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TULUA Abdominoplasty: Unrestricted
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Liposuction and Wide Transverse Plication
FranciscoVillegas
22
22.1 Background
During abdominoplasty, liposuction of the detached
supraumbilical ap is not recommended because of its
vascular impairment and the possibility of skin and fat
necrosis [1].
Direct ap dissection above the umbilicus implies perforator vessel sectioning in a critical area in the midline,
involving the angiosomes of the superior epigastric artery.
Perfusion studies after such dissection demonstrate vascular
impairment [2]. On the other side, no undermining of the
ap has been conrmed to preserve the perforators and its
blood ow despite tumescent liposuction [3]. Well-known
plastic surgeons such as Illouz and Vila-Rovira directed
their efforts to create techniques without direct dissection
(no undermining) of the abdominal ap to increase safety
[4, 5]. No undermining at all impedes to correct the abdominal wallaccidity.
In order to perform wall laxity correction doing plication,
discontinuous undermining, and limited dissection to a tunnel
in midlineof the upperabdomen,were described by Lockwood,
Avelar, and widely published by Saldanha [6–12].
Main contributions of Lockwood’s workto the development of abdominoplasty were as follows: (1) to elucidate
that direct dissection was not necessary to close the abdomen
after wide pannus resection; (2) liposuction can be added to
the undetached ap to mold it and to allow discontinuous
dissection allowing ap sliding down for closure, while
maintains vascularity; and (3) diminished tension in wound
closure is a key point to prevent wound dehiscence and
improve quality of the scar [13].
The positions of the scar and umbilicus are crucial
aspects in evaluating abdominoplasty outcomes; frequently,
these factors are not directly addressed or adequately
planned, leaving their positions to random events during
surgery [14, 15].
In modern lipoabdominoplasty, amputation of the old
umbilicus and the creation of a new one (neoumbilicoplasty)are gaining acceptance because of its positioning, safety, and predictable results [16, 17].
Following these reasonings and in a constant search for
safety and good results, radical modications to current
abdominoplasty have been made consisting in no ap detachment above the navel instead of limited detachment or wide
detachments; transverse plication of the abdominal wall
instead of vertical plicature; complete unrestricted ap liposuction instead of limited lipoplasty; original umbilicus
amputation followed by skin graft neo-umbilicoplasty; and
proper location of the abdominoplasty abdominal scar under
diminished tension (TULUA) [18, 19] (Box 22.1).
F. Villegas (*)
Private Practice at Clínica San Francisco, Tuluá, Colombia
Plastic Surgery Unit, Universidad del Valle, Cali, Colombia
e-mail: francisco.villegas@correounivalle.edu.co
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_22
341
342
LIMITED DISSECTION
TULUA
CONVENTIONAL
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Box 22.1: TULUA acronym based on abdominoplasty modications; compared with lipoabdominoplasty and
conventional abdominoplasty
F. Villegas
LIPOABDOMINOPLASTY
Vercal plicaon
Supraumbilical tunnel dissecon
Liposucon
Umbilicoplasty by stump
exteriorizaon
Low scar locaon limited by no
supraumbilical dissecon
Modified from references 18,20,21,25
ABDOMINOPLASTY
Transverse plicaon Wide vercal plicaon
T
Undermining halted at the
U
umbilicus
Liposucon (without
L
restricons)
Umbilicoplasty with a skin
U
gra
Abdominoplasty with low
A
transverse scar localizaon
TULUA is the acronym that summarizes the modications to
the current abdominoplasty techniques and is the name of the
city in Colombia, South America, where the idea was developed since 2005. The name Tuluá means in the indigenous
language easy and fertile earth.
22.2 Surgical Technique
ABDOMINOPLASTY
Wide dissecon
Without liposucon or limited
("danger zones")
Umbilicoplasty by stump
exteriorizaon
Abdominoplasty with scar
locaon according to flap tension
22.2.1 Patient Selection
Careful selection of each patient is recommended using criteria similar to those for conventional abdominoplasty,
avoiding active smokers, body mass index more than 30,
patients with morbid obesity, uncontrolled comorbidities,
previous history of venous thrombosis, and pulmonary
thromboembolism (Box 22.2).
The plastic surgeon must be sure of knowing all the details of
the operative technique before starting the rst case, he or
she must be familiar with tumescent liposuction and with
lipoabdominoplasty [20–22].
