Pitanguy, Ivo M.D.
Current sedentary lifestyle and dietary excesses, associated with factors such as genetic determination, pregnancy, and the aging process, contribute to alterations of body contour that result in the loss of the individual’s body image. This creates a strong psychological motivation for surgical correction.1 Localized fat deposits and skin flaccidity are sometimes resistant to the most sincere efforts in weight loss and sport activities. This ever-increasing request for contour surgery has been met favorably by safe and effective anesthesiology and efficient surgical techniques, resulting in a high degree of patient satisfaction.
It is essential that today’s aesthetic surgeon understand the motivations of patients who present with body contour deformities. A request for surgical treatment should be seen as a legitimate desire to achieve a physical form that approximates the individual with his or her ideal self-image. Additionally, the surgeon must always consider the possible benefit of including the participation of a multidisciplinary team approach. Depending on each case, this team should include consultants in endocrinology, dermatology, oculoplastics, pediatrics, and other appropriate specialties.
This article addresses various body contour deformities, which can be corrected satisfactorily by surgical treatment. These may be deformities involving only one anatomic region or more complex deformities involving multiple body regions. They may be treated by a single simple surgery or may require more complex combined procedures. In some cases, multiple or severe deformities will require a multistage approach, such as in patients who have undergone dramatic weight loss.
Herein I consider body contour deformities through an anatomic analysis, explaining the evolution of my different techniques over the past three decades. The concepts and principles that have been fundamental in developing my personal approach are presented, analyzing the areas that most commonly present for surgery, which include the breast (hypertrophy, ptosis, and hypomastia; gynecomastia; and deformities of the nipple-areola complex), the abdomen (lipodystrophy and atypical deformities), the upper limbs, and the lower limbs [lipodystrophy and flaccidity of the inner thighs and the trochanteric region, and the “riding breeches” (or “saddlebag”) deformity].
In the Brazilian population, breast hypertrophy represents the most common contour deformity. Breast hypertrophy should not be considered a frivolous reason for aesthetic correction. Determining factors should include not only the unaesthetic aspect of a heavy upper trunk but also the functional considerations of large, cumbersome breasts, the effects on the osteo-articular system of the shoulders and the back, and overall physical discomfort. In extreme cases, the sheer weight of macromastia could diminish pulmonary capacity. 2–7
Breast reduction before 1959 required extensive dissections and undermining that often resulted in large dead space with subsequent collection and skin necrosis. Resections that involved the upper pole caused early flattening and sagging, with an upward projection of the nipple. These were the principal motivations for seeking a technique that would limit resection to the lower pole, not separating the “container from the content,” thus allowing the breast to be supported in a natural brassiere-like fashion. 2
When evaluating a surgical technique for the correction of breast deformities, certain general aspects that are unique to this structure must be emphasized, such as its psychosocial importance, the primary sensual connotation of the breast, and the embryologic origin and lactiferous function of the mammary gland. 8–10 Thus, a surgical procedure must preserve function and maintain sensitivity while limiting the extension of the scars. 5,11–18 These general principles are equally applicable to other breast deformities, such as asymmetry and ptosis. They have served as guidelines in developing, and subsequently enhancing, my personal techniques. It has been rewarding to observe how these principles have been easily grasped by the younger surgeons.
The basic steps for breast reduction enable the performance of many types of resections with ease and consistency, and without being inhibited by fixed measurements or predetermined location for the nipple-areola complex. The feasibility of the techniques is further emphasized when considering the results of 3243 personal cases and those obtained at our infirmary at Santa Casa, where a total of 3702 patients have had operations. There, the great majority of reduction mammaplasty procedures have been performed by senior residents under the supervision of me and my assistants. The predictability and safety of these procedures are demonstrated by noting that final results are comparable between the two groups of patients (Table I).
