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Fat Grafting to the Mons Pubis (Volume Restoration)

Autologous fat grafting to the mons pubis is the volume-restoration counterpart to monsplasty. It is used to restore contour to the pubic mound when volume is depleted by aging, weight loss, constitutional thinness or prior surgery. Vulvovaginal fat-grafting series report volume restoration and histologic evidence of neocollagenesis, neoangiogenesis and estrogen-receptor upregulation, which the authors attribute to adipose-derived stem cells (ADSCs) in the graft.[1][2] For positioning versus other female cosmetic options see Cosmetic Genital Surgery — Female.

Society positioning. The ACOG 2020 Committee Opinion No. 795 states that the safety and effectiveness of procedures to alter sexual appearance or function, other than those done for clinical indications, have not been established.[3] FIGO's 2025 ethics statement considers purely aesthetic genital surgery in women without structural or functional abnormalities ethically inappropriate for obstetrician-gynecologists to recommend, perform, or refer; it distinguishes reconstruction for congenital anomalies or injury.[18] Assess for body dysmorphic disorder (BDD) when indicated, and refer patients with suspected psychological concerns for evaluation before considering surgery.[3] Evidence for fat grafting to the mons is predominantly Level IV, and no universal protocol exists.

Indications​

Fat grafting to the mons addresses volume deficiency rather than excess. The indications below are drawn from vulvovaginal and genital-beautification series, and none of the cited series reports mons-only outcomes[4][2][7][1]:

  • Age-related volume loss. Atrophy of subcutaneous fat in the mons with aging produces a deflated, skeletonized appearance.
  • Post–massive weight loss. A concave or deflated mons can follow bariatric surgery or significant weight loss. The pubic-contouring literature stresses eliminating pubic fat without creating a significant concavity, which is the setting in which over-resection produces a volume-deficient mons.[5][6]
  • Related GSM treatment, not a mons indication. Menkes 2021 treated 50 women with microfat in the labia majora and nanofat in the vagina.[2]
  • Post-surgical contour deformity. Concavities or irregularities after prior abdominoplasty, panniculectomy or aggressive liposuction are a practical indication. No cited series reports outcomes for this indication.
  • Related post-vaginoplasty reconstruction, not a mons indication. Patel 2021 reports labia-majora fat grafting in 6 of 182 patients after penile-inversion vaginoplasty, most often for flattened labia majora (5/6).[7]
  • Aesthetic enhancement. Fat injection into the mons pubis and labia majora is used for pubic contour and fullness as part of genital beautification.[4][8]
  • Scar tissue and pain. Fat grafting has been used for scar release and scar pain in a mixed face and body series, and in vulvovaginal tissue after grafting the pain-associated marker PGP 9.5 was lower on histology.[1][9]

Anatomy and volume considerations​

Seleem 2023 (Aesthet Surg J, 214 women in two BMI groups) reported calculated volumes and weights of the mons pubis and labia majora[10]:

ParameterNormal BMIOverweight / obese
Mons pubis volume~ 200 mL~ 300 mL
Mons pubis weight~ 180 g~ 270 g
Labium majus volume~ 30 mL~ 40 mL
Labium majus weight~ 27 g~ 36 g

Mons height is approximately three-quarters of its length and half its width. The authors propose these dimensions and ratios as a basis for aesthetic planning.[10]

Surgical technique​

Harvest​

  • Donor sites. The abdomen, thighs and flanks are used.[9] Reviews found no significant difference in graft outcome or cell viability between donor sites.[11][12]
  • Tumescent infiltration before aspiration.[13]
  • Syringe aspiration (Toomey) or low-pressure power-assisted liposuction with 3.0–3.7 mm cannulas.[9][11]

Processing​

  • Centrifugation is a common method. Strong 2015 found more favorable clinical outcomes with centrifugation than sedimentation, although animal experiments found no difference; Sinno 2016 concluded that washing versus centrifugation played little role in graft survival.[11][12] A 2023 systematic review of 24 studies (2,413 patients) favored washing/filtration for long-term outcomes across studied sites, but found no significant difference in breast volume retention and reported no mons-specific comparison.[20]
  • Filtration and sedimentation are alternatives.
  • In Menkes 2021 (n = 50, GSM), structural microfat was grafted into the labia majora for volume and mechanically emulsified nanofat was placed in the vagina as a proposed trophic treatment.[2]