Contraindicaons Relave
Indicaons
22 TULUA Abdominoplasty: Unrestricted Liposuction and Wide Transverse Plication
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Box 22.2: Selection of patients for TULUA abdominoplasty
Contraindicaons
Lack of technical knowledge Lack of previous
experience with the
technique
Morbid obesity Obese without
comorbidies
Pathological diastasis (more
than 5 cm, bulging or
invaginaon)
Epigastric hernia Ventral hernia in
Acve smoker Doubts about smoking
Personal history of venous
thrombosis and pulmonary
thromboembolism
Excessive epigastricscarring,
skin inelascity, excessive
fibrosis
Excessive transverse skin
flabbiness in the
epigastrium
Nulliparity Is parity not sasfied? Parity sasfied
Younger than 18 or older
than 60
Very high expectancy
accompaniedbygreat
deformity
Diastasis (les than 5 cm) Any paent who has an
hypogastrium
status, passive smokers,
chronic obstrucve
pulmonary disease
Family historyof venous
thrombosis and
pulmonary
thromboembolism
Midline upperabdomen
scars, moderate skin
adherences
Moderate skin laxity Redundancy (skin and fat)
Ages younger than 18 or
older than 60
High but reasonable
expectancy and deformity
343
Know technical details
Postbariatric, stabilized weight.
indicaon for abdominoplasty
without clinical diastasis or
epigastric hernia.
Umbilical hernia
No acve smoker
Adequate assessment of
Caprini's Score
A previous abdominoplasty,
abdominal surgery, scars,
subcostal scar.
epigastrium
Age 18-60
Adequate expectancy and
deformies
It is preferable not to operate patients younger than 18 or
older than 60years; postbariatric patients’ weight must be
stable, and their comorbidities controlled for at least 1 year.
Pathological diastasis must be ruled-out by physical
examination, with the patient lying down active trunk exion
is asked while the epigastric midline is carefully palpated.
If the interrectus distance is wider than 5cm, or if there is
a palpable bulging or undesirable sagging of the midline, the
patient is not a good candidate for isolated TULUA, and the
deformity must be addressed directly, and a combination of
vertical and transverse plications is recommended.
A routine ultrasound examination or computed tomogra-
phy of the abdominal wall is not necessary.
Variations of the conventional procedure must be
explained to the patient in detail, clarifying possible
advantages and disadvantages to obtain written informed
consent for the operation.
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22.2.2 The Operation
Intermittent pneumatic compression devices are used to prevent
deep vein thrombosis, warming blankets, patient warming air
devices, and intravenousuids warming are also encouraged.
22.2.3 Markings (Figs.22.1, 22.2, 22.3 and22.4)
Surgical markings are similar to conventional abdominoplasty, with emphasis on upper bimanual traction of the mons
veneris to plan the lowest midpoint of the incision, 6cm
above de anterior vulvar commissure or base of the penis.
After dening the midpoint, the skin traction is released, and
a line is drawn 2.5cm above the inguinal crease from medial
to lateral, the length of the incision must be long enough to
avoid rotation cones (dog ears)during wound closure, the
lateral part of this line can follow a natural abdominal crease
and can vary according to patients preference. A symmetrical line is drawn on the opposite side, completing the inferior
limit of the resection, an ellipse is competed drawinga line
passing above the umbilicus.
F. Villegas
Fig. 22.2 TULUA skin incision marks. After dening the lowest
midpoint of the inferior incision, skin traction is released. From the
center to the sides, symmetrical lines are drawn 2.5cm above the inguinal creases, symmetry is encouraged. Markings extend laterally as long
as necessary to avoid dog ears
Fig. 22.1 Skin markings for TULUA. A 35-year-old female, BMI
27kg/m2, two previous cesarean sections, is asking for abdominoplasty.
During preoperatory surgical markings, she exerts strong upward traction of the abdominal skin to determine the lowest point in the midline
6cm above the anterior vulvar commissure
Fig. 22.3 Skin marking of the lower abdomen resection during
TULUA abdominoplasty. The lateral limits of the lower incision can
vary from patient to patient; usually, they can reach the mid axillary or
posterior axillary lines. The markings are completed drawing a curved
line passing above the umbilicus to form an ellipse
22 TULUA Abdominoplasty: Unrestricted Liposuction and Wide Transverse Plication
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22.2.4 Liposuction oftheAbdomen
Under general anesthesia, a tumescent inltration of normal
saline and epinephrine 1:500,000 is used to produce turgor
and pallor on the entire abdomen, anks, trunk, and additional areas to be liposuctioned.
After a time-lapse of 7–15min, unrestricted, deep, and
supercial conventional liposuction of the upper abdomen,
anks, mons pubis, trunk, and complementary areas is per-
formed using 4or 5mm cannulas (Figs.22.5 and 22.6).
Adequate ap thickness and mobility are then checked.
Flap thickness in the midline must be about 2cm to have
enough umbilical deep after its creation at the end of
surgery.
