The setting may be Park Avenue or Bel-Air or avenue Foch, but the scenario is always the same. A woman, accustomed to the best, decides it's time for some plastic surgery. She compiles list after list of surgeons and has a few consultations. Just when she has almost made up her mind, she wonders, Maybe I should be going to that guy in Brazil.

For three decades, Rio's Iva Pitanguy has been the most famous plastic surgeon in the world, operating on the internationally rich and fabulous, from (it's rumored) Josephine Baker to Empress Farah Diba, Sophia Loren, Gina Lollobrigida, Candice Bergen, and more than one U.S. First Lady. Today Pitanguy is also the most controversial plastic surgeon in the world.

In his heyday, the 70s and 80s, "going to Rio" became a euphemism for checking into his 17-bed clinic for the ultimate beauty treatment—his signature body sculpting. A decade before liposuction and unhampered by malpractice laws, Pitanguy developed the surgical tummy tuck, buttocks-lift, and breast-lift-procedures that put him far ahead of other plastic surgeons of the day. He was also renowned for a natural-looking facelift. In good years, with fees ranging from $20,000 to $50,000, the clinic was probably grossing between $15 million and $25 million.

Inevitably, that level of celebrity and money stirs up gossip and backbiting. Today Pitanguy's name evokes a litany of rumors about his personal conduct, gripes about his penchant for self-promotion, reports of declining business, and questions about his vitality.

Another rumor on the circuit contends that Pitanguy, after years of celebrity, has been forced in the last few years to beat the bushes for cases. Because of the recession and concern about crime in Rio, clinic volume has been down in recent years, and to keep the operating rooms busy, insiders say, the clinic has made deals with corporations. But Pitanguy doesn't talk about that. "I don't touch money or discuss it," he says.

The advent of liposuction 17 years ago was, in many ways, the beginning of the end of the Pitanguy era. Fat suctioning has replaced a good percentage of body-contouring operations. Although Pitanguy uses liposuction, other surgeons have written the books on it. Meanwhile, new aggressive face-lift techniques being done in the United States have taken the spotlight away from Pitanguy's conservative technique. More radical North American surgeons believe Pitanguy's face-lift is as dated as the 60s Knoll furniture in his clinic.

Finally, they question how much surgery he actually does. "How old is he? He's got to be 80 by now" is a common remark. "I assure you," says one self-proclaimed insider, "Pitanguy does not operate anymore. His residents do everything."

"For 20 years they've been saying I don't operate anymore," says Ivo Pitanguy, without animosity, as he performs a face-lift maneuver on a German woman in his clinic in Rio. Working confidently, the ambidextrous Pitanguy switches the scalpel from his right to his left hand as he trims away several centimeters of facial skin in front of the patient's ear.

Some people think he's trimmed a few years off his age with equal dexterity. Pitanguy insists he's only 68. "It doesn't matter if he's 72," says Kirk Brandow, a Philadelphia surgeon (and former tennis pro) who trained with Pitanguy in the 80s. "His hands don't shake. He's in great shape. He's smart as a whip. And he plays tennis like he's 55."

Pitanguy's technical competence has never been an issue. "There are five or six great surgeons I have come across in my career who are gifted in the way they put in sutures. Pitanguy is one of them," says San Francisco plastic surgeon Bruno Ristow, one of Pitanguy's first residents.

The trouble with Pitanguy is his penchant for publicity, say critics. "I love Ivo," says a respected surgeon who doesn't want to be identified, "but he's had too much publicity."

Although Pitanguy speaks six languages, "publicity-shy" and "no pictures, please" have never been a part of his vocabulary. Long before Lifestyles of the Rich and Famous, his flamboyant way of life was a continuous photo opportunity for tabloids—to the dismay of the plastic surgery establishment.