Injection​

  • Small-caliber blunt cannulas (0.9 mm was used for the face in one series) through stab incisions.[9][14]
  • Micro-autologous fat transplantation (MAFT) in Lai 2023 delivered small parcels (1/120 mL each) to the vaginal submucosa with a MAFT-GUN.[1]
  • Subcutaneous plane in multiple passes; small filaments deposited on each cannula withdrawal.[13][14]
  • Slower injection speed was associated with higher retention in the studies reviewed.[11]
  • In Lai 2023, the mean volume was 20.8 mL in the combined vulva/mons region among 14 external graft recipients and 21.9 mL in the vagina among all 20 patients; no mons-only mean was reported. Graft volume is titrated to the individual deficit.[1]

Adjunctive strategies​

  • ADSC-assisted fat grafting had the highest graft-survival ranking (SUCRA 82.17%) among simple, PRP-assisted, SVF-assisted and ADSC-assisted grafting in the Dong 2024 network meta-analysis of 31 trials (1,656 patients, all body sites).[15] ADSC enrichment is not part of routine practice.
  • Combined with fractional CO₂ laser for vulvovaginal rejuvenation has been described as part of a combined regimen (Toplu 2021).[4]

Mechanism of action​

Two mechanisms are proposed[1][11][13]:

  1. Volumetric restoration. Surviving adipocytes may provide lasting contour and fullness, but long-term volume retention in the mons has not been quantified.
  2. Regenerative or trophic effects. ADSCs within the graft are proposed to promote neocollagenesis, neoangiogenesis and estrogen-receptor upregulation in the recipient tissue. In Lai 2023, vaginal-wall histology was obtained 3 months after grafting from one additional patient outside the 20-patient outcomes cohort. Grafted tissue showed greater collagen deposition, vascularity and estrogen-receptor staining, and lower protein gene product 9.5 than adjacent nongrafted tissue.[1]

Outcomes in mixed vulvovaginal series​

EndpointResultReference
Author-reported sexual-function scoreLai reports 43.8 to 68.6 at 6 months (p < 0.001; n = 20, mixed vulvovaginal treatment). The scoring method is unclear, and these values cannot be interpreted as the conventional 2–36 FSFI total.[17]Lai 2023[1]
VHI (vaginal health)Significantly increased at 1 and 3 months (p < 0.0001; n = 50, GSM)Menkes 2021[2]
FSD (sexual distress)Significant improvement; data for 80% of patients normalized at 6 months on both scalesMenkes 2021[2]
FGSIS (genital self-image)17.7 ± 1.6 preoperatively, 20.9 ± 1.4 at 6 months (p < 0.001 vs baseline), and 22.2 ± 1.8 at 12 months (p = 0.013 vs 6 months; n = 97, labia majora augmentation and vaginal tightening)Cihantimur 2021 (360)[8]
Patient satisfaction after combined genital proceduresAt 1 year, the authors reported appearance satisfaction in 33/37 and functional satisfaction in 30/37; their printed percentages conflict with these counts; their printed percentages conflict with these counts.Toplu 2021[4]
GSM outcomes at 18 monthsThe authors described results as stable at 18 months after combined labial microfat and vaginal nanofat; VHI and Female Sexual Distress were followed, but graft-volume retention was not measured.Menkes 2021[2]

Fat-graft retention​

  • One technique review reported retention of 20–120% of injected volume, stabilizing at 60–90 days.[13]
  • Higher retention was observed in less mobile areas.[11]
  • The mons pubis is relatively stable and well-vascularized, favorable for graft survival in principle, although site-specific retention data for the mons are limited.
  • In a face and body series (127 procedures, mainly face and breast), 16% of patients needed at least one additional grafting procedure. No mons-specific touch-up rate is available.[9]

Complications​

ACOG advises counseling patients considering elective female genital cosmetic surgery about pain, bleeding, infection, scarring, adhesions, altered sensation, dyspareunia and possible reoperation.[3]

  • GRAFT recorded 7,052 procedures (94% in women), but complication rates were calculated from the 4,390 (62%) with at least one documented follow-up. Among followed procedures, rates were 2.86% for "other" areas, 1.94% for the face, 7.29% for the breast and 4.19% for the buttocks. The mons was not reported separately.[16]
  • Common minor complications. Ecchymosis and edema at donor and recipient sites are the most common and are self-limited. Transient tenderness in the pubic area and erythema at the graft site also occur.[8][9]
  • Less common and serious complications. In GRAFT, facial grafting had palpable mass (0.54%) and infection (0.54%) as the most common complications.[16] Oil cyst, asymmetry and under- or over-correction also occur. Fat necrosis and fat sclerosis were the most prevalent complications in the network meta-analysis.[16][15] Severe pulmonary fat embolism has been reported after combined vaginal and breast fat grafting; the authors presumed it resulted from direct injection of fat into vessels around the vagina.[19]
  • In the two small genital series cited, no infection, lipoma or granuloma was noted (Cihantimur 2021, n = 97) and no major side effects were observed (Menkes 2021, n = 50).[8][2] Lai 2023 observed mild palpable nodulation in 1/20 women undergoing vaginal fat grafting; 14 also received labia majora grafting, including the affected woman, who also underwent labiaplasty.[1]