Basic Principles of Pitanguy’s Techniques for Breast Reduction
The Pitanguy technique is indicated in cases of large hypertrophies. 2–7,13–16 The patient is usually operated on under general anesthesia and is positioned on the table with arms outstretched, in a semisitting position. Initially, the surgeon determines point A, as first described by me, which is the projection of the inframammary sulcus along the vertical mid-clavicular line. This point marks the general location of the areola at the completion of surgery. The next two landmarks, points B and C, will form a triangle with point A and are determined by pinching the skin on both sides of the areola and bringing them together at the midline. This maneuver allows the surgeon to estimate how much tissue should be resected (Fig. 1).
The last two points, D and E, will define the medial and lateral extension of the incision respectively; they are placed along the mammary sulcus. The anterior axillary line determines the lateral extension of the scar. Medially, the incision should not extend over the mid-sternal region. This demarcation is carefully transferred to the opposite breast, by compass and also by two long sutures placed at the sternal notch and the xiphoid process. The lines of demarcation may be either straight or curving, depending on the amount of skin that the surgeon intends to resect. Final demarcation ensures the principle of adjusting the container (skin envelope) to its content (remaining breast parenchyma) (Fig. 2).
As mentioned, glandular resection is restricted to the inferior pole of the breast, respecting the principle of avoiding large dissections. Resection varies according to the firmness of breast parenchyma and may be straight when the parenchyma is composed mainly of fatty tissue, or can resemble an inverted “ship’s keel” if breast tissue is more glandular. In either case, two pillars or columns (lateral and medial) are created (Fig. 3).
When the pillars are approximated, all dead space is obliterated and the nipple-areola complex ascends to its correct position. Continuity between skin and gland is ensured, along the lateral, medial, and superior aspects of the breast (Fig. 4). In very large hypertrophies, the adipose capsule of the upper pole acts as a third pedicle and serves to project the breast mound.
An appropriately sized areola demarcator is chosen, checking for symmetry and correct placement of the future nipple-areola complex. This position will be about point A, yet the surgeon has considerable freedom to demarcate the new bed, depending on his judgment (Fig. 5). This does not occur when the technique is based on fixed measures and demarcations. The position of the nipple-areola complex should not be too high, because a subtle but definitive downward shift of the breast parenchyma gradually occurs over the first few months, which will tend to project the nipple superiorly (Figs. 6 and 7).
In cases of moderate hypertrophy or ptosis, when less tissue is to be resected, the Arié-Pitanguy technique (also called the rhomboid technique) is well indicated. 5–7 (Modification of the procedure proposed by Prudente and Arié in 1957 19 included moving the incision above the areola to the place where the nipple would rest at the conclusion of closure, termed point A. All measures were subsequently marked in relation to this point.)
The rhomboid technique, which has the same principles as described for the Pitanguy procedure, stands as the origin of many different surgical approaches to breast reduction. Demarcation is in the shape of a vertical ellipse, extending around the areola, and the final incision becomes a single vertical line. This approach is also useful in patients who present with ptosis and atrophy of breast parenchyma, where the placement of an implant is indicated. Excess skin is removed, and the implant is easily placed through the incision. It should be noted that, whereas the lines of tension of the breast are in fact transverse, gravity forces collagen in the lower pole to assume a longitudinal, vertical distribution, resulting in a very satisfactory final vertical scar. 2 In patients who present with large hypertrophy and are anxious about an extensive horizontal scar, the adaptation to the rhomboid technique, although not ideal, can also be feasible.
Initially, point A is determined as previously described, and by pinching the medial and lateral skin on either side of the nipple, points B and C are marked, thus delineating the excess skin. Point D, which should not be below the mammary sulcus, will complete the elliptical demarcation. Resections can include a variable amount of breast tissue, always from the lower pole (Fig. 8).
