SPECIAL TOPIC

Pubic Contouring after Massive Weight Loss in

Men and Women: Correction of Hidden Penis,
Mons Ptosis, and Labia Majora Enlargement
Gary J. Alter, M.D.
Background: Weight gain and subsequent weight loss usually result in unsightly
Los Angeles, Calif. large fat deposition in the pubic areas along with ptosis of the fat pad and
skin. Men also complain of burying of the penis and the woman complains of
labia majora enlargement, both causing secondary sexual dysfunction, hygiene
issues, discomfort, and aesthetic concerns. Even with weight loss, most of these
deformities persist.
Methods: The hidden (buried) penis is characterized by a lack of firm attach-
ments between the Buck fascia surrounding the tunica albuginea of the cor-
pora and the dartos fascia and skin. Successful treatment requires the penile
skin and dartos fascia to be stabilized to the penile corporal bodies to make the
penis one integrated unit. The method of surgery is usually to excise and lift
excess pubic skin, eliminate the pubic fat without creating a significant pubic
concavity, and stabilize the penile skin to the corporal bodies with tacking
sutures dorsally and ventrally. If inadequate penile skin is present, scrotal flaps
or skin grafts are used to cover the penis. Treatment of the mons pubis requires
similar pubic lifting, fat excision, and pubic tacking. Labia majora reduction
requires skin and usually fat excision.
Results: Results are excellent with the use of these techniques.
Conclusions: Pubic contouring after massive weight loss in men and women
is very successful and safe if performed meticulously. Treatment improves self-
esteem along with the associated physical and aesthetic deformities.  (Plast.
Reconstr. Surg. 130: 936, 2012.)

W
eight gain and subsequent weight loss
cause significant alternations in the
appearance of the male and female geni-
talia. The weight gain usually results in unsightly
large fat deposition in the pubic areas along
with ptosis of the fat pad and skin. The male
patient also complains of burying of the penis
and the female patient complains of labia majora

From the Division of Plastic Surgery, University of Califor-
nia, Los Angeles.
Received for publication January 3, 2012; revised April 23,
2012.
Presented at the VIIth International Symposium on Plastic
Surgery, in São Paolo, Brazil, March 24 through 26, 2006;
First International Course About Aesthetic Genital Surgery
Male and Female, February 17, 2007; “Panel: Genital Re-
juvenation and Reconstruction: Fringe Procedure or New
Frontier,” American Society of Plastic Surgeons Annual
Meeting, in Baltimore, Maryland, October 31, 2007; Spe-
cial Seminar, “ Cosmetic Rehabilitation of the Post-Bariatric
Patient,” American Society for Aesthetic Plastic Surgery
Annual Meeting, in San Diego, California, May 2, 2008;
Sexual Medicine Society of North America Annual Meeting
at the American Urological Association Meeting, in Chi-
cago, Illinois, April 26, 2009; Web Symposium “Surgical
Problems in Pediatric Gynecology,” Case Western University,
in Cleveland, Ohio, September 10, 2009; Society of Geni-
tourinary Reconstructive Surgeons, General Membership
Annual Scientific Session in association with the American
Urological Association, in San Francisco, California, May
30, 2010; American Society of Plastic Surgeons/American
Society for Aesthetic Plastic Surgery Breast Surgery and Body
Contouring Symposium, in Santa Fe, New Mexico, August
27, 2011; Cutting Edge 2011: Advanced Body Sculpting
Head to Foot, 31st Aesthetic Surgery Symposium, the Ameri-
can Society of Plastic Surgeons, and the International So-
ciety of Aesthetic Plastic Surgery, in New York, New York,
December 1 through 3, 2011.
Copyright © 2012 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e318262f57d
Disclosure: The author has financial interest to
declare in relation to the content of this article. No
outside funding was received.