Fat-graft survival optimization​

FactorRecommendationReference
Donor siteNo significant difference between sitesStrong 2015; Sinno 2016[11][12]
Harvest techniqueNo significant difference between harvest techniques when tumescent solution is used; low-shear devices maintain fat structural integrityStrong 2015; Sinno 2016[11][12]
ProcessingCentrifugation gave more favorable clinical outcomes than sedimentation; wash or centrifuge decision plays little role in another reviewStrong 2015; Sinno 2016[11][12]
Injection speedSlower injection is associated with higher retentionStrong 2015[11]
Injection techniqueMulti-layer, multi-tunnel, small aliquotsMAFT (Lai 2023); Locke 2008[1][14]
Recipient mobilityLess mobile areas retain more fatStrong 2015[11]
TimingInject soon after harvestSinno 2016[12]
AdjunctsADSC-assisted grafting ranked highest for survival (SUCRA 82%)Dong 2024 NMA[15]

Fat grafting vs excisional monsplasty​

FeatureFat grafting to monsExcisional monsplasty
GoalVolume restoration / augmentationVolume reduction / lift
Typical patientVolume-depleted, atrophic mons (postmenopausal, post-bariatric over-correction)Excess fat / skin, ptotic mons (post-bariatric, obesity)
TechniqueAutologous fat injectionSkin / fat excision ± liposuction ± fascial suspension
InvasivenessMinimally invasiveModerately invasive
AnesthesiaLocal ± sedation, or generalUsually general
Recovery1–2 weeks2–4 weeks
Repeat proceduresTouch-up sometimes needed (16% of a face and body fat-grafting cohort; mons-specific rate unavailable)[9]Long-term repeat-procedure rate not established

The two procedures may be combined in the same patient at different times, for example excisional monsplasty followed by fat grafting to correct contour irregularities.

Limitations​

  • ACOG 2020: the safety and effectiveness of procedures to alter sexual appearance or function have not been established.[3]
  • No universal protocol for mons-specific fat grafting; volumetric retention measurements are rarely reported for the mons.
  • No randomized trials compare fat-grafting strategies in the mons.
  • Most evidence is Level IV retrospective single-center.
  • Patients should be counseled about the unpredictability of fat-graft survival and the possible need for repeat sessions.

Postoperative management​

  • Activity restriction. As a practical postoperative regimen, avoid intercourse and strenuous exercise for at least 2 weeks after vaginal fat grafting and protect the donor site.[1] Lai 2023 advised at least 2 weeks without intercourse or strenuous exercise after vaginal fat grafting; 14/20 patients also received external grafting.[1]
  • Pressure considerations. Compression at the donor site; avoid pressure on the recipient site so as not to compress the graft.
  • Wound care. Ice 48–72 h; loose-fitting clothing.
  • Follow-up. 1 week (donor and recipient), 6 weeks, 6 months, 12 months, with FSFI / FGSIS / VHI / FSD as relevant to indication.
  • Counseling on durability and touch-ups. Graft survival is unpredictable, and repeat sessions may be needed.

Key takeaways​

  • Fat grafting to the mons is minimally invasive. Small retrospective genital series report volume restoration and improvements in sexual function and genital self-image, and none reports mons-only outcomes.[1][2][4]
  • In a 37-patient combined-procedure series, the authors reported appearance satisfaction in 33 and functional satisfaction in 30 at 1 year.[4]
  • Site-specific retention data for the mons are limited, and counseling includes the possibility of a repeat session.
  • The evidence is predominantly Level IV, and no universal protocol for fat grafting has been established.[11][15]
  • Slow injection of small aliquots in multiple layers is the technique described; ADSC enrichment ranked highest for survival in the network meta-analysis but is not routine.[1][15]

See Also​

References​

1. Lai YW, Wu SH, Chou PR, et al. Autologous fat grafting in female genital area improves sexual function by increasing collagenesis, angiogenesis, and estrogen receptors. Aesthet Surg J. 2023;43(8):872–884. doi:10.1093/asj/sjad040

