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J. M. Avelar
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Fig. 1.9 Mastopexy combined with lipoabdominoplasty and medial and lateral plication of the
musculoaponeurotic structures. Photos (a, c) before surgery; (b, d) after combined procedures
improving body contouring; (e) TC of the abdominal structures before plication shows diástases on
medline and lateral as well; (f) TC after reinforcement of the abdominal wall
The Accumulation ofLocalized Adiposities
Abdominal walls may present the accumulation of localized adipose tissue, as may
the lateral and posterior aspects of the thighs and buttocks, producing unaesthetic
and inelegant appearances. Such imperfections were described as trochanteric lipodystrophies or the “riding breeches” deformities (Pitanguy 1964, 1977). Quite
often, the bulging area of adiposity develops a depression in the posterior lateral
aspects of the buttocks (Fig.1.1). A similar deformity is frequently apparent on the
inner side of the thighs, usually accompanied by the accidity of the skin and subcutaneous tissue. The drooping of the buttocks secondary to musculocutaneous
accidity from aging is another type of deformity that has shown signicant
improvement after a combination of remodeling via skin resection and tunnelization without panniculus undermining (Avelar 1999a, b, c, d, e, f) (Figs. 1.10
and 1.11).
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Fig. 1.10 Correction of unaesthetic deformities caused by previous surgery on buttocks. I
employed liposuction combined with my surgical principles without panniculus undermining.
Photos (a) preoperative of a 69-year-old female patient presenting bilateral unaesthetic depression
with scars secondary to previous surgery; (b) surgical demarcations following Pitanguy’s technique with two segments of skin resection bilaterally and the area for liposuction; (c) nal result of
aesthetic reparation; (d) posterolateral view showing depression caused by previous operation; (e)
nal result on posterolateral on right side
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J. M. Avelar
Fig. 1.11 Correction of accidity of buttocks and trochanteric regions employing new procedure
without panniculus undermining following Pitanguy’s technique. Photos (a) posterior view showing surgical demarcation on gluteal folds and inner aspect of the thigh; (b) after tunnelization with
cannula the excess of skin was resected; (c) wide raw area after cutaneous resection; (d) the raw
area was sutured by inverted stitches folded over itself; (e) preoperataive on posterior view; (f)
postoperative; (g) oblique posterolateral view before surgery; (h) same patient 6months after surgery. Six months later she underwent silastic prosthesis inclusion on inner side of the thigh performed by Dr. Montellano
Liposuction
The liposuction operation introduced and popularized by Illouz (1980, 1983a, b,
1986a, b), which opened up a new era of body-contouring surgery, is doubtless an
important step in improving and remodeling the body’s contours. On one hand,
some deformities from the severe accumulation of adiposities in certain regions
may yield important surgical results when isolated liposuction is performed
(Figs.1.3 and 1.12). On the other, other deformities require procedures to achieve
harmonious aesthetic results (Figs.1.10, 1.11, and 1.13).
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Fig. 1.12 Isolated liposuction of the anks and buttocks without skin resection in a 19-year-old
girl presented excessive accumulation of fat with unaesthetic appearance. Photos (a, c) before
operation; (b, d) after liposuction on the buttocks
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Fig. 1.13 Unaesthetic deformities of buttocks caused by unsuccessful silastic prosthesis inclusion. Photos (a) posterior view showing severe scars with ungraceful appearance of the buttock;
(b) demarcation of the procedure according to Pitanguy’s technique; (c) cutaneous incisions following demarcations; (d) cutaneous undermining with knife; (e) traction upwards of the inferior
segment and resection of the excess of skin followed by internal suture to approximate the borders;
(f) nal suture on left side of the patient one can see the improvement comparing with the right
one; (g) same patient 1year after surgery on posterior view; (h) posterior oblique view on right
side with unaesthetic aspect of the buttocks and ungraceful scars caused by extrusion of silastic
prosthesis; (i) nal result with reshaping of the buttocks
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J. M. Avelar
Buttock Remodeling
The remodeling of an accumulation of localized adiposities on gluteal regions
has shown good improvement on body contouring under liposuction, with
inconspicuous scarring and harmonious surgical results (Figs. 1.3 and 1.12).