936 www.PRSJournal.com
Volume 130, Number 4 • Pubic Contouring after Weight Loss
enlargement, both causing secondary sexual dys-
function, hygiene issues, discomfort, and aesthetic
concerns. Even with weight loss, most of these
deformities persist.1,2
MEN
In men, the pubic fat and ptotic skin commonly
obscure all or part of the penis while standing,
or the partially visible penis may completely bury
as the patient bends or sits (Figs. 1 through 5).
The fat or ptotic skin may overlap the penis but,
more commonly, the penis buries into the pubic
skin and fat and scrotum. The terms “buried,”
“hidden,” and “concealed” penis all refer to
maladies in which the functional and visual
penile length is obscured.1,3-24 The deformity
is characterized by a lack of firm attachments
between the Buck fascia surrounding the tunica
albuginea of the corpora and the dartos fascia and
skin. Thus, the corporal bodies remain attached
to the suspensory ligament and pubic bones, and
the penile skin turns inside out and telescopes
over the glans.1,20 Chronic burying of the penis
with its associated dampness causes irritation of
the penile skin and glans penis, which can lead to
balanitis xerotica obliterans, midshaft or foreskin
phimosis, and eventual destruction of the penile
skin. On rare occasions, penile cancer can result.
The long-term effect can cause inadequate skin
to cover the penile shaft. Even with weight loss,
the buried penis remains because of the ptotic
skin, lack of dartos-to-Buck attachments, and
chronic inflammation. Many physicians are
under the mistaken belief that the hidden penis
is associated with an excess of penile shaft skin,
which may lead them to perform a circumcision,
sometimes at the level of a phimotic ring. This
can exacerbate the situation and also remove
remaining penile skin that may be necessary
to cover the shaft on surgical correction of the
condition.
WOMEN
In the female patient, the ptotic skin and fat
in the female mons pubis area usually combines
with fatty infiltration of the labia majora and
subsequent ptosis of the anterior labial commis-
sure (Figs. 6 and 7). These deformities also per-
sist despite weight loss. Sexual intercourse may
be problematic because of the bulky majora and
deeper location of the vagina. Difficulty wearing
clothes and poor hygiene can result. Chronic fun-
gal infections of this area are common.
MEN AND WOMEN
Previous attempts to correct the buried penis
in the male patient and the mons pubic descent
in the female patient have often failed because of
lack of tacking sutures of the pubic area to stabilize
the pubic skin to the rectus fascia (Figs. 5 and 6).
In the male patient, the penile skin and dartos
fascia must also be stabilized to the penile corporal
bodies to make the penis one integrated unit.1,21
EVALUATION
Men
Various factors must be evaluated to correct the
buried or hidden penis, including the following:
the amount of ptosis and skin excision needed
to elevate the penopubic junction to the pubic
symphysis, the amount of pubic and inguinal
fat, the adequacy of penile shaft skin when the
penopubic skin is elevated to the pubic symphysis,
the presence of inflammation of the penile skin
and glans penis, the presence of phimosis or
tight penile skin, the presence of a penoscrotal
web, the adequacy of attachments from the Buck
fascia to the dartos fascia at the penoscrotal
junction, the presence of a significant hydrocele,
and the necessity of excising a large abdominal
panniculus or of performing an abdominoplasty.
Most commonly, the patient after massive weight
loss will have pubic skin excess with ptosis and
a buried penis with sufficient penile skin to
cover the shaft. Severe inflammation is relatively
uncommon.
The goal of surgery is to excise and lift excess
pubic skin, eliminate the pubic fat without creating
a significant pubic concavity, and stabilize the penile
skin to the corporal bodies with tacking sutures dor-
sally and ventrally (Fig. 1). An abdominoplasty can
be performed at the same time as the pubic lift, but
these procedures are often performed separately
because of patient or surgeon preference.
Unfortunately, almost all urologists are unfa-
miliar with the pathophysiology and treatment of
the buried penis. A reconstructive urologist can
be very helpful. Consultation and operative coop-
eration between the plastic surgeon and urolo-
gist enables each surgeon to contribute his or her
diverse expertise. The urologist can assist with the
anatomy of the genitalia, a pharmacologic erec-
tion, the surgical correction of a hydrocele, and
some other aspects of the procedure. However,
the plastic surgeon should usually take the lead in
most aspects of the operation, especially the pubic
region and the skin coverage.
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 Plastic and Reconstructive Surgery • October 2012