2. Menkes S, SidAhmed-Mezi M, Meningaud JP, et al. Microfat and nanofat grafting in genital rejuvenation. Aesthet Surg J. 2021;41(9):1060–1067. doi:10.1093/asj/sjaa118

3. Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. Elective female genital cosmetic surgery: ACOG Committee Opinion No. 795. Obstet Gynecol. 2020;135(1):e36–e42. doi:10.1097/AOG.0000000000003616

4. Toplu G, Altinel D. Genital beautification and rejuvenation with combined use of surgical and non-surgical methods. Aesthet Plast Surg. 2021;45(2):758–768. doi:10.1007/s00266-020-01980-z

5. Alter GJ. Pubic contouring after massive weight loss in men and women: correction of hidden penis, mons ptosis, and labia majora enlargement. Plast Reconstr Surg. 2012;130(4):936–947. doi:10.1097/PRS.0b013e318262f57d

6. Alter GJ. Management of the mons pubis and labia majora in the massive weight loss patient. Aesthet Surg J. 2009;29(5):432–442. doi:10.1016/j.asj.2009.08.015

7. Patel V, Morrison SD, Gujural D, Satterwhite T. Labial fat grafting after penile inversion vaginoplasty. Aesthet Surg J. 2021;41(3):NP55–NP64. doi:10.1093/asj/sjaa431

8. Cihantimur B, Aglamis O, Ozsular Y. 360 genital fat transfer. Aesthet Plast Surg. 2021;45(6):2996–3002. doi:10.1007/s00266-021-02488-w

9. Le JM, Bosworth JW, Honeywell B, Ananthasekar S, Collawn SS. Adipose grafting for volume and scar release. Ann Plast Surg. 2021;86(6S Suppl 5):S487–S490. doi:10.1097/SAP.0000000000002873

10. Seleem M, Osman OM, Kashmar SG, Lotfy R. Dimensions, ratios, volumes, and weights of the fatty parts of the vulva (mons pubis and labia majora). Aesthet Surg J. 2023;43(9):1002–1012. doi:10.1093/asj/sjad106

11. Strong AL, Cederna PS, Rubin JP, Coleman SR, Levi B. The current state of fat grafting: a review of harvesting, processing, and injection techniques. Plast Reconstr Surg. 2015;136(4):897–912. doi:10.1097/PRS.0000000000001590

12. Sinno S, Wilson S, Brownstone N, Levine SM. Current thoughts on fat grafting: using the evidence to determine fact or fiction. Plast Reconstr Surg. 2016;137(3):818–824. doi:10.1097/01.prs.0000479966.52477.8b

13. Fulton JE, Parastouk N. Fat grafting. Dermatol Clin. 2001;19(3):523–530, ix. doi:10.1016/s0733-8635(05)70292-8

14. Locke MB, de Chalain TM. Current practice in autologous fat transplantation: suggested clinical guidelines based on a review of recent literature. Ann Plast Surg. 2008;60(1):98–102. doi:10.1097/SAP.0b013e318038f74c

15. Dong Y, Huang Y, Hou T, Li P. Effectiveness and safety of different methods of assisted fat grafting: a network meta-analysis. Aesthet Plast Surg. 2024;48(13):2484–2499. doi:10.1007/s00266-024-04060-8

16. Kaur S, Rubin JP, Gusenoff J, et al. The General Registry of Autologous Fat Transfer: concept, design, and analysis of fat grafting complications. Plast Reconstr Surg. 2022;149(6):1118e–1129e. doi:10.1097/PRS.0000000000009162

17. Rosen R, Brown C, Heiman J, et al. "The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function." J Sex Marital Ther. 2000;26(2):191–208. doi:10.1080/009262300278597

18. Capito L, Antsaklis A, Gupte S, FIGO Committee on Ethical Aspects of Human Reproduction and Women's Health. "FIGO statement: Cosmetic genital surgery." Int J Gynaecol Obstet. 2025;170(1):11–14. doi:10.1002/ijgo.70203

19. Wang C, Wang X, Huang J, Yu N, Long X. "Severe fat embolism after autologous fat grafting in vaginal tightening and breast augmentation surgery." J Int Med Res. 2020;48(8):300060520949109. doi:10.1177/0300060520949109

20. Langridge BJ, Jasionowska S, Khan H, et al. "Achieving optimal clinical outcomes in autologous fat grafting: A systematic review of processing techniques." J Plast Reconstr Aesthet Surg. 2023;81:9–25. doi:10.1016/j.bjps.2023.01.003