What Is a Pfannenstiel Incision and How Does It Heal?

A Pfannenstiel incision is a low, horizontal cut made just above the pubic bone, and it is by far the most common way surgeons open the abdomen for cesarean deliveries, hysterectomies, and a growing list of other procedures. First described in 1900 as a transverse approach for gynecological surgery, it became the standard partly because it follows the natural tension lines of the skin, heals into a scar that sits below most underwear and swimsuit lines, and carries a dramatically lower risk of hernia than vertical alternatives. Understanding what the incision involves, how it compares to other options, and what to expect during recovery can help you have a more informed conversation with your surgeon before and after the procedure.

What the Incision Looks Like and How It Is Made

The skin is cut horizontally roughly four centimeters above the top edge of the pubic bone, typically spanning about 10 to 15 centimeters depending on the procedure and the patient’s body. The cut goes through the subcutaneous fat until it reaches the tough fibrous sheet that overlies the abdominal muscles, called the rectus sheath. That sheath is opened transversely as well, and the surgeon then separates its layers to the left and right, following the natural fiber directions of the muscle coverings underneath. The rectus muscles themselves are not cut; instead, the sheath is peeled away from the muscles above and below, creating a window large enough to reach the pelvic organs. If a band of tissue tethers muscle to sheath partway through this dissection, the surgeon carefully cuts it free without damaging either structure.¹

This muscle-sparing design is the single biggest reason the Pfannenstiel incision heals the way it does. Because the rectus muscles stay intact and the fascial layers are split along their grain, the structural integrity of the abdominal wall is largely preserved. That matters for everything from hernia risk to how quickly you can move around after surgery.

The Hernia Advantage Over Vertical Incisions

Incisional hernia, where abdominal contents push through a weakness at the old surgical site, is one of the most common long-term complications of any open abdominal surgery. The Pfannenstiel incision’s track record here is striking. A 2025 systematic review and meta-analysis found that midline vertical incisions had a pooled hernia rate of nearly 19%, while transverse incisions came in around 7%. The Pfannenstiel incision specifically fell even lower, in the range of about 2 to 9%.² Older data is even more dramatic: two studies comparing vertical midline and Pfannenstiel incisions directly reported hernia rates of roughly 17 and 16% for the vertical approach versus 0% for the Pfannenstiel.³

The difference is large enough that in colorectal surgery, where midline incisions have traditionally dominated, researchers found midline approaches carried more than eleven times the odds of hernia formation compared with transverse techniques.⁴ This is a genuine structural advantage, not just a statistical quirk. Cutting across the grain of multiple fascial layers rather than splitting a single midline seam creates a repair that the body has an easier time holding together.

How It Compares to Other Transverse Incisions

The Pfannenstiel is not the only transverse lower-abdominal incision available to surgeons, and the differences between the options matter depending on what kind of surgery you are having and how much room the surgeon needs.

The Joel-Cohen Incision

The Joel-Cohen approach uses a slightly higher, straighter skin cut and relies more on blunt finger dissection rather than sharp cutting through the tissue layers. Multiple trials and a meta-analysis have compared the two techniques for cesarean delivery. The Joel-Cohen approach consistently comes out ahead on operating time, with one meta-analysis finding operations about ten minutes shorter on average, alongside reduced blood loss and shorter hospital stays.⁵ Individual trials have also reported less postoperative pain and faster recovery milestones like getting out of bed and walking without support.⁶ One randomized trial found that over half of patients in the Pfannenstiel group needed strong analgesics compared with about a fifth of the Joel-Cohen group.⁷

That said, wound complication rates and newborn outcomes were similar between the two in the trials that measured them. For people with a BMI of 35 or above, a randomized trial comparing the Cohen incision to the Pfannenstiel found no significant differences in surgical site infection, hematoma, seroma, wound separation, or hemorrhage.⁸ So the Joel-Cohen advantage seems to be about speed and early comfort rather than safety.

The Cherney and Maylard Incisions

When the surgeon needs more room in the pelvis than a standard Pfannenstiel can provide, the Cherney and Maylard incisions offer wider exposure. The Cherney detaches the tendons of the rectus muscles from the pubic bone, while the Maylard cuts through the muscles themselves. Both provide better access to deep pelvic structures, which matters in complex gynecologic cancer surgeries or large fibroid removals. A study comparing Cherney and Pfannenstiel incisions for abdominal myomectomy (fibroid removal) found that Cherney incisions were used for larger uteri and heavier specimens, reflecting this exposure advantage.⁹ A randomized trial comparing the Maylard with the Pfannenstiel for hysterectomy found less postoperative abdominal distension with the Maylard and fewer additional analgesics needed, with no differences in blood loss, surgery duration, or hospital stay.