Fig. 1.  (Above, left) The typical hidden or buried penis, which is usually associated with pubic skin ptosis and excess pubic fat. The
penis buries into the pubic fat and scrotum. (Above, right) The pubic fat is elevated off the rectus fascia between the external rings
to the pubic symphysis. The pubic fat is liposuctioned and sharply excised if necessary, leaving 1 to 2 cm of subcutaneous tissue.
The subdermal tissue of the pubic flap is sutured to the rectus fascia in rows of three sutures of no. 1 polydioxanone. The first row
starts 1 to 2 cm cephalad to the penopubic junction and is sutured to external rings. (Below, left) A Z-plasty incision is usually made
at the penoscrotal junction. Two bilateral tacking sutures are placed from the tunica albuginea just proximal to the penoscrotal
junction and lateral to the urethra to the subdermal tissue of the upper scrotum. (Below, right) The postoperative appearance with
the excess pubic skin and fat removed along with stabilization of the pubic and penoscrotal skin to the corporal bodies. (Printed
with permission copyright Lori A. Messenger, CMI, and Alter GJ. Surgical techniques: Surgery to correct hidden penis. J Sex Med.
2006;3:939–942.)

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Volume 130, Number 4 • Pubic Contouring after Weight Loss

Fig. 2.  (Left) Preoperative view of a 26-year-old man with a hidden penis after a 250-pound weight loss. (Center) The markings for skin
excision to lift the pubic escutcheon. (Right) Postoperative view, 1 week after suprapubic dermatolipectomy with pubic and peno-
scrotal tacking. The patient did not want an abdominoplasty at the time.

Fig. 3.  (Left) Preoperative view of a 25-year-old typical patient with a hidden penis after 60-pound weight loss. He has excess pubic skin
and fat. (Right) Postoperative view, 5 months after suprapubic dermatolipectomy with liposuction, pubic tacking, and penoscrotal tacking.

The patient should be evaluated and marked
standing in front of a mirror, sitting to see whether
his partially buried penis disappears, and lying
flat. While standing, the pubic skin and fat at the
penopubic junction is pushed down to the rec-
tus fascia just above the pubic symphysis. At the
same time, the penoscrotal junction is pushed in.
This gives the projected appearance of the penis
postoperatively and also allows an estimate of the
amount of pubic skin ptosis. Because the skin will
retract somewhat on pubic fat removal, one should
be careful to avoid overestimating the amount of
pubic skin to be removed. Further skin excision
is possible later in the procedure. A horizontal
crescent or similar variant excision is marked just
parallel and just below a panniculus line to make
closure easier22 (Figs. 1 and 4). If abdominoplasty
is not performed, a partial panniculectomy may
occasionally need to be performed at the same
time as the hidden penis to prevent a steep over-
hang of excess abdominal skin (Fig. 2, center).
Occasionally, a man with a buried penis will
present with no pubic skin ptosis or significant
pubic fat pad and with sufficient penile skin. He
may have had a previous abdominoplasty and
possibly pubic tacking (Fig. 5). However, the
buried penis persists because of a lack of strong
attachments of the penile skin to the Buck fascia
and tunica albuginea. Instead of a pubic lift with
an upper pubic incision, this patient should
undergo tacking of the subdermal tissue of the
penopubic junction to the tunica albuginea
through a small lower pubic incision, usually with
pubic liposuction, and penoscrotal tacking.
If phimosis (tight cicatrix), relative phimosis,
or chronic penile skin inflammation is present,
a several-week course of strong cortisone cream
such as clobetasol 0.05% can be used to loosen

