent liposuction for narrowing.

Her result showed significant abdominal improvement and a flat pubis with a narrowed waistline. Liposuction can be very helpful in improving a tummy tuck result outside the zone of tissue excision. The pubic region should be one area considered for liposuction if needed to avoid a prominent postoperative bulge below the scar line.

Case Highlights:

1) Many patients with excess and loose abdominal tissue have pubic sagging or ptosis. This area should be evaluated before tummy tuck surgery to determine if modifications should be made to include its correction.

2) While a tummy tuck will provide some pubic lift, it may not be enough if the amount of pubic sagging or fullness is significant.

3) A modification of the incisional design and/or liposuction should be added to the tummy tuck for pubic reshaping if needed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Suprapubic Mound Liposuction and Lift For Uncovering the Buried Penis

Monday, July 4th, 2011

Background:Penile length or show is an important feature of a man’s body image. While there can be debate as to how much penile length is normal or of importance, all would agree that some penile show is needed. When little to no penis is seen, this can impact a man’s self-image severely as well as inhibit its sexual capability.

There are a variety of conditions that can cause a hidden or concealed penis which merit a full urologic work-up and evaluation. The overlying soft tissues, including the suprapubic mound and the lower part of the abdomen, can either cause or magnify other medical causes of the buried penis condition. Shrinking the size of all tissues that surround the penis may help increase the amount of shaft length seen in the non-erect state.

Case Study:A 34 year-old male was seen with the desire to have greater penile exposure. Despite some significant weight loss, he was unable to still see his penis. While it became more evident when erect, it was nearly complete buried when not. This was a major source of embarrassment for him.

On examination, there was a moderate-sized suprapubic mound around the penis of which only the very tip of it could be seen. On pressing down around the mound, greater shaft length appeared. There did not appear to be any tethering or restriction of the penile skin. There was also a hood of suprapubic skin excess from the lower abdomen which pushed down onto and almost over the buried location of the penis.

The first step in the surgical treatment of his buried penis was liposuction of the suprapubic mound. Using the Smartlipo probe at 30 watts, the suprapubic mound and lower abdomen was initially treated with7,500 joules of energy. Then a 4mm cannula was used to aspirate a total of 275cc of fatty aspirate creating a visible reduction of size of the mound. Because of the size of the lower abdominal area, a suprapubic lift was done removing 8” of skin and fat vertically and 22” horizontally across the lower abdomen. This was excised down to the abdominal fascia in a wedge fashion and removed. A drain was inserted and a compressive dressing was applied. This was done as an outpatient under general anesthesia.

The drain was removed one week later. He wore lower abdominal compression for three weeks after surgery. At that time, the largest amount of swelling had gone down and the benefits of the procedure could be seen. Swelling continued to go down and a final result was reached by eight weeks after surgery. Penile show was much improved and the shape of the lower abdomen and suprapubic mound was significantly flatter. He felt he got an ‘extra’ 3 inches of visible penile length and his self-confidence skyrocketed…to quote him directly.Final results will take a full 3 months to appreciate until the suprapubic mound area again feels soft with normal skin sensation.

Case Highlights:

1) One of the contributing causes of a buried penis is a large enveloping suprapubic mound of fat and a suprapubic and lower abdominal skin overhang. Penile length can be severely shortened when buried by overlying and surrounding soft tissues.

2) Liposuction of the suprapubic area can help increase penile show by reduction of an obscuring fatty mound.

3)Suprapubic liposuction for the buried penis may be combined with excision of lower abdominal skin and fat to simultaneously create a suprapubic lift as well. Fat reduction and skin lifting combine for the best exposure of penile length.

Dr. Barry Eppley

Indianapolis, Indiana

The Pubic Lift with or without a Tummy Tuck

Thursday, October 1st, 2009

Sagging and fullness of the pubic area, also known as the Mount of Venus, is a very common problem in mature woman. This condition is often observed in patients who have been suffering abrupt weight loss, pregnancies or simply because of aging. The falling down (known in plastic surgery as ptosis) of the pubic area happens due to flabbiness and looseness of the skin in the frontal pelvic area.

Even in the face of a lack of a lot of excess skin, a woman may have fat deposits in her pubic region which causes an unsightly bulge in her clothes. This deposit may have been present since birth or acquired with weight gain. It is also a common development after a tummy tuck where the scar line and  above is quite flat and the pubic fullness bulges out from below.

An isolated pubic bulge can be eliminated by liposuction, particularly when there is not a loose skin issue. When aging or weight gain has caused the pubic and vaginal regions to descend, rejuvenation can be done by excising excess skin above the pubic hair and removing excess fat in the pubic region. The pubic liposuction and pubic lift procedure are often a part of tummy tuck procedure. Even if not done as part of a tummy tuck, it can be done as a secondary procedure using the existing tummy tuck scar.