The trade-off is that cutting or detaching muscle introduces more tissue disruption, which can complicate recovery and future surgeries at the same site. Most surgeons reserve these incisions for cases where the standard Pfannenstiel simply will not give them the view they need.

Closing the Incision and What That Means for Your Scar

How the skin is closed after a Pfannenstiel incision affects both pain in the first few days and the final appearance of the scar. The two main options are surgical staples and subcuticular sutures, the latter being a continuous stitch that runs just beneath the skin surface and is either absorbable or pulled out later.

A systematic review and meta-analysis found that staples were faster to place, which shaves a few minutes off the total procedure, but the two methods were similar overall for pain, cosmetic outcome, and patient satisfaction.¹⁰ However, an earlier trial specifically comparing the two in Pfannenstiel closures found that patients reported less pain at discharge and at their postoperative visit after subcuticular suturing, and both patients and physicians rated the suture scar as more cosmetically attractive.¹¹ A study looking at tissue adhesive (surgical glue) versus subcuticular sutures found no significant difference in scar scores at six to eight weeks after surgery, suggesting glue is a reasonable alternative as well.¹²

A separate question is whether to close the subcutaneous fat layer beneath the skin. A recent meta-analysis of cesarean deliveries found no significant differences in surgical site infection, wound separation, seroma, hematoma, or overall wound complications between closing and not closing that layer.¹³ Many surgeons still close it in patients with thicker subcutaneous tissue, but the evidence suggests the decision does not make a dramatic difference for most people.

Cosmetic Satisfaction Over Time

The low placement of the scar and its alignment with skin tension lines mean that Pfannenstiel scars tend to fade and flatten more readily than vertical ones. A prospective study tracking patients who had kidney removal through a Pfannenstiel incision found cosmetic satisfaction averaging 93% at one week and climbing to nearly 98% by six months. Over 92% of patients said they would choose the same incision again or recommend it to someone facing a similar operation.¹⁴ Complications in that series, including minor wound infections and one case of wound gaping, all occurred in patients with a BMI above 35, and no incisional hernias or keloid formations were seen.

Scar recurrence is a concern when the same site is opened repeatedly, as happens with repeat cesarean deliveries. A retrospective study of women undergoing their second or later cesarean found that about 13% developed a recurrent problematic scar after the previous one had been excised. Emergency surgery and darker skin tone were associated with higher recurrence rates, with emergency cesarean emerging as the strongest risk factor.¹⁵

Pain After the Pfannenstiel Incision

Post-surgical pain at the incision site is usually managed with a combination of non-opioid medications and opioids as needed. One area of active research is whether regional nerve blocks provide an advantage over simply injecting local anesthetic directly into the wound. A meta-analysis of five randomized trials found no meaningful differences in opioid consumption, pain scores, patient satisfaction, or side effects between a transversus abdominis plane (TAP) block and direct wound infiltration for post-cesarean pain relief.¹⁶ A separate randomized trial confirmed this, finding nearly identical morphine use over 48 hours in both groups, with the TAP block actually causing slightly more sedation.¹⁷ The practical takeaway is that the simpler, cheaper wound infiltration approach works about as well as the more involved nerve block for this incision.

A recent randomized trial also tested a low-tech approach: applying a cold gel pack to the incision site after cesarean delivery. The cold pack cut average opioid use by roughly two-thirds compared with the control group, although self-reported pain scores at 6, 12, and 24 hours were not significantly different.¹⁸ If you want to reduce the amount of pain medication you take while keeping comfort roughly the same, icing the area is a simple addition worth discussing with your care team.

Chronic Pain and Nerve Entrapment

Most Pfannenstiel incision pain resolves within a few weeks, but a small percentage of patients develop persistent pain that lingers for months or years. The nerves most at risk are the iliohypogastric and ilioinguinal nerves, which run through the lower abdominal wall roughly in the path of the incision. If scar tissue catches or compresses one of these nerves during healing, the result is nerve entrapment: a burning, shooting, or aching pain near the scar that can be triggered by movement, pressure, or even light touch.