Several kinds of deformities of the buttocks require surgical corrections for reparation with resections of the cutaneous covering (Figs.1.10 and 1.11). Some
patients have undergone unsuccessful operations, such as silastic implants in the
gluteal region with unaesthetic results (Fig.1.13). For correcting such reparation, Pitanguy’s technique (Pitanguy 1964, 1977) is an excellent support in order
to demarcate the skin resection, to orient the skin undermining, and to resect,
even when remodeling the buttocks (Fig.1.13). Mammary silastic implants have
been employed for the reconstruction of severe deformities to the buttocks
Fig. 1.2) (Avelar 1974a, b, 1977), improving body contouring. Later, a new
prosthesis was developed specically to improve the aesthetics of gluteal
implants.
Torsoplasty
The posterior aspect of the torso has a peculiar anatomy in the subcutaneous panniculus that requires the appropriate technique to improve body contouring
(Fig.1.14). Some localized adiposity along the posterior regions of the torso may be
remodeled via isolated liposuction when there is no redundant skin (Fig.1.15). The
accumulation of localized fat has so far required skin resection associated with the
liposuction procedure when performed under new approaches without panniculus
undermining (Avelar 1999a, b, 2000a, b) (Figs.1.5 and 1.16). Many kinds of body
asymmetry may be remediated by employing isolated liposuction or a combination
of it with skin resection to achieve good harmonious contouring to the torso and
abdomen (Fig.1.17).
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Fig. 1.14 Regions of the posterior regions of the torso. Diagram (a) one can observe the three odd
(interscapular, vertebral, and sacral) and three even (scapular, lumbar, and suprailiac); (c) shows
the most frequent regions presenting localized adiposities on posterior side of the torso, inside of
the fascia supercialis
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Fig. 1.15 Accumulation of localized adiposities on interscapular region and its treatment; (a, d)
preoperatory photos indicating the adiposities by arrows; (b, e) postoperative photos showing correction of deformities; (c) photo during operation with the patient on ventral position on operating
table the cannula works through a cutaneous incision on lower border of the interscapular region
with adiposities
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J. M. Avelar
a b c
Fig. 1.16 Torso lipoplasty performed as combined procedure of skin resection plus liposuction
without panniculus undermining. Diagram (a) shows surgical planning on right side: demarcation
of skin resection and lipoplasty; (b) preoperatory photo shows full-thickness skin resection as well
as demarcations for liposuction; (c) diagram demonstrates full-thickness skin resection indicated
by arrow
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Fig. 1.17 Liposuction procedure repairing asymmetric body contouring. Photos (a, c) a 42-yearold female patient presenting complex asymmetry of the body in front view as well as on posterior
one. Photos (b, d) after liposuction combined with lower abdominoplasty and liposuction on posterior regions of the torso
Aesthetic Surgery onThighs andButtocks
The appearance of aging may occur all over of the human body. Any region may
present skin accidity, striae, redundancy, or the accumulation of local adiposities.
Before Illouz introduced the liposuction technique in the 1980s (Illouz 1980, 1983a,
b, 1984), such deformities could be treated with Pitanguy’s technique (Figs.1.10
and 1.11) (Pitanguy 1964, 1977). Later, both procedures, liposuction alone and lipo-
suction combined with panniculus resection, may be employed, without panniculus
undermining, by following the surgical method that I previously described
(Fig.1.18) (Avelar 1999a, b). Ever since this liposuction technique was introduced,
several deformities have been adequately treated to achieve harmonious body contouring (Figs.1.3, 1.12, 1.15, 1.17, and 1.18).