22.2.5 Resection oftheAbdominal Pannus
The inferior marking of the resection is incised above the
Fig. 22.4 TULUA transverse plication abdominoplasty. For
demonstrative purposes, a red ellipse is drawn in the hypogastric area
with the approximate size of the wall plicature. The red paramedical
vertical arrow demonstrates the vector of the advancement of the rectus
muscles during its imbrication with the plicature. Obliquely oriented
arrows indicate the expected advancement of the external oblique muscles. Vertical lines in the upper abdomen are the surface marks of rectus
muscles, and semicircular lines in the anks depict the external oblique
muscles
pubic area (Fig.22.7) and proceed in a beveled dissection
into the fat layer, to avoid a step deformity during wound
closure because the supraumbilical zone is thinner than the
mons veneris.
En bloc resection (Fig.22.8) above the muscular fas-
cia,of the demarcated ellipse is performed. The perforator
vessels in the hypogastrium are carefully electrocoagu-
345
Fig. 22.5 Unrestricted
liposuction during a
TULUA procedure. After
tumescent inltration, enough
to perform wet liposuction.
Suction-assisted lipectomy is
completed; there is not a
restriction in the midline.
Supercial and deep planes
are suctioned through 4–6
ports using “candy cane” 4
or5mm cannulas in multiple
crisscrossed tunnels
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Fig. 22.6 TULUA allows
unrestricted liposuction:
Left: the pinch test before
tumescence and liposuction.
Right: after liposuction, the
pinch test demonstrates
signicative fat resection, a
fat layer of about 2cm thick
must be preserved in the
midline to have deep enough
to create the umbilicus and to
avoid a step deformity during
the mons veneris closure
F. Villegas
Fig. 22.7 Lower abdomen resection during TULUA. Left: not lipo-
suction is performed below the umbilicus, unless that, additional fat is
needed for grafting: The lower incision is performed as low and, as long
as planned. In the area above the mons veneris, a beveled incision is
carried down to preserve some amount of fat to avoid a step deformity
lated; dissection is halted at the umbilical level. The
resection includes the umbilicus, a palpation maneuver of
the umbilical stalk, and a milking massage avoids an accidental injury of the viscera during the umbilicus sectioning. The remaining umbilical ring defect is closed with
sutures.
Above the navel, dissection is not performed.
during the wound closure. Right: the resected pannus is elevated, two
black arrows are pointing the umbilical stalk, dotted black line encircles
the preserved suprapubic fat to have a better thickness match with the
supraumbilical ap during the closure
22.2.6 Plication oftheAbdominal Wall
With the operating table exed 30°–45°, and under muscle
relaxation, a horizontal ellipse is drawn on the abdominal
fascia from one anterior iliac spine to the other and from
the umbilicus to pubis to do a transverse plicature.
Dimensions of the plicature can vary from patient to patient,
22 TULUA Abdominoplasty: Unrestricted Liposuction and Wide Transverse Plication
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Fig. 22.8 En bloc pannus
resection during TULUA
abdominoplasty. Left: after
being sure that there are no
visceral organs in the
umbilical stalk, it is sectioned.
Right: after resection of the
planned fat and skin, note that
there is no dissection above
the umbilicus, careful
hemostasis must be
guaranteed
Fig. 22.9 Transverse
plicature markings on the
abdominal wall during
TULUA. Left: the surgeon
extends his or her left hand
and produces a furrow on the
lower abdomen to determine
the size of the plicature.
Right: the transverse plicature
is depicted. It can vary in each
patient according to the wall
accidity; usually, it is
10–14cm high by 26–32cm
wide. Note how the lower
border of the external oblique
muscle coincides with the
upper lateral marking of the
planned plication
347
testing by manual depression on the abdominal wall
(Figs.22.9 and 22.10). Excessive height can produce fascia
tearing during the plication. The transverse plicature is performed doing two layers of stitches (0 polypropylene), the
rst layer with interrupted sutures with buried knots, followed by a running suture for reinforcement.
If signicant diastasis recti is observed during thissurgical phase, a limited tunnel dissection can be done up to the
xiphoid to perform a vertical plicature, followed by transverse plication. These combined cases area named
TULUANHA (Because it is a combination with Saldanha
technique).
22.2.7 Closure
The wound is closed, repairing Scarpa’s fascia (Fig. 22.11)
using multiple interrupted sutures of 2-0 USP polyglycolic
acid. The dermis is repaired with 3-0 interrupted sutures of the
same suture material, a subcuticular running suture with 3-0
absorbable monolament in a cutting needle completes the
wound closure. Closed suction drainage is recommended.