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 Plastic and Reconstructive Surgery • October 2012

Fig. 4.  (Above, left) Preoperative view of a 57-year-old man with weight loss, buried penis, and phimosis. (Above, right) Appearance
after pubic tacking and release of phimosis with penile degloving. The patient was given a pharmacologic erection, which revealed
inadequate penile skin to completely cover the shaft. (Center, left) The dorsal skin was sutured to itself in the midline to cover the

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Volume 130, Number 4 • Pubic Contouring after Weight Loss
Fig. 5.  (Left) Preoperative view of a 51-year-old man who continued to have a buried penis after a 90-pound weight loss and after
an abdominoplasty 6 years earlier. (Right) Postoperative view, 6 months after penopubic tacking, pubic liposuction, and penoscrotal
tacking. The patient still has some inflammation of the glans penis.
the phimotic ring and resolve much of the inflam-
mation. If the phimosis can be loosened enough
to expose the glans penis and resolve some inflam-
mation, needed penile skin for shaft coverage may
be salvaged, possibly avoiding scrotal flaps or skin
grafts. If the patient has phimosis or if the skin
cannot be pulled back to expose the shaft, a more
accurate amount of pubic skin removal is deter-
mined during surgery. After the hidden penis sur-
gery and the chronic dampness from urine and
sweat is eliminated, much of the penile inflamma-
tion usually resolves.
Pubic or penopubic tacking sutures provide
good dorsal stabilization. However, the ventral
penoscrotal tacking sutures may not persist over
time. The tension on these sutures is increased
if there is a large scrotal hydrocele(s) pulling
down on the tacking sutures, so a significant
hydrocele(s) should be eliminated. A penoscrotal
web should also be corrected to give the patient
more usable ventral penile length.
Women
Most publications on mons pubis lift are
associated with an abdominoplasty.25-28 However,
Fig. 4.  (Continued) dorsal shaft while the penis was erect. The
skin was sutured to the coronal skin cuff. (Center, right) There
is now a ventral skin deficiency. An incision is made down the
median raphe. Lateral incisions are made in the scrotum for rota-
tion and advancement of scrotum flaps to cover the ventral shaft
of the penis. Penoscrotal tacking sutures are also placed. (Below,
left) Appearance after ventral skin closure. A drain is placed in
the scrotum. (Below, right) Postoperative view, 4 months after
suprapubic dermatolipectomy with liposuction, pubic tacking,
and scrotal flap skin coverage.
many women do not seek an abdominoplasty at
the same time because of cost, morbidity issues,
or surgeon preference. Like buried penis surgery,
the procedure outlined below can be performed
with or without an abdominoplasty.
The woman should be evaluated standing in
front of a mirror and in the lithotomy position.
Estimated skin and fat excision is performed by
elevating the anterior labial commissure to the
pubic symphysis. A panniculus may need to be
raised or partially excised. Often, only a few cen-
timeters of pubic skin may need to be excised,
because the skin will modestly contract once fat
is removed. In cases of massive horizontal skin
excess, an upper inverted wedge of skin and sub-
cutaneous tissue can be used.25 The wedge has a
superior base, with the vertex pointing toward the
anterior labial commissure, but is uncommonly
needed. If it is carried down to the anterior com-
missure, it can be very unsightly and can make
tacking sutures difficult to place. The usual skin
marking is made as a transverse crescent or vari-
ant incision, which is placed just below the pan-
niculus line or in a previous abdominoplasty scar.2
The horizontal skin excision is just long enough
to excise the excess skin and access the pubic sym-
physis. If an abdominoplasty is also performed,
the incision is placed approximately 7 to 8 cm
above the anterior labial commissure but can be
altered to make sure the commissure is placed at
the pubic symphysis.25
Elevation of the pubic skin also raises the
labia majora and decreases labial protuberance2
(Fig. 8). If reduction of the labia majora is to be
performed, a decision is made as to the amount
of labial skin and fat to be excised. Limited labial
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 Plastic and Reconstructive Surgery • October 2012

