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Part I
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Introduction: Surgical Fundaments for
Body Contouring Surgery
Chapter 1
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Surgical Principles forBody-Contouring
Approaches
JuarezMoraesAvelar
Abstract Ever since I was a resident at Prof. Pitanguy’s clinic, I used to often hear
Pitanguy say the terms body-contouring surgery and facial-contouring surgery.
Those expressions were related to combined procedures improving body and facial
contours, respectively. These new concepts impressed me so much that at the beginning of my career, I became motivated to organize the Brazilian Symposium of
Abdominoplasty and the Brazilian Symposium on Facial Contouring, at which Prof.
Pitanguy delivered a lecture and wrote a remarkable chapter about it. In fact, the
associated operations were frequently performed during the period of my training
under excellent team organization in the operating room and with outstanding surgical results, greatly improving body and facial contouring.
Such operations were performed daily at his clinic according to Pitanguy’s technique, on thighs, buttocks, and the trochanteric lipodystrophy regions. His memorable approach opened up a new era for body surgery in that it became possible to
remove redundant skin and localized adiposities, which used to be removed through
vertical incisions on the lateral and inner aspect of the thigh.
During my residency, people, both female and male, had constant demands for
their physical appearance, as they still do today. In addition to food administration,
diet, and physical activities, surgery is used to eliminate the signs of obesity and
actual obesity to achieve desirable physical appearances. During the last decade,
obesity has been replaced by people looking to reshape their bodies after weight
loss, which is an important eld with a large number of patients.
Thanks to the liposuction technique introduced by Illouz, it became possible to
remove excess localized adiposity without redundant skin, leaving only inconspicuous scars. The accumulation of adipose tissue on abdominal walls presenting with
excess cutaneous tissue was not treated. So far, a combination of liposuction with
conventional abdominoplasty has been able to improve body contouring by remov-
J. M. Avelar (*)
Brazilian Scientic Institute of Plastic and Reconstructive Surgery, São Paulo, Brazil
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_1
3© The Author(s), under exclusive license to Springer Nature
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ing the accumulation of fat through the new approach. However, such a combined
procedure has come with a very high incidence of complications, such as seroma
formation, hematoma, slough from the panniculus, and others. Those undesirable
situations occurred because the wide undermining of the abdominal panniculus
used to be performed to remove the excess cutaneous covering. Those complications seriously concern me and other plastic surgeons. After a very short period of
time, I decided not to perform such a combined procedure of liposuction and resecting the redundant panniculus. Later, I dedicated to conduct research on my previous
anatomic dissections and introduced new concepts for abdominoplasty without panniculus undermining while preserving the perforator vessels, which work as multiples pedicles, providing adequate blood supply to the remaining abdominal
panniculus. A similar procedure may be employed for remodeling other regions to
improve body contouring on areas such as the anks, torsos, medial thighs, arms,
and axilla.
Keywords Liposuction · Trochanteric region · Body conoturing · Conventional
resection · Remodeling the body
J. M. Avelar
Introduction
New techniques for body-contouring surgery were introduced by Pitanguy (1964,
1977) for remodeling the abdominal wall, medial thigh, buttocks, and trochanteric
regions (Fig. 1.1). Such surgical techniques impressed me during my period of
training at Prof. Pitanguy’s clinic (where I worked from 1970 to 1972). Currently,
combined operations are still performed very often at his clinic under excellent team
organization in the operating room, achieving outstanding surgical results in greatly
improving body and facial contouring.
I used to often hear Pitanguy say the terms body-contouring surgery and facial-
contouring surgery, which were related to the combined procedures for improving
body and facial contouring. In addition to hearing those expressions, I also participated in some scientic articles on these techniques. I had such expressions in mind
that even at the beginning of my career, such as when I had some female patients
presenting severe buttock deformities caused by infection after injection. They presented very deep depressions, which were repaired by using mammary silastic prostheses, achieving good surgical results (Fig.1.2) (Avelar 1974a, b, c). Notably, we
didn’t have gluteal prostheses at the time, because they wouldn’t be developed until
several years later. A paper on this subject was presented as my thesis for me to
become a full member of the Brazilian Society of Plastic Surgery.