As described in the classic technique, two pillars or columns are created. Once they are approximated, the superior pole together with the nipple will rise to its new position. On the other hand, resection can be restricted to skin when simple ptosis is present and no excess tissue need be removed. When the vertical incision extends more than 1 cm below the sulcus, the final incision should be complemented with a small horizontal component, converting the single vertical scar into an “L” or inverted “T” (Fig. 9). This maneuver also corrects skin pleats that would otherwise remain and that are aesthetically displeasing to the patient. It is our observation that the degree of skin retraction is actually less than what other authors mention (Fig. 10).
The rate of complication for these techniques is very small, because all dead space is closed with the approximation of the two columns of breast tissue. Flap ischemia is also avoided, because no undermining is done between skin and parenchyma 7,14–16 (Table II).
By adapting principles of the classic procedure, a peri-areolar technique was developed, aiming to reduce the incisions. The ideal patient for this procedure is a young woman with healthy, elastic skin not damaged by excessive ptosis and presenting with moderate, not large, hypertrophy. 20,21 The best results are thus obtained in a very small and select group of women. An earlier tendency to indicate this procedure for patients with breast ptosis resulted in a large amount of unaesthetic areola scarring. This limitation of the technique has emphasized the concept that the skin tension lines are parallel to the vertical line of the lower pole of the breast and not around the areola. In this manner, breast ptosis is best corrected by the rhomboid procedure described previously. The peri-areola technique, in these cases, is not adequately indicated, because there is a high rate of areola deformity and a flattening of the conical breast. A considerable decrease in the indication of this approach has therefore been noted.
Finally, all resected breast tissue is submitted to histopathologic examination. In a study of 2046 consecutive cases of breast reduction, the following results were found: 1.2 percent had malignant tumors (the most common of which was the papilliferous duct carcinoma), 3.2 percent had benign tumors, and 4.6 percent had altered parenchyma. 22,23
The distribution of these three procedures for the treatment of breast hypertrophy or ptosis over the last 40 years can be noted in Figure 11.
Techniques for Other Breast Deformities
Severe psychological problems often accompany breast hypoplasia, which should not be considered as simply an aesthetic alteration. Feelings of inferiority affect the woman’s emotional life. Correcting the underdeveloped breast may be a fundamental factor in reestablishing the intimate satisfaction in a woman, emphasizing the important role of the breast as a sensual organ. 24–26
It is my preference to insert a breast implant through a transareolar incision. 27 This access, described in 1966, 28 has proven to be versatile in treating many types of breast deformities, such as resection of benign tumors or excess glandular tissue (as in gynecomastia) and also for correction of nipple deformities (Fig. 12). When the diameter of the nipple-areola complex is reduced, or when a large implant is chosen, an alternate technique is used.
This incision should be made along the equator of the nipple-areola complex, not extending beyond its border. In my experience, the resultant transareolar scar is of good quality; the incision is easy to perform and the innervation and blood supply to the nipple-areola complex are totally preserved 1,27 (Fig. 13). This does not occur when performing a periareolar incision, which places a scar in the transition of two different types of skin, besides affecting, in some cases, the sensitivity of the nipple-areola complex.
The subglandular plane is easily reached through the transareolar incision, and an adequate pocket is created for the implant by dissection. Alternatively, when the patient presents with ptosis, breast hypoplasia may be corrected by placing the implant by a rhomboid demarcation for removal of excess skin (see earlier description of the rhomboid technique).
As already mentioned, the transareolar approach is the incision of choice for the correction of gynecomastia. Through it, the surgeon gains access to glandular tissue and also allows for the introduction of cannulas for complementary liposuction. Two small flaps should be developed below the nipple-areola complex and at closure should be overlapped, so as to avoid the unaesthetic “dish deformity” that occurs when the nipple-areola complex adheres to the muscle fascia. 28,29
Our interpretation of the inverted nipple is that underdeveloped galactophorous ducts form bands that pull the nipple inward and maintain it in this position. 30 The freeing of these fibers is necessary to allow the nipple to evert. This is done again by incising the nipple-areola complex along its equator, with a transareolar incision. Once exposed, these fibers are identified and severed; sutures by planes ensure that the nipple will remain in this natural protrusion. 30,31
The hypertrophied nipple is not a common finding; however, when it does exist, it is often significantly troubling to the patient and should be addressed by the surgeon with appropriate consideration. The technique described is a simple and efficient way to reduce the height of the nipple. 32 A partial transection is performed, and half of the nipple is removed. The remaining half is rotated upon itself and sutured. This technique, which may also be useful for harvesting of tissue for nipple reconstruction, respects the physiology of the nipple, because it preserves at least half the amount of galactophorous ducts 32,33 (Fig. 14).