Fig. 6.  (Left) Preoperative views of a 23-year-old woman with a protruding mons fat pad. She underwent a 160-pound weight loss, an
abdominoplasty, and a medial thigh lift, which caused a short escutcheon. Her labia majora were enlarged but not hanging. (Right)
Postoperative views obtained 4 months after pubic lift and liposuction of her labia majora. (Reprinted with permission from Alter GJ.
Management of the mons pubis and labia majora in the massive weight loss patient. Aesthet Surg J. 2009;29:432–442.)

fat can be excised through the pubic incision or
removed by liposuction, but these approaches are
not as effective as precise resection through labia
majora incisions.
Labia majora reduction has been reported by
removing lateral labial tissue,29 but lateral excisions
can be unsightly. Medial excisions tend to be less
visible. The labial markings are made in the lithot-
omy position. Labial skin is excised as a crescent
incision extending from the anterior to posterior
labial commissures2 (Figs. 7 and 9). The anterior
or posterior ends may need to be extended later-
ally to prevent dog-ear formation and to prevent
meeting in the midline. The medial incision line
is usually placed in the lateral portion of the labial
sulcus at the start of the hairline. The labia majora
skin should not be overresected, which can cause
the introitus to gape on leg abduction. The width
of the excision in the mid introitus is determined
with the legs abducted in the lithotomy position.
Usually, a minimum of 2 cm of pigmented majora
skin is kept laterally to prevent gaping. Because
the size of each labium may vary, adjustments of
the width of the crescent incisions are made to
achieve symmetry. Fat removal in different parts
of the majora may vary.
Labia majora skin reduction should probably
not be performed at the same time as a pubic lift
if the patient has had a previous medial thigh
lift. The intervening skin between the thigh and
majora incisions may theoretically have inade-
quate vascularization, especially if fat is excised. If
a medial thigh lift is contemplated at a later date,
the labial skin excision should be conservative.
TECHNIQUE
Men
Suprapubic Dermatolipectomy with
Liposuction
The pubic area is initially infiltrated with
lidocaine with epinephrine.22 The upper cres-
cent incision is incised to the rectus fascia and

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Volume 130, Number 4 • Pubic Contouring after Weight Loss
Fig. 7.  A 42-year-old woman presented after a 40-pound weight loss with pubic lipodystrophy and labia majora skin and fat enlarge-
ment. (Left) Markings for bilateral crescent skin excisions. (Center) Skin and fat excision on the right side. The fat taken from the right
side is placed on top of the left labium. (Right) The patient after labia majora reduction and pubic lift with tacking.
the subcutaneous skin and fat are elevated to the
pubic symphysis. The lateral margins of elevation
are usually the external inguinal rings. The lower
incision is made and fat is excised conservatively.
The pubic and inguinal areas are then
infiltrated with the usual tumescent fluid used for
liposuction. Liposuction is then performed on
the pubic flap and inguinal regions to eliminate
the pubic fat excess.19 Liposuction has the
advantage over open resection of achieving better
contouring without significant pubic concavities,
leaving adequate fibrofatty tissue for the pubic
tacking, and shortening the surgical time and
amount of dissection. Some sharp excision may
be necessary with extremely large pubic fat pads
or fibrotic fat, but 1 to 2 cm of subcutaneous tissue
under the pubic skin flap should be kept. Inguinal
lymph nodes should not be excised. Excision of
large spermatic cord lipomatous tissue improves
the result.
If the patient has phimosis, preservation
of penile skin is essential. A ventral slit is made
through the phimotic ring to release the ring.
The incision is made just long enough to deliver
the glans penis, but it may need to extend to
1  cm from the ventral corona. A pharmacologic
erection is induced with an intracavernosal injec-
tion of 10 μg of prostaglandin E1. The amount of
penile skin required to achieve a full erection is
then determined. The pubic tacking sutures are
then placed.
The first row of three pubic tacking sutures
of no. 1 polydioxanone on a CTX needle is then
placed through the subcutaneous and subder-
mal tissue of the pubic flap starting usually 1 to
2 cm cephalad to the penopubic junction (Fig. 1,
above, right). Each suture is then placed into the
rectus fascia just cephalad to the pubic symphy-
sis between the external inguinal rings. The penis
should be erect and the sutures placed so that
there is no significant tension on the erect penis.
If there is borderline penile skin, the sutures are
placed slightly more cephalad on the pubic skin
to prevent pulling on the penis and shortening
of the erection. The sutures should cause mild
to minimal dimpling of the pubic skin. Usually,
three rows of three sutures are needed to stabilize
the pubic skin up to the incision line, but more
sutures may be needed.
Once the tacking sutures are placed, any
further excess pubic skin can be excised. If an
abdominoplasty is not performed, occasionally
liposuction of the superior incision or a conser-
vative abdominal panniculectomy needs to be
performed to prevent a sudden drop-off from
the abdominal side of the incision. A no. 10 flat
closed suction drain is placed from the pubic sym-
physis, along the right side of the wound, placed
under the length of the incision, and brought
out through a stab incision in the left pubic area.
The subcutaneous tissue and skin are closed.
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 Plastic and Reconstructive Surgery • October 2012