Improvement of the pubic region through lifting and/or liposuction is often referred to as genital rejuvenation or mons pubis rejuvenation. The mons pubis is the hair-bearing area of the pubis. Both women and men can have this problem, although most men acquire it through significant amounts of weight loss.

Whenever I do an abdominoplasty in my Indianapolis plastic surgery practice, an evaluation of the appearance of the pubis is done to determine whether or not the pubic area needs to be lifted. All tummy tucks will cause a certain amount of pubic lift. But the design of the tummy tuck can be done to cause a greater amount of pubic lift if needed. In all cases, the top of the pubic hairline will reach to the scar line which will also raise the level of the hairline as well. Patients often undergo laser hair removal later to create a ‘hair-free’ buffer between the scar and the pubic hair line. A few patients have also reported that the amount of pubic lift has resulted in the clitoris becomes more exposed, allowing for improved stimulation.

When a pure pubic lift is done, a caesarian type scar just above the pubic hair is used as the approach for lifting the pubis. This scar heals well as a horizontal scar just above the pubis. It is also combined with liposuction as well. Unlike a tummy tuck, this is a fairly simple procedure that does not require a drain and can be completed in less than an hour.

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

Pubic Lifts and Liposuction for Mons Rejuvenation

Sunday, April 19th, 2009

Weight gain and loss, pregnancy, and aging  all contribute to a sagging abdominal area…and often the pubis as well. Even after a tummy tuck or abdominal panniculectomy, the pubic area can be left full and with some sag. The abdomen may be quite flat above the tummy tuck scar, but the pubis or mons region can be left bulging outward. Many patients are not aware that the pubic area can be flattened and/or lifted.

Pubic lifts or mons pubis rejuvenation is a tuck of a sagging pubic area.  The mons pubis is the hair-bearing area of the pubis. Fullness and sagging of this area affects both men and women. At the least, it can produce an unattractive bulge for women that is visible in clothes. At the worst, its overhang can obscure the female urethra and a portion of the male penis.

In my Indianapolis plastic surgery practice, whenever I do an abdominoplasty I evaluate the appearance of the pubis to determine whether or not the pubic area needs to be lifted. In some cases, the pubic area can be defatted at the time of tummy tuck closure. Or it can be liposuctioned after closure. If there is significant sag, I will extend the level of the tummy tuck incision lower into the pubic than beyond it to get a simultaneous pubic lift at the same time.

Many times, however, the bothersome appearance of a pubic bulge or sag may not be obvious until after a tummy tuck or body lift. This can be treated by Smartlipo (laser liposuction) if bulging is the issue or by an isolated public lift. For the pubic lift, this is a simple procedure that removes a strip of skin and fat and the pubic area is then lifted up so that it is closed within the tummy tuck scar. In rare cases, someone may have a pubic sag despite not having a lot of overhanging abdominal skin or not having had a tummy tuck. When a pure pubic lift is done, a caesarian type scar just above the pubic hair is used as the approach for lifting the pubis. This scar heals well as a horizontal scar just above the pubis.

Pubic rejuvenation, through either lifts or liposuction, results in a less obvious and more streamlined pubic area. It can make for a better appearance in clothes and help with urogenital health and function as well.

 Dr. Barry Eppley

Indianapolis, Indiana

Pubic Lifts (Monsplasty) in Extreme Weight Loss Women

Sunday, December 28th, 2008

One area of sagging skin in the abdominal region that is not frequently addressed is in the pubic or mons area. Although a tummy tuck or body lift removes a lot of loose abdominal skin, it can still leave excess pubic skin behind resulting in a mons sag. This is often disturbing for patients as they did not anticipate this residual problem. In some, this sagging pubic skin is significant enough that it may interfere with intimacy or the urinary stream in some female patients.  Mainly, however, it is just a cosmetic problem with a mismatched sagging pubic mound sitting below the horizontal abdominal scar from their abdominal contouring surgery.

A pubic lift (monsplasty) can be incorporated as part of a body lift or tummy tuck. I use a more inferior placement of the lower central abdominal incision when performing a body lift or tummy tuck so that the sagging pubic area (if present) gets lifted more than the surrounding areas.  This is a simple modification of the frontal abdominal excision that may avoid the need or desire for a secondary pubic procedure. It is like dropping a shallow ‘U-shaped’ extension of the planned lower abdominal incision. One of the cosmetic ‘problems’ that this modification will create, however,  is the the buffer zone between the final incision/scar and the pubic hair line is lost. The pubic hairline will be brought right up to the scar line. This can be easily remedied later by laser hair removal.

If a sagging mons area exists after a tummy tuck or an abdominal panniculectomy, it can be lifted by a fairly minor operation later. An inverted U-shaped cutout pattern is done starting at the existing lower abdominal incision. The extra loose skin is removed so that the sagging part of the pubic area is brought up to the scar. The same problem with connecting the upper part of the pubic hairline with the horizontal abdominal after will result also.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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