A study of patients who had undergone Pfannenstiel incisions found nerve entrapment in about 3.7% of them.¹⁹ Among patients who reported moderate-to-severe chronic pain at the incision site, nerve entrapment was found in more than half.²⁰ This is an underrecognized problem. Many patients and some clinicians attribute lingering incision-site pain to normal scar tenderness when it is actually a treatable nerve issue. Treatments range from targeted nerve blocks and physical therapy to surgical neurectomy, where the trapped nerve is deliberately cut to stop the pain signal.

Special Considerations for Higher Body Weight

The Pfannenstiel incision sits in a skin fold for many people with higher BMIs, which creates a warm, moist environment that can complicate wound healing. Even so, it tends to outperform the alternatives. A study of morbidly obese patients found that those who received a high transverse incision (placed above the pannus fold, near or above the umbilicus) had more than three and a half times the odds of wound complications and nearly six times the odds of wound infection compared with those who received a standard low Pfannenstiel.²¹

At the extreme end of the weight spectrum, the picture becomes less clear. A study of patients with a BMI of 50 or above found no significant difference in wound complication rates between Pfannenstiel and supraumbilical vertical incisions. However, the vertical group had substantially more blood loss (a median of about 1,000 versus 835 milliliters), longer operating times by roughly half an hour, and much higher rates of classical (vertical) uterine incisions, which carry their own risks for future pregnancies.²² In these patients, the choice of incision involves a real trade-off between surgical exposure and overall recovery, and it is worth discussing the options explicitly with your surgeon beforehand.

Adhesions and Repeat Surgery

Every time the abdomen is opened, the body forms adhesions: bands of scar tissue that can stick organs and tissue layers together. For people having repeat cesarean deliveries, the type of incision used the first time around matters. A study in a Tanzanian hospital found that severe adhesions were present in over half of second cesarean deliveries and nearly two-thirds of third ones. Prior use of a midline skin incision was associated with adhesions at the second surgery, while a Pfannenstiel incision was not.²³

Adhesions matter because they make subsequent surgery harder and riskier. Dense adhesions increase operating time, blood loss, and the chance of accidentally injuring nearby organs like the bladder or bowel. If you know that future abdominal surgery is likely, the first incision choice can have consequences years down the road.

Uses Beyond Obstetrics and Gynecology

Although the Pfannenstiel incision was designed for gynecological access, surgeons in other specialties have adopted it when they need to reach pelvic structures and want the cosmetic and structural benefits. Urologists have used it for radical prostatectomy (prostate removal for cancer), reporting excellent cosmetic results across a large series and noting that the same incision conveniently allows hernia repair if needed.²⁴ It has also been used for robotic-assisted radical cystectomy (bladder removal) with construction of a new bladder from intestinal tissue, where the Pfannenstiel serves double duty as the site for both specimen removal and neobladder creation.²⁵

In laparoscopic surgery, where most of the operation happens through tiny ports, the final step often requires a larger incision to pull the removed organ out of the body. The Pfannenstiel incision has become a popular choice for this “extraction site” in procedures like laparoscopic kidney removal, precisely because it heals well and rarely leads to hernia. The prospective study of patients who had their kidney extracted through a Pfannenstiel incision found zero hernias or keloids across the entire follow-up period, a result that reflects the incision’s structural reliability even when accommodating a large specimen.²⁶

In robotic colorectal surgery, where the specimen also needs to come out somewhere, a study comparing Pfannenstiel and other extraction sites found no significant differences in pain scores, opioid use, or opioid refills between the groups. The Pfannenstiel group actually needed fewer non-opioid pain medications prescribed at discharge.²⁷ The growing use of this incision across surgical disciplines speaks to a simple reality: in any procedure that needs a transverse lower-abdominal opening, the Pfannenstiel tends to heal with fewer structural complications and a more discreet scar than the alternatives.

What Has Changed Since 1900

Hermann Johannes Pfannenstiel published the original description of his transverse incision for cesarean section at the turn of the twentieth century.²⁸ The basic geometry of the incision has barely changed in over a century, which is unusual in surgery. What has evolved is almost everything around it: the closure techniques, the pain management strategies, the understanding of nerve injury, and the expansion into non-gynecologic fields. The Joel-Cohen modification addressed speed and tissue handling. The Cherney and Maylard modifications addressed exposure. Robotic and laparoscopic surgery turned the Pfannenstiel into an extraction port rather than the primary operative field. Yet the core idea, a low transverse cut that spares the rectus muscles and follows the skin’s natural lines, has proven durable enough that surgeons keep building on it rather than replacing it. Few surgical innovations from 1900 are still this central to daily practice.