Fig. 8.  (Left) Fat excision is illustrated. It is tapered to the pubic symphysis. The thickness cephalad matches the abdominal side.
(Right) Three rows of tacking sutures are usually placed. Care should be taken to prevent significant dimpling insofar as possible. The
labia majora and anterior labial commissure are pulled up. A closed suction drain is placed from the pubic symphysis around the right
side and then under the deep closure. (Courtesy of William Winn, and reprinted with permission from Alter GJ. Management of the
mons pubis and labia majora in the massive weight loss patient. Aesthet Surg J. 2009;29:432–442.)

Fig. 9.  (Left) Illustration of the crescent of skin 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. (Right) Illustration of the closure, which is performed in lay-
ers. A subcuticular closure is performed on the skin, and a deep drain is placed only if significant fat is removed. Technique of labia
majora reduction. (Courtesy of William Winn, and reprinted with permission from Alter GJ. Management of the mons pubis and labia
majora in the massive weight loss patient. Aesthet Surg J. 2009;29:432–442.)

Penile Skin Coverage If there is an absence of all or most of the

If there is adequate skin in a patient with phi-
mosis or a tight cicatrix, the circumcision can be
completed, leaving a 1- to 1.5-cm collar of subcoro-
nal mucosal skin. If the patient has a skin shortage
from chronic inflammation, a circumcision inci-
sion is made, the chronic indurated or phimotic
inflamed skin is excised conservatively, and the
penis is degloved (Fig. 4). Possibly, there is enough
remaining penile skin to cover the dorsal and ven-
tral erect penis using various transposition flaps.
penile skin, a thick split-thickness skin graft is
used to cover the penis.20,23,24 The proximal pubic
and scrotal skin is tacked to the Buck fascia and
attached to the skin graft. The skin graft seam
is placed ventral. However, a skin graft is not
ideal because of concerns regarding unnatural
color and texture of the graft, hypertrophic and
unsightly scarring, possible failure to achieve a
uniform graft survival resulting in a cosmetic or
functional deformity, possible chronic penile