One article after another showed the "pope of lifting" at the controls of his small plane, relaxing on his private Island of Pigs, spearing fish with actress Virna Lisi, boating with Margaux Hemingway, on skis in Gstaad with wife Marilu and the four kids, at home (where he hangs his Magritte and Dalis) in Rio's exclusive Gavea enclave. A Rio samba club created a Carnival float with a papier-mache effigy of him under the banner "Champagne, Caviar, and Pitanguy."

Declaring the publicity a "bad image for plastic surgery," the staid American Society of Plastic and Reconstructive Surgeons (ASPRS) revoked Pitanguy's corresponding membership in the early 1980s. "Iva is a man of many talents, an excellent surgeon, but there are many excellent surgeons all over the world whose public image has not been purchased by publicity," says Mark Gorney, the San Francisco plastic surgeon who was president of the ASPRS at the time. Pitanguy (who denies ever employing a public relations agent) was eventually reinstated. But the publicity had a momentum of its own.

It's no surprise, therefore, to arrive at his clinic and find it teeming with members of a French television crew. France's TFI is making a documentary about the wonders of Brazil, featuring the Amazon, Pele, and, of course, Pitanguy. The patients don't mind the inconvenience. It just proves they've come to the right doctor.

Pitanguy's reputation as a lady-killer must be based on his charm rather than his looks. He is built low and solid. The piercing eyes of his youth are now shaded by bushy salt-and-pepper eyebrows. Gravity's toll could be worse. Who did his face-lift? "You flatter me," says Pitanguy. (Word of mouth credits plastic surgeon Thomas Rees, now retired, but Rees denies it.) Smaller vanities include a touch of Grecian Formula, elevated heels, and custom-made blue scrub suits. "But I've never put my name on them," he says. That would be redundant.

The man known for self-aggrandizement is surprisingly self-effacing. "You can't call me the best anything," he insists. Like every surgeon, he concedes, he has complications. "In time, it happens less and less." And he refuses to disparage other surgeons. "In my school we don't criticize others."

Questioned about techniques, he directs a secretary to supply one of his 800 papers. He prefers to talk about art (he has been the president of Rio's Museum of Modern Art) or philosophy (he is the only physician in Brazil's Academy of Arts and Letters).

His recent writing concerns the modern-day dissatisfaction with appearance. "Man has always sought to be similar to his peers, to his tribe and his social group," he said in a 1993 speech, "Creativity and Plastic Surgery." "Difference implies being ostracized." But today's media-and-information bombardment, he said, "interferes with the perception of reality and has deep emotional consequences, [creating] impossible dreams. The individual aspires no longer to be like his peers, but rather to this group or that, whose economic and cultural supremacy has imposed their own image on him." Well-being, he said, is "the capacity to be in harmony and peace with his own image."

Pitanguy was born into surgery. His father was a general surgeon in Belo Horizonte, north of Rio. When young Iva felt faint watching his first operation, Pitanguy senior said the aversion was normal, but one had to get used to it because "human life depends on us." By his twenty-first birthday, Iva had his medical degree from the University of Brazil. During his general surgery residency in Cincinnati, he decided to become a plastic surgeon.

The specialty was just beginning to be recognized. Many practitioners were secretive. Some even charged admission to observers. Pitanguy obtained visiting fellowships with the leading reconstructive surgeons of the day—including Sir Harold Gillies and Sir Archibald Mclndoe in England and Paul Tessier in France.

By the late 50s, Pitanguy had established a power base—he was chief of plastic surgery, hand surgery, and burns—at a charity hospital in Rio. Resolving that the poor had as much right to his services as the rich, he wangled government support for his impoverished departments. "People wondered why he did so much free work," says his wife of 38 years, Marilu, the European-educated daughter of a Sao Paulo publishing magnate. And he was driven. "He was always working late on cadavers, trying to get a better scar or to perfect a nose," she adds.