Concerning the expression body contouring, I organized the Brazilian Symposium
on Abdominoplasty and the Brazilian Symposium of Facial Contouring, at which
Prof. Pitanguy delivered two brilliant lectures and about which he wrote two useful
chapters (Pitanguy 1982, 1983). Moreover, he wrote a useful chapter concerning
body contouring in our book Liposuction, featuring the fundaments and surgical
principles concerning his new technique (Pitanguy 1986). Localized adipose tissue
as an accumulation of fat on abdominal walls and on the lateral, posterior, and
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a
e
bc d
f
g
h i
Fig. 1.1 Sequential drawings to illustrate Pitanguy’s technique for surgical treatment of trochanteric lipodystrophy. (a) Posterior view with typical deformities, and demarcations; (b) posterolateral view showing the incision extending anteriorly; (c) a wedge of panniculus is resected on
right side; (d) reduced area of cutaneous undermining on each border is done; (e) after suture on
right side showing advancement of lower ap indicated by arrows. When the medial thigh presents
deformities associated with lipodystrophy the posterior cutaneous incision extends into the inguinal crease. (f) Diagram shows tunnelization of the cutaneous aps of the incision on anterior aspect
of the thigh; (g) after reduced area of cutaneous undermining the cutaneous ap is pulled and
advanced upwards for resection the excess medially and anteriorly indicted by arrows. (h, i)
Perioperative photos showing cutaneous incisions on inguinal crura using knife. The nal scar lies
on inguinal sulcus
medial aspects of the thighs and buttocks may damage the contouring of these
regions, producing unaesthetic and inelegant appearances. Such abnormalities were
described by Pitanguy (1964, 1977) as trochanteric lipodystrophy, or the “riding
breeches” deformity. It could be repaired through his new techniques because those
deformities used to be removed through vertical incisions on the lateral and inner
aspect of the thigh (Farina etal. 1960).
In addition to the accumulation of adiposity, very often a depression is present on
the posterior and lateral aspect of the buttocks (Fig.1.1). A similar accumulation of
fat is quite frequently apparent on the inner side of the thighs, which may be accompanied by the accidity of the skin and subcutaneous tissue. Owing to this accumulation of localized adiposities, the buttocks may droop, caused by musculocutaneous
accidity; secondary to aging, this droop may bring an even-more-unaesthetic
appearance to the region. The original technique described by Pitanguy (1964,
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J. M. Avelar
ab
d
e
f g
h
c
j
Fig. 1.2 A 19-year-old female patient with severe deformities on right buttock caused by infection
after injection in infancy which was repaired in two surgical stages with mammary silastic prosthesis in 1972. Photos (a, d) before operation; (b, e) 1year after surgery; (c) an X-ray 1year after
operation where one can see the prosthesis indicated by arrows; (f) before the rst stage the brotic
scar tissues are demarcated with continuous black line to be resect and doted lines indicate the area
of the panniculus to be undermined; (g) scheme in prole view showing the scar tissue area of
resection during rst stage; (h) scheme after rst stage the aps B and C after undermining were
sutured over the ap A underneath; scheme (i) it is showing the prosthesis placed below the ap A;
(j) photo perioperative when prosthesis was introduced through a lateral cutaneous incision
i
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1977) treated the localized adiposity along the lateral side of the thighs and cor-
rected the depression in the buttocks. Although extensive scars remained on the
trochanteric and buttocks regions after surgery, it was possible to reshape the abnormalities, which was an important development for body-contouring surgery
(Pitanguy 1964, 1977) (Fig.1.1).
A few years later, Illouz (1980, 1983a, b, 1984) introduced and popularized the
liposuction method, which was one of the most revolutionary procedures in plastic
surgery in the twentieth century. Therefore, removing accumulations of fat, especially on the abdominal walls and buttocks, became a much simpler procedure that
resulted in only very small scars (Fig.1.3). However, quite often, there were evident
redundancies of skin after liposuction on abdominal walls, which were real problems and constant challenges. Such excesses of cutaneous covering, which bothered
me and my patients, were solved through skin resection (Avelar 1985a, b, 1986),
which became a new approach. Although such combined approaches did not bring
any new sorts of complications, they came with very high incidences of seroma
formation and other adverse situations. Because of such complications and after a
very short period of time, I made the denitive decision to not perform those combined procedures anymore (Avelar 1988).