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Volume 130, Number 4 • Pubic Contouring after Weight Loss
lymphedema, and penile shortening or curvature
resulting from graft contraction.
A moderate penile skin deficiency can often
be best resolved with ventral scrotal rotation-trans-
position flaps (Fig. 4). With a pharmacologic erec-
tion, the remaining penile skin is transposed to the
dorsum from each side to cover the dorsal shaft to
the subcoronal sulcus, resulting in a distal dorsal
incision line. The remaining ventral penile skin is
incised in the midline along the median raphe as
far posterior on the scrotum as necessary. A sig-
nificant hydrocele is then corrected. The penile
skin is then sutured bilaterally from the dorsal
midline to ventral along the subcoronal sulcus
to cover as much of the penis as possible, which
causes the penis to temporarily bend ventral. This
leaves a ventral deficit of penile skin, which usu-
ally extends from the ventral glans to the scrotum.
An estimate is made of the amount of scrotal skin
that needs to be transposed to the ventral penis,
and bilateral lateral incisions are made into the
scrotum to allow rotation and advancement of the
scrotal skin onto the penile shaft. A disadvantage
of scrotal skin is hair growth on the shaft, but elec-
trolysis can be performed at a later time. Peno-
scrotal tacking is then performed to give better
definition of the penoscrotal junction.
Penoscrotal Tacking
Placement of ventral tacking sutures is
necessary to prevent the penis from burying into
the scrotum, which can occur despite suprapubic
tacking1 (Fig. 1, below, left). In addition, many
of these patients have penoscrotal webbing. If
the patient has sufficient penile skin and no
Fig. 10.  Technique of penopubic tacking. (Left) A 3- to 4-cm transverse incision is made approximately 1 to 2 cm cephalad to the
penopubic junction. The penis was given a pharmacologic erection. Two sutures are placed in the tunica albuginea at the penopubic
junction at both the 10-o’clock and 2-o’clock locations. The ink marks are the points at the penopubic junction where the sutures will
be placed. (Right) The sutures are tied from the tunica to the subdermal tissue at the penopubic junction. The penopubic junction is
well defined.
significant penoscrotal web, a midline Z-plasty or
double Z-plasty incision is made at or just inferior
to the penoscrotal junction.30 If the patient has
a large penoscrotal web, the amount of web to
be excised is determined when the patient has a
pharmacologic erection. The web is excised as an
elliptical excision along the medial raphe of the
penis and scrotum.31
Dissection is then made through the dar-
tos fascia to the corpora spongosa and tunica
albuginea.1,22 Two ventral tacking sutures of
2-0 polydioxanone or Ethibond (Ethicon, Inc.,
Somerville, N.J.) on an SH needle are placed
transversely from the tunica albuginea on each
side of the urethra just proximal to the penoscro-
tal junction to the subdermal upper scrotal tissue
on each side. The penis should be erect to prevent
overtightening of the penile skin. It is important
to have some dimpling of the scrotum to ensure
that the sutures will hold. The dartos and scrotum
are then closed in layers, and the skin is closed
with a 1- to 2-cm Z-plasty at the penoscrotal junc-
tion to prevent scar retraction.
Penopubic Tacking
If the patient has no significant skin ptosis or
large pubic fat, penopubic tacking is performed
instead of suprapubic dermatolipectomy31-33 (Figs. 5
and 10). The patient is given a pharmacologic erec-
tion using prostaglandin. The penopubic junction
is marked at the 2- and 10-o’clock positions and esti-
mated at the point on the dorsal penis that matches
it without causing overtightening of the penile skin.
A 3- to 4-cm transverse incision is made 1 to 2 cm
cephalad to the penopubic junction. Dissection
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 Plastic and Reconstructive Surgery • October 2012
proceeds to the corporal bodies and the Buck fascia.
The dorsal neurovascular structures in the Buck fas-
cia are seen. At the level of the penopubic junction,
blunt dissection only is very carefully performed
parallel and usually lateral to the nerves traveling
in the Buck fascia at the 2- and 10-o’clock positions.
Enough tunica albuginea is visualized to allow
placement of two parallel sutures of 2-0 Ethibond or
polydioxanone on an SH needle at each location.
The two sutures on each side are then placed into
the subdermal tissue at the penopubic junction at
both the 2- and 10-o’clock locations. Extreme care is
