Modified Lipoabdominoplasty: Updating Concepts—Our Postbariatric Experience

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We read with great interest the article entitled “Modified Lipoabdominoplasty: Updating Concepts” by Ribeiro et al.1 We would like to congratulate the authors for their work and their improvements that confirm our thoughts on monsplasty following abdominoplasty. In our daily practice, we systematically perform mons fixation without liposuction following abdominoplasty or body lift.2,3 Contrary to the authors’ experience, the majority of our patients achieved massive weight loss by means of bariatric surgery. The problem with this specific population is the poor skin tone, the flaccidity, and the great laxity of skin that may compromise the long-term result by a moderate degree of ptosis recurrence. We would like to report our experience based on 26 monsplasties performed during the last half of 2015 and discuss two points.
First, in this specific population, the problem is the opposite of that in patients treated by the authors. The goal of monsplasty is to prevent recurrent ptosis despite higher scar positioning, whereas the authors performed pubic fixation to prevent flap ascent. The aim of this operative step was to bring tension to the pubic region, ascending and flattening it.4 Briefly, preoperative markings were with an arc circle placed at 7 cm from the vulvar fork5 and distant from 5 cm on either side of the midline. During the procedure, monsplasty was performed with three separate stitches using nonabsorbable suture. The first stitch was positioned medially between the Camper fascia and rectus abdominis aponeurosis, and the two lateral stitches were positioned close to the anterior superior iliac spine to apply oblique lateral traction. In our case series, the mean patient age was 44.0 ± 10.1 years; the mean American Society of Anesthesiologists physical status was 1.7 ± 0.5; and patients had a massive weight loss with a pre–massive weight loss body mass index of 49.1 ± 8.3 kg/m2 and a mean preoperative body mass index of 28.5 ± 4.3 kg/m2 (range, 21.1 to 41.4 kg/m2). No complications occurred. Patients reported aesthetic but also functional improvement.
Second, we did not perform a mons liposuction, unlike the authors. Before April of 2015, we used the same strategy, with initial liposuction under the pubic area using a 4-mm cannula. Long-term aesthetic results were similar, but the postoperative course was marked by complications: major edema up to 3 months, bruising, and loss of sensitivity. That is why we stop the use of liposuction with satisfactory results and better patient comfort. Indeed, our technique allows us to flatten the mons, like liposuction without suspension of the pubis (Figs. 1 and 2).
In conclusion, we absolutely agree with the authors regarding the possibility offered to surgeons who perform pubic fixation following a body lift or abdominoplasty. In our opinion, the goal with the aesthetic patient is opposite that of the postbariatric patient. Monsplasty is an easy, fast, and safe step that must be performed at the same operative time as abdominoplasty or body lift.
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