Aiming to solve those problems motived me to develop new techniques for
abdominoplasty that may be used to remodel several other regions of the human
body, as I described in my publications on my new technique for
abdominoplasty (Avelar 1999a, b, c, d, e, 2000a, b) (Figs.1.4 and 1.5). Even for
a
efg
Fig. 1.3 Liposuction procedure improving body contouring in a 24-year-old patient after two
pregnancies presenting complex accumulation of localized adiposities on abdomen, buttocks,
anks, and trochanteric regions. Photos (a, c, e) before surgery presenting severe alterations on
body contour. Photos (b, d, f) after liposuction on abdomen, buttocks, and trochanteric regions
combined with mastopexy. On photo (g) it is a superposition of the silhouette after surgery comparing with her body contouring before liposuction
bcd
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cd
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J. M. Avelar
a
bc d
ef
Fig. 1.4 A 39-year-old patient underwent lipoabdominoplasty with plication of the musculoaponeurotic wall combined with augmentation mastoplasty and mastopexy. Photos (a, c) before surgery; (b, d) post-operatory view showing improvement of body contouring; (e) tomography of the
muscular abdominal wall showing diástases of the muscles; (f) same patient after operation
ab
ef
Fig. 1.5 A 54-year-old patient underwent upper and lower lipoabdominoplasty combined with
torso lipoplasty. Photos (a, c, e) before surgery; (b, d, f) after operation
ab
cd
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Fig. 1.6 A 65-year-old female patient underwent lipoabdominoplasty and 6 months later medial
thigh lifting was performed to achieve harmonious body contouring. Same patient in oblique view
showing improvement of the abdomen and thigh
patients who have undergone severe weight loss, this technique could be used to
simultaneously treat several regions, achieving harmonious body contouring
(Fig.1.6).
Technique
Each patient must undergo a full-body analysis in a standing position and in front of
mirrors for them to be properly evaluated for adequate surgical treatment to improve
their body contouring (Fig.1.7). As several regions may be in disharmony with the
other segments of the body, there is no gold-standard procedure to employ. For these
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J. M. Avelar
Fig. 1.7 Examining room in my clinic there are two vertical mirrors, one in front of the other and
two other ones placed 45° above them. In this drawing one can see that a patient in stand position
in front of one vertical mirror she or he can observe in front view. When the patient looks at the
superior mirror placed 45° she or he can see the posterior side as well as the whole body contouring
reasons, each patient must be treated according to their unique physical imperfections when improving body contouring.
Abdominoplasty
Abdominoplasty is one of the most frequently used procedures to improve body
contouring, and it is performed either alone or in combination with other techniques (Figs.1.5 and 1.6). A combination of liposuction with abdominoplasty and
without panniculus undermining has been introduced, achieving smooth surgical
results and minimizing complications (Avelar 1999a, b, c, 2000a, b). In this modal-
ity of lipoabdominoplasty, the umbilicus is transposed and a new umbilical area is
created. The selection of patients before surgery is a fundamental step for the
gh
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surgeon to evaluate the possibility of removing all skin in suprapubic region, and
the cutaneous area above the umbilicus may be pulled downward to be sutured to
the inferior border of the surgical incision (Figs.1.4 and 1.6). Finally, abdominoplasty may be performed according to the techniques designed by Callia (1965),
Pitanguy (1967), Sinder (1975), or others, bringing considerable renements to
aesthetic body contouring.
Reduction or Augmentation Via Mastoplasty
Large breasts or small breasts may cause unsatisfaction for female patients, motivating them to undergo aesthetic procedures to reshape their body’s silhouette
(Fig.1.8). Each surgeon may follow their own techniques which are more used to
performing in order to remodel of the body. Reduction mastoplasty, which is also
used to improve the shape of the breasts, can provide harmony to all segments of the
body (Fig.1.9).
a
bc d
ef
Fig. 1.8 A 42-year-old patient after bariatric surgery presenting improvement of body contouring
through mastopexy with prosthesis inclusion associated with upper and full-lipoabdominoplasty.
Photos (a, c, e, g) before operation; (b, d, f, h) postoperative photos after associated procedures.
Photos (c, d) one can see surgical planning of upper and full-lipoabdominoplasty
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