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Fig. 1.18 Female patient with lipodystrophy of the lower extremities presenting improvement of
body contouring through Pitanguy’s demarcations associated with medial thigh lifting without
panniculus undermining (Avelar 1999b). Photos (a, c) unaesthetic appearance; (b, d) surgical
result with scars on inguinal sulcus
Abdominoplasty Combined withAesthetic Surgery onThighs
andButtocks
When adiposities accumulate on the abdominal walls of the external and inner sides
of the thighs, the treatment is performed as a combination of surgeries on all the
affected regions. My preference is to perform my procedures without panniculus
undermining (Figs.1.6, 1.8, and 1.18) (Avelar 1999a, b, c, 2000a, b)
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J. M. Avelar
Discussion
The combined procedure for reshaping body contouring was introduced by Pitanguy
(1977, 1982, 1986). Ever since I was a resident at Prof. Pitanguy’s clinic, I used to
often hear him say the terms body-contouring surgery and facial-contouring sur-
gery. Those expressions were related to combined procedures meant to improve
body contouring and facial contouring, respectively. At the beginning of my career,
I was so impressed with those concepts that I became motivated to organize the
Brazilian Symposium of Abdominoplasty and Facial Contouring, and Prof. Pitanguy
delivered lectures at each of those events and wrote two memorable chapters about
those elds (Pitanguy 1982, 1983). In fact, associated operations were performed
frequently during the period of my training at Pitanguy’s clinic, under outstanding
surgical team organization in the operating room and yielding excellent surgical
results showing great improvements to body and facial contouring. Given all the
knowledge that I gained from Pitanguy; our warm professional relationship; and my
deep and sincere gratitude, at an event that I organized in São Paulo, I paid him
homage (Fig.1.19). After the liposuction technique had been introduced by Illouz
(1980, 1983a, b, 1984, 1986a, b), body-contouring surgeries received important
support to achieve better surgical results. Again, given the opportunity I had had to
learn the liposuction technique and our later partnership in several professional
activities, even together publishing a book (Liposuction), I offered Prof. Illouz my
deep recognition and ardent thanks (Fig.1.20).
Nevertheless, the techniques of associated operations were regularly performed
at Pitanguy’s clinic—on thighs, buttocks, and the trochanteric regions—according
to Pitanguy’s technique (Pitanguy 1964, 1977). His memorable approaches opened
up a new era for body surgery because the removal of redundant skin and localized
adiposities became possible, which used to be removed through vertical incisions
on the lateral and inner aspect of the thigh (Farina etal. 1960).
Nowadays, people are exposed to two antithetical propagandas: a wide and
intense variety of food with lessons on how to prepare delicious dishes that
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Fig. 1.19 My homage to Prof. Pitanguy during a Symposium in São Paulo (Brazil) August 2002.
Photo (a) during the ceremony specially dedicated to give Prof. Pitanguy a surgical instrument (a
knife) made in gold; (b) photo of the instrument with a plac in gold with my sentence: “To Prof.
Pitanguy, my gratitude to teach me how to work with this surgical instrument. São Paulo,
August 2002”
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Fig. 1.20 During the First Congress of the Prof. Illouz Association (PIA), held in Brasilia (Brazil)
in 2008, our homage to Prof. Illouz. Photos (a) I gave him a plac made in gold as my gratitude; (b)
photo of the plac with the map of Brazil with a canula from Fortaleza (where he made his rst
lecture) pointing to São Paulo (where we organized several events to teach liposuction); (c) a certicate from the Board of Prof. Illouz Association to him. Few years later during an ISAPS event
in Paris I was invited for a reception at Illouz’ ofce, he was so happy to show and he said to
everybody my gifts with a map of Brazil that I offered as a symbol of my gratitude
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stimulate people to eat more and more on one hand and on the other constant information about diet and physical exercises to eliminate the signs of obesity and real
obesity, both for appearance and for improving health conditions. Consequently,
there is a constant demand from people, female and male, for a desirable physical
appearance.
Over the past few decades, bariatric surgeries have been performed more and
more to treat obesity, and plastic surgeons perform reparations for people after
weight loss (Figs.1.6, 1.8, and 1.11). In such way, all regions of the body require
intense effort from plastic surgeons aiming to remodel the body’s contours (Figs.1.3,
1.4, 1.5, and 1.12). Ever since the liposuction technique introduced by Illouz (1980,
1983a, b, 1984, 1986a, b) made possible the removal of excess localized adiposities,
leaving inconspicuous scars, it has been an important procedure for removing accumulations of adipose tissue from abdominal walls and other regions. So far, redundancy of cutaneous tissue has not been treated, but a combination of liposuction
with conventional abdominoplasty has improved body contouring (Avelar 1985a,
b, 1986).
However, such a combined procedure comes with very high incidences of complications, such as seroma formation, hematoma, slough from the panniculus, and
others. Aiming to avoid these sorts of complications motivated me to search for new
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