The abdomen plays a central role in the person’s profile, emphasizing its importance in defining body contour. Deformities of the abdominal wall cause variable aesthetic and/or functional alterations. 1 The main causes of contour deformities of the abdominal wall are obesity; flaccidity of the muscles; localized lipodystrophy; and sequelae of trauma or previous surgery that result in scars, hernias, and eventrations.
Historically, abdominoplasties were first described for the correction of large hernias and resection of severe lipodystrophies. 34 Many different incisions were proposed, and with time the final scar was gradually situated in the lower abdomen. 35–37 A personal approach to abdominal deformities was described 1967, 38 and both function and aesthetics were emphasized. This will be described later.
A system of classification allows for correct diagnosis of abdominal contour deformities. 39 Specific surgical planning should be based on a diagnostic classification, to ensure appropriate and individualized treatment of each case, increasing the patient’s self-esteem and improving the functional status of the abdominal wall.
• Patients with type I deformities present with isolated lipodystrophy of the abdominal wall, and suction-assisted lipectomy is indicated.
•Type II deformities include lipodystrophy and moderate skin flaccidity, with or without diastasis. A mini-abdominoplasty is indicated, and this may be performed by videoendoscopy if the surgeon is familiar with the technique. Complementary liposuction may also be indicated.
• Lipodystrophy together with accentuated skin flaccidity and muscle diastasis, with or without eventration, defines type III deformities, and a classic abdominoplasty is indicated.
•Type IV patients present the same deformities as type III patients, together with a vertical scar from previous surgery. A classic abdominoplasty with a vertical incision is indicated.
The principles of my technique have remained over these 30 years and include the aesthetic positioning of the final scar so that the incision is placed immediately above the pubic area with a horizontal lateral extension, curving slightly upward, to be hidden inside the current beach attire. There may be a certain variability, dictated by the patient’s preference for bathing trunks. 40–47
Undermining of the abdominal flap is done over the muscle fascia, reaching the costal margins. Muscle diastasis is repaired through plication of the rectus abdominis aponeurosis, without opening the muscle fascia, as had been done previously. This reinforcement of the abdominal wall, which I first proposed, 38 begins at the xiphoid process to correct epigastric protrusion and extends down to the pubis. Strong nonabsorbable sutures are placed in an “X” fashion, inverting the knot, approximating the aponeurosis of the rectus abdominis muscle (Fig. 15).
Exceptionally, the surgeon may be forced to open the fascia when there is a large diastasis or when severe eventration precludes approximation without excessive tension. Reinforcement of the abdominal wall with a mesh, firmly fixed to healthy tissue, is necessary when hernias or eventrations do not allow for primary closure of the musculoaponeurotic layer. Abundant adipose tissue should be left over the mesh to avoid extrusion. 45,48 Previous expansion of the abdominal wall with tissue expanders is an interesting recourse to close extensive scars in selected cases. 39
The patient’s trunk is raised slightly to an angle of 15 degrees and the flap is fixed by a temporary suture at the midline. The lateral flaps are pulled downward and toward the midline, and with a long Pitanguy flap demarcator the amount of excess tissue is estimated and marked. The same is done to the opposite side, and both demarcations are checked for symmetry (Fig. 16).