taken to prevent nerve injury or entrapment when
placing or tying the sutures.
Liposuction can then be performed in the
pubic and inguinal regions.19 A small closed suc-
tion drain is placed in the penopubic area and
brought out through a small stab incision. The
wound is closed, revealing a well-defined penopu-
bic junction. Ventral penoscrotal tacking sutures
are then usually also placed (see above).
Women
Mons Pubis Lift
The patient is placed in the lithotomy position.
The same technique for male pubic lift and tacking
is used on the mons lift, because this procedure was
derived from the buried penis surgery2 (Fig. 8). Plac-
ing the anterior labial commissure to the level of the
pubic symphysis is the guide to the amount of eleva-
tion. Mons elevation and fat excision will not injure
the clitoris if dissection stays superior to the pubic
symphysis. If labia majora skin excision is not to be
performed at the same time, liposuction or excision
of majora fat can be performed from above.
Labia Majora Reduction
The labia majora reduction is performed after
the pubic lift. The area is infiltrated with lidocaine
with epinephrine. The crescent skin excisions are
performed and checked for symmetry2 (Figs. 7
and  9). If fat needs to be excised, the superficial
Colles fascia is opened, and appropriate fat is
removed. The clitoris can be palpated. No injury to
the clitoris will occur if the resection is performed
lateral to the pubic symphysis and clitoral hood and
superficial to the ischium. Enough fat should be left
to maintain normal labial contour and cushioning.
Meticulous hemostasis is imperative. If large volume
fat is removed from each side, bilateral closed
suction drains are placed and brought through
stab incisions in the lateral pubic areas. The Colles
fascia is closed with 4-0 Monocryl (Ethicon). The
superficial subcutaneous tissue is closed in a running
layer of 4-0 or 5-0 Monocryl, which also catches the
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Colles fascia to eliminate dead space. The skin is
closed with a subcuticular Monocryl suture.
COMPLICATIONS
Men
Some tacking sutures may not ideally hold over
time, which may cause a less-than-ideal result. Pubic
sutures can be replaced, but secondary penopubic
tacking sutures are often more effective. It is not
uncommon for the penoscrotal tacking sutures to
not maintain holding the subcutaneous scrotal sub-
dermal tissue, but the results are always better than
before surgery and can be repeated. Edema of the
penis and dimpling of the pubic incision can persist
for several months. Significant blood loss has not
occurred. The coverage of the penis with scrotal
flaps may need a secondary revision at a later date
for better functional and aesthetic appearance.
Achieving good functional length and aesthetics
with penile skin grafts can be challenging.21,23
Women
Simultaneous aggressive pubic fat and labia
majora fat removal can result in significant labia
minora and clitoral hood edema that may per-
sist for several months. If performing a pubic lift
with labia majora at the same time, adequate fat
and subcutaneous tissue should be kept to main-
tain lymphatics. The anterior labial commissure
should not be overly raised. Infection and hema-
toma are uncommon.
CONCLUSIONS
The most common buried penis operation
includes the pubic lift and pubic tacking along
with penoscrotal tacking. Penopubic tacking is
relatively uncommon unless the patient failed a
previous pubic lift. Coverage of the penis with
scrotal flaps or skin grafts is relatively uncommon
because most patients have adequate penile skin.
However, the surgeon must be prepared to per-
form these procedures if the patient has chronic
skin inflammation and a tight cicatrix or phimosis.
In the female patient, liposuction of the mons
pubis may be all that is necessary, but skin exci-
sion and tacking is necessary if the patient has
significant pubic mons ptosis. The labia majora
reduction is usually performed only if the patient
complains of excessive size.
Patients with severe weight loss often have
severe self-esteem issues relating to their genita-
lia in addition to genital discomfort and chronic
Volume 130, Number 4 • Pubic Contouring after Weight Loss

irritation. The surgery to correct these genital
deformities can be very challenging but is very
successful, leading to markedly improved self-
image and quality of life along with a return of
sexual activity and elimination of discomfort.
Gary J. Alter, M.D.
416 North Bedford Drive, Suite 400
Beverly Hills, Calif. 90210
altermd@altermd.com
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