The vulva includes the mons pubis, labia majora, labia minora, vaginal vestibule, and bulb of the vestibule (FIG 1).

The mons pubis is superficial to the pubic bone.

The labia majora are paired cutaneous folds that extend posteriorly from the mons pubis and contain variable fatty tissue. The labia majora converge with the labia minora at the posterior commissure or fourchette.

The labia minora are cutaneous folds located medial to the base of the labia majora. The visible rounded portion of the clitoris is located near the anterior junction of the labia minora, above the openings of the urethra and the vagina.

The vasculature of the female external genitalia includes the anterior labial arteries, branches of the external pudendal arteries, the posterior labial arteries, and branches of the internal pudendal artery. The labial veins drain to the pudendal and femoral veins.

The vulva is innervated anteriorly by the anterior labial nerves and branches of the ilioinguinal nerve and by the genital nerve, which extends from the genitofemoral nerve. The vulva is innervated posteriorly by posterior pudendal branches.

Mons pubis and labia majora morphology are impacted by aging, pregnancy, and weight changes that in turn impact fat composition, dimensions, and ptosis.

The youthful mons pubis is narrow, with good skin tone, and has a moderate amount of fat in the subcutaneous plane to provide padding against the bony symphysis.

With age, pregnancy, or weight fluctuations, the mons pubis can appear wide and protuberant with poor skin tone (FIG 2). The labia majora may be deflated, and there is ptosis of the external genitalia with increasing distance from the abdomen inferiorly.

With obesity, the mons becomes increasingly protuberant with a relatively high composition of fat, which often lends itself to surgical correction with liposuction alone. Difficulty with sexual intercourse and maintenance of hygiene as well as discomfort when wearing pants and swimsuits may result. This situation can also impact self-esteem.

Techniques to correct the protuberant mons and pubic descent with excess skin address these issues with pubic lifting, fat excision and liposuction, and/or elevation and suspension of the fatty layers to the rectus abdominis fascia.

The surgical consultation should begin with discussion of patient concerns and desired outcomes. Discomfort or dissatisfaction with sexual intercourse, bladder control, problems with exercise or wearing certain clothing, and hygienic concerns could result in a patient initiating a surgical consultation.

Medical history should be explored for any medical conditions and history of weight gain or loss and pregnancies, as well as surgical history.

Physical examination is comprehensive and involves the abdomen as well as the external genitalia.

A surgical plan is then developed to address patient desires and goals, as well as physical findings, adjusting treatment to health and safety concerns.

This is not applicable to monsplasty management.