The pedicle of the umbilicus may be shortened with sutures anchoring it firmly to the abdominal wall. The umbilicus should be exteriorized at a level corresponding to its natural position, without traction to avoid displacement. The same demarcator is used to check for the correct position of the umbilicus on the exterior surface of the abdominal wall. Finally, a transverse or semicircular incision measuring approximately 2 cm is done at this point to exteriorize the umbilicus. There is no resection of skin. This straight line becomes a natural ring when the flap is positioned. A resection of subcutaneous tissue is removed below this incision in a “cork” fashion, so as to cause a smooth peri-umbilicus depression (Fig. 17).
Suction-assisted lipectomy of the flanks is performed very frequently, contouring and enhancing the waistline. It should be stressed that neither liposuction nor lipectomy is done to any area that has been undermined, because there is a certain risk of necrosis of the abdominal flap.
Serosanguineous collections are reported as one of the most frequent complications following abdominoplasties. 41 A few maneuvers have been adopted as part of the classic technique and have proven useful in preventing collections. These include the covering of all dissected tissues with moist sterile towels to avoid desiccation. Rigorous hemostasis and the placement of drains are routine. We have been using a plaster shield, molded over a thick, soft dressing, as part of our routine. 49 This custom-designed anterior abdominal plate is held in place for the first 2 postoperative days, during which a 2-kg weight is placed to ensure an even and firm pressure over the dissected abdominal flap, guaranteeing adhesion of the undermined tissues (Fig. 18). This diminishes the risk of hematoma and seroma and has been noted to decrease patient discomfort during the first 48 postoperative hours (Table III) (Figs. 19 and 20).
An important contribution to abdominoplasty has been the introduction of suction-assisted lipectomy, which has permitted the removal of fat deposits by means of minimal incisions. 50–52 Contouring of the abdomen has been enhanced considerably, either as a single procedure or associated with surgery, allowing the surgeon to complement an abdominoplasty with liposuction of nonundermined areas. On the other hand, liposuction has also decreased the necessity for larger dissections, thus contributing to lessen the rate of serosanguineous collection. This association of techniques is extremely favorable, as can be seen in Figure 21, showing the increase in the use of liposuction since its introduction in the mid-1980s. 1,39,47
The Upper Limbs
Treatment of contour deformities of the upper limbs requires a very critical appraisal of the patient’s complaints and expectations. The surgeon should be emphatic regarding limitations and possibilities of surgical procedures. A visible scar is inevitable when treating brachial lipodystrophies. Therefore, resection of excess tissue is indicated only in select cases, when the deformity causes a significant disharmony between the upper limbs and the patient’s overall body contour.
Liposuction has become the procedure of choice in moderate cases of fat accumulation on the posterior aspect of the arm, removing excess adipose tissue through minimal incisions. On the other hand, a small dermolipectomy is indicated in cases in which the deformity is restricted to the upper third of the arm. A transverse incision is placed inside the armpit, dissection is performed below the subcutaneous layer, and excess tissue is pulled superiorly and demarcated with a Pitanguy flap demarcator. 44,53
A larger resection is warranted when the patient presents with visible looseness of skin, secondary to the aging process or after considerable weight loss. An elliptic demarcation is done along the posterior and inner aspects of the arm, thus ensuring that the final scar is placed at the least visible location of the upper limb, which is at the internal bicipital sulcus. Dissection of tissues is done in a posterior direction, so as to bring the excess flap inward. 53
Some patients present with excess tissue that affects the elbow, the upper limbs, and the lateral aspect of the thorax. These patients are treated by a technique called a thoracobrachial dermolipectomy. 54 The patient is examined and marked standing up and with the arms open so as to demonstrate excess ptotic tissue. A sinuous demarcation begins distally, at the elbows, and moves along the inner aspect of the arms, continues along the armpit, where it is “broken” by a Z-plasty, avoiding scar retraction. The demarcation proceeds along the lateral aspect of the upper trunk and finishes at the submammary sulcus (Fig. 22).
The final scar is seen to be more satisfactory with this sinuous demarcation than when compared with other techniques that employ straight lines, which risk developing a “bow-string” deformity along anatomic creases with consequent unfavorable retractions. Suction-assisted lipectomy has become a valuable adjunct to this procedure.