Pitanguy was prepared when, on December 17, 1961, the plastic tent of the Gran Circo Norte Americano, performing in nearby Niteroi, was torched by a madman, trapping 2,500 people. Nearly 400 people, mostly children, died the first day. Hundreds more had second-and third-degree burns. Pitanguy mobilized their care. Syringes, antibiotics, and skin for grafts came pouring in from U.S. hospitals and the United Nations. The horror made headlines around the world (with a boost, critics carp, from his influential father-in-law). "For three days and three nights," wrote Pitanguy in his autobiography, "we operated, grafted, nursed and prayed."

Pitanguy had an epiphany when one of the survivors, a young man, looked at his scarred face in a mirror and said, "I'd rather be dead."

"At that moment, I realized it was not enough to repair. I dedicated my life to beauty," wrote Pitanguy. Soon he launched a U.S.-style surgical residency program, vowing to let anyone observe and to make cosmetic surgery respectable. In a period when U.S. surgeons would sneak celebrities into hospitals at night for face-lifts and then pretend they rarely did cosmetic surgery, Pitanguy showed people they could improve their looks—and that there was no shame in wanting to.

The concept was not a hard sell in Rio, where the beach is Main Street and bodies are always on parade. Thanks to Pitanguy, the mythical girl from Ipanema expects to have two or three "face liftings" in her lifetime. Her breasts, which, according to the Brazilian ideal, should fill but not overflow her bikini top, are often the result of breast-reduction surgery. (One of Pitanguy's innovations was not separating the nipple from the nerve supply.) If she wasn't blessed with abundant bund, she knows she can have a buttocks-lift, another of his innovations.

Pitanguy became the Pied Piper of cosmetic surgery. The pacesetters he met on continual trips abroad to medical meetings or visits to Switzerland (where he had a house and his eldest son was in school) invariably accepted his invitations to Rio.

Tucked away behind high walls on a shady street of embassies and faded town houses in Botafogo, a once-fashionable residential district, the clinic has become a Rio landmark. Armed guards (a fact of life in contemporary Rio) man the sliding corrugated-metal gates. The two sides of the clinic are the yin and yang of Pitanguy. One building, a nineteenth-century Baroque confection, is the psychological side. Here patients wait on face-powder-peach banquettes and are seen by Pitanguy in one of five examining suites (each with its own dressing cabinet and family waiting area). The artworks are all gifts from grateful patients (as are Pitanguy's numerous gold watches), including the portrait of the doctor by Gina Lollobrigida and the tapestry from Empress Farah Diba.

Pitanguy considers the consultation more important than the operation: "I try to get inside the soul, not just the body." He is adamant about not imposing his vision on the patient. Take a 16-year-old Brazilian girl he is seeing today. At first he thought she came for her nose. But no. "She has uneven breasts," he says. "One is large, one is quite small. The breasts are very important organs, and any asymmetry is very upsetting," says Pitanguy. "This girl doesn't care about her nose—which is very prominent. She only cares about her breasts, She will have a stigma if you don't correct it in puberty." He tells the nurse to schedule the surgery and never mentions the nose.

The consultations are brief. Patients arrive at the clinic essentially presold. Most time-consuming is having to explain why he won't operate to a patient who has traveled halfway around the world to see him. Pitanguy supposedly refused to operate on the aging Duchess of Windsor, considering it a health risk.

The newer building is the scientific side, housing offices, a library, a slide collection, an outpatient clinic, three operating rooms, and the much-talked-about 57-seat auditorium, where students and visiting doctors follow operations in progress on closed-circuit television and converse with Pitanguy, ("Watching Pitanguy operate is like going to the Louvre," says Luiz Toledo, a Sao Paulo plastic surgeon.)

Pitanguy's island off Rio (which he leases from the Brazilian navy) has come in handy—and still does. lnfluential patients who are not healed sufficiently to make the flight home convalesce there. (A Middle Eastern princess, who supposedly spent millions for surgery on herself and her entourage, recuperated there.) Flying too soon after surgery can be dangerous. The jet set was agog when the strong-willed wife of an oil-drilling-equipment magnate checked out, against doctor's orders, and burst her derriere stitches on the plane to Paris. The gossip didn't hurt Pitanguy. It just confirmed the caliber of his patients.