The operating table is returned to its 180° at position,
and the new umbilical position is determined, according to
the golden proportion 1:1.62; where 1 is determined by the
distance from the vulvar introitus or base of the penis to the
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Fig. 22.10 TULUA
abdominoplasty improves
the waistline. Left: an Allis
forceps is grasping the lower
border of the external oblique
muscle, simulating the
downwardly and medially
displacement that will occur
with plication. Right: two
initial stitches of 0 USP
polypropylene with buried
knots are being placed in the
external oblique muscles
demonstrating how they
advance to improve the
waistline
Fig. 22.11 Plication
completed and wound
closure starting during
TULUA. Left: a two-layered
closure of the abdominal wall
completes the plicature (the
operating table is exed
30°–45°). The surgeon is
closing the umbilical ring
with sutures. Note how the
epigastric undetached ap
slides down to reach the lower
incision. Right: a tension-free
closure is possible. The
Scarpa’s fascia is carefully
repaired with interrupted
sutures 2-0 USP polyglactin.
Suction drains are left in place
F. Villegas
incision (V), and 1.62 corresponds to the distance from the
incision to the neoumbilicus (H). During this step, a
Fibonacci sterile caliper is useful but not indispensable.
Frequently the V distance is 6cm, then the umbilicus must be
created a new, about 9.7cm above the closed transverse skin
incision.
Neoumbilicoplasty (Figs. 22.12, 22.13, and 22.14) is
made by an inverted U-shaped incision. A 2.5 cm wide
depression is formed around the U incision by means of
direct defatting around with scissors until the linea alba is
visible and palpable. After these maneuvers, the dermis of
the incised “U” is rmly sutured to the linea alba using 6
buried stitches of 2-0 USP polyglycolic acid suture. The
remaining raw area on the fascia corresponds to the bottom
of the new umbilicus and is grafted with a full-thickness skin
graft sutured with 3-0 plain catgut sutures (Box 22.3).
22 TULUA Abdominoplasty: Unrestricted Liposuction and Wide Transverse Plication
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Fig. 22.12
Neoumbilicoplasty planning
during TULUA. Left: with
the operating table extended,
the midline is marked, the
distance from the vulvar
commissure to the incision is
measured (V), and this
distance is multiplied by 1.62
(golden proportion) to get the
length of the distance H
corresponding to the span
from the neoumbilicus to the
incision. Right: a golden
proportion compass of
Fibonacci is corroborating the
measurements and
calculations
349
Fig. 22.13
Neoumbilicoplasty during
TULUA. Left: an inverted U
is incised, then some defatting
around it creates a
periumbilical depression with
soft slopes. The underlying
dermis of the U is sutured
with buried knots interrupted
2-0 polyglactin sutures to the
linea alba. Right: a fullthickness skin graft is sutured
to the midline abdominal wall
with 3-0 plain catgut, to
recreate the umbilical bottom
350
one week sucon drainage, anthromboc prophylaxis.
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Fig. 22.14 TULUA allows
wide dissection and
tension-free closure. Left:
before surgery, an assistant is
demonstrating the amount of
resection and epigastric ap
mobility. Right: Samepatient
on the operating table, after
unrestricted tumescent
liposuction, no undermining
of the ap above the
umbilicus, transverse
plication, layered wound
closure, and
neoumbilicoplasty
Box 22.3: TULUA abdominoplasty operative technique details
F. Villegas
Surgeon's Preparaon Qualified plasc surgeon,who knows the convenonal
technique, and alternave techniques, has combined
liposucon and abdominoplasty previously, knows details of
the TULUA technique.
Paent selecon No diastasis, no epigastric hernia. Any paent who qualifies
for convenonal lipoabdominoplasty at the surgeon's
"intuive" criteria. (Avoid difficult or secondary cases to
start doing TULUA)
Operang room cerfied according to the laws of each country, the
possibility of hospitalizaon, anthromboc protocol,
surgery table with the possibility of flexion.
Markings Upper tracon, 5 to 6cm from the genitalia
Liposucon. Tumescent without restricon, midline upper abdomen and
Flanks. ( useof energies to do liposucon is not
recommended unl more experience is gained)
Pannus resecon En block,no Scarpa's fascia preservaon, no liposucon in
the lower abdomen
Plicaon From pubis to the umbilicus, or less if the tension does not
allow. Dimensions can vary according to each paent.
Wound closure Layered closure, Scarpa's fascia repair,very low placement,
no tension, anchorage to pubis,use drains.
Neo-umbilicoplasty Small gra, only for the navel boom 1.5 cm. Inverted U
incision, the skin of the U aached to fascia with sutures.
The golden number and Fibonacci compassare useful but
not indispensable.
Postoperative period Moderate lycra compression, early ambulaon, no massage,
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