The Gluteal Region and the Lower Limbs
Lipodystrophy of the trochanteric region is a common contour deformity that has been the subject of interest among different authors. 55 When accentuated, this deformity causes severe disharmony with the patient’s ideal self-image and may also lead to physical discomfort and bad posture.
Before the advent of liposuction, surgeons were restricted in their armamentarium. Large resections were performed, resulting in extensive scars. In 1964, a technique was described in which the natural anatomic creases were used to hide or camouflage surgical incisions. 56 The “riding-breeches ”deformity was thus treated by a single incision, rotating the flap around the upper thigh rather than pulling, and removing excess tissue, with minimal undermining and traction on the final scar 57–60 (Figs. 23 and 24).
Suction-assisted lipectomy has considerably decreased the indications for dermolipectomy of the thighs. Patients who present with a large volume of adipose tissue may be treated with serial liposuctions, with intervals of no less than 6 months, allowing for skin retraction, which in selected cases is surprisingly satisfactory. However, it is interesting to observe that the principles described more than 30 years ago for trochanteric dermolipectomy are still valid and that the areas demarcated for resection match the exact areas that today are treated by suction-assisted lipectomy.
There is currently a restricted group of patients who still are candidates for this surgery. They present with either a severe degree of trochanteric dystrophy or extremely severe flaccidity of thigh skin associated with lipodystrophy following massive weight loss, or they have previously undergone liposuction and present with excess skin with irregularities. Again, dermolipectomy follows the principles of the rotation technique, rather than pulling of the flaps (Fig. 25).
Combined Contour Procedures
Not infrequently, patients present with a variety of complaints regarding contour deformities, and the surgeon must decide and plan for two or more procedures accordingly. There are, of course, many benefits for the patient if associated procedures can be performed during a single operation and hospitalization. However, there are important aspects to be considered before attempting to establish multiple surgeries. In associating procedures, the extent of the operation and surgical trauma and the length of anesthesia should not be greatly increased. The attention to fine detail should, of course, be as great as if a single procedure were to be performed. Lastly, the increased alteration in body image may cause psychological discomfort in patients who are not prepared for this change. 1,61–64
Preliminary considerations include realistic patient motivation, a complete physical and laboratory examination, and adequate hospital facilities with a competent nursing team. The preparation of an expert surgical team is essential. Each component should be well apprised of its role (Fig. 26). Close collaboration with the anesthesiology team is mandatory, because many of these procedures require changing the position of the patient. The surgical plan may be altered secondary to an unforeseen situation during surgery, and the patient must be made aware of this. Autologous blood transfusion must be considered and previously prepared in cases in which blood loss is expected and in borderline patients.
The most frequently performed associated procedures in my experience, in two large time periods, are shown in Tables IV and V. Facial cosmetic surgery is included, which will be covered in the following article.
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2. Pitanguy, I. Breast Hypertrophy. In Transactions of the 2nd Congress of the International Society of Plastic Surgeons, 1960. P. 509.
3. Pitanguy, I. An eclectic approach to breast problems. Rev. Bras. Cir. 41:179, 1961.
4. Pitanguy, I. Une nouvelle technique de plastique mammaire: Estude de 245 cas consecutifs et presentation d’une technique personelle. Ann. Chir. Plast. 7:199, 1962.
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41. Pitanguy, I. Thigh Lift and Abdominal Lipectomy. In R. M. Goldwyn (Ed.), Unfavorable Results in Plastic Surgery. Boston: Little, Brown, 1972. P. 387.
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47. Pitanguy, I., and Mazzarone, F. Addominoplastica. In I. Pitanguy and F. Ferrari (Eds.), Chirurgia Estetica: Strategie Preoperatorie, Tecniche Chirurgiche. Torino: Unione Tipografico-Editrice Torinese, 1997. Pp. 327–336.
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