But success created pressure to do more in less time. Pitanguy adopted the controversial assembly-line system used by Houston heart surgeon Denton Cooley, among others, and disapproved of by many plastic surgeons who pride themselves on doing an operation in toto, or skin-to-skin, as it's called. Pitanguy makes no apologies for doing only the key parts of each operation. (In a face-lift, he does the critical lifting, rotation, and skin trimming. In a breast reduction, he does the nipple placement and tissue resection.) When he completes his part, he changes his gloves and gown and moves to the next operating room. He then retires to his dressing room, where he supervises the operations via closed-circuit television and offers suggestions. How else could he have done 45,000 operations in his 40-year career?

"Operating is very pleasant and creative," Pitanguy explains, "but in many operations there are long periods that belong not to the surgeon. A nose, I do it all, but an abdominoplasty, assistants can do it as well as or better than myself." Eight or nine cases—many involving multiple procedures—a day is not unusual. Each operation is started and finished by one of his five full-time assistants—all accredited plastic surgeons, some of whom have been on his staff for 15 years. They "are paid in proportion to what I make," says Pitanguy. "They can have their own patients. If I needed an operation, I'd be operated on by any of them." (Today specialists are brought in to do hand and craniofacial surgery because Pitanguy hasn't kept up with those fields.) Would Pitanguy modify the system for a Sophia Loren? "I treat them all the same," says the surgeon. "The beggar and the king."

Pitanguy allows few outsiders in the operating room, to maintain sterility. And he likes a calm atmosphere, believing that the patient can hear everything. Pitanguy is notorious for taking phone calls in the operating room on a special headset. One former resident recalls an animated conversation in Portuguese that turned out to be Pitanguy ordering lobsters for dinner.

Two hundred fifty surgeons apply every year for 5 places in Pitanguy's three-year residency program, run in conjunction with a charity hospital. There is no pay. Pitanguy selects four or five to spend their second year as his clinic residents. "It is a complete honor to be chosen," says Sheila Bushkin, a New Yorker who was a clinic resident last year. Dismissing reports that Pitanguy is slowing down, she says, "Professor Pitanguy is never late for surgery. He is always sharp. He is a born educator. He loves to come into the auditorium while his assistants are finishing up and explain what he did and why."

Since 1963 more than 400 have earned the right to say "trained by Pitanguy" and have a picture with him to prove it. Even surgeons who didn't train with him hang the obligatory photograph. "Many of these people are riding Pitanguy's coattails," cautions Mark Gorney. "Maybe they just stood around and watched for a while." Actually, 2,000 visiting doctors and fellows have spent one to three months just observing.

Except for emergencies, the operating rooms are closed whenever the peripatetic doctor is away vacationing, lecturing, or doing demo operations abroad, another activity that makes his colleagues apoplectic. "He comes in, skims off cases, charges huge fees, and leaves the local doctors to handle the follow-up problems," explains a European surgeon. Another gripe is that Pitanguy is indiscriminate in the groups he talks to. "He will speak at the Society of Toenail Specialists," quips one disenchanted U.S. colleague.

Meanwhile, an ambitious new generation of plastic surgeons is breathing down his neck. "Every plastic surgeon in Brazil wants to be the new Pitanguy," says O Globo society columnist Hildegard Angel. "One guy has a RollsRoyce to show he's as successful as Pitanguy. Others copy Pitanguy's way of dress. They go to Switzerland to ski. They want to have an island, fly a plane, like he does."

These style-conscious surgeons are missing the point, however. Pitanguy was always more than a lifestyle, and even more than a good technician. Underneath the hype, Pitanguy understood the role of cosmetic surgery in the twentieth century and established its importance. "Pitanguy is larger than a single technique," says Bruno Ristow. "He is an attitude toward excellence. He established an era."