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22 TULUA Abdominoplasty: Unrestricted Liposuction and Wide Transverse Plication
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22.2.8 Postoperative Period
A middle-pressure compression garment is dressed with the
patient still under anesthesia to dress all the surgical areas.
The patients are hospitalized overnight, intermittent compression devices on the legs are maintained and replaced for
graduated compression stockings after 12 h, additional
thromboprophylaxis with enoxaparin is used for a week, and
ambulation is forced the same day of surgery. Regular ofce
visits are on days 5 or 7, where drains are removed. No additional physical therapies or massages are used.
22.3 Results
Expected results are good in most of the patients with a very
acceptable shape of the umbilicus, and adequate scar and
navel location. Epigastric residual bulge is not observed. The
waistline is diminished.
Quantified results in 845 patients operated by 68 plastic surgeons in 10 different countries demonstrated
scores of 13.7 out of the maximum possible 16 points
score) [23, 24].
A modied Salles’ score was used to measure 8 parameters on each patient from 0- to 2 points [25, 26]. Results of
the measures were as follows:
1. Volume of the abdomen 1.82 points of a maximum 2
points score
2. Lateral contour 1.78 points
3. Skin excess/sagging 1.83 points
4. Umbilicus appearance 1.78 points
5. Scars on the abdominal wall 1.47 points
6. Location of the scar distance V. (Distance from the ante-
rior vulvar commissure to the transverse scar) 1.64 points
7. Proportionality between umbilicus and scar positions
(H/V ratio) 1.58 points
8. Epigastric bulging due to residual muscle wall laxity 1.75
points (Figs.22.15, 22.16, 22.17, 22.18 and 22.19)
In a previous study, TULUA demonstrated signicative
changes in waistline perimeter [27], results must be due to
liposuction without restriction, and to the fact that lowermedial borders of the external oblique muscles are involved
in the transverse plication and displaced inferiorly and to the
midline, allowing the reshaping of the waist.
Fig. 22.15 Representative
TULUA case 1. Left: a
28-year-old female, BMI 23,
Gravida 3, with satised
parity, asking for
augmentation mastopexy and
abdominoplasty. Frontal view
demonstrates skin and wall
laxity with fat deposits. Right:
15months after augmentation
mastopexy and TULUA
abdominoplasty. The
abdomen is at with contour
improvement, diminished
waistline, and no
compensatory epigastric
bulge. Scar and umbilicus are
well located
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Fig. 22.16 Representative
TULUA case 1. Left: the
same patient of Fig.22.15,
oblique preoperative view,
note skin accidity fat
deposits, and low umbilicus
relative to a high lower
abdominal crease. (Use the
lower abdominal crease to
place the incision is a
common mistake). Right:
15months after mastopexy
with implants and TULUA
abdominoplasty. Skin and
wall laxity have been
corrected, fat deposits
removed, midline, and
waistline improved their
denition. There is no step
deformity in the scar. A
correctly placed scar is noted
after planning it 6 mc above
the genitalia
F. Villegas
Fig. 22.17 Representative
TULUA case 1. Left: the
same patient of Figs.22.15
and 22.16. Lateral view
before surgery. Right:
15months after implants
mastopexy and TULUA
abdominoplasty. No residual
or compensatory bulge in the
epigastrium is noted
22 TULUA Abdominoplasty: Unrestricted Liposuction and Wide Transverse Plication
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Fig. 22.18 Representative case 2: TULUA corrects epigastrium
deformity. Left: patient with BMI 31, asking for mastopexy and
abdominoplasty. Skin and wall laxity are noted, beside a vertical infra-
Fig. 22.19 Representative case 2: TULUA corrects epigastrium
deformity. Left: the same patient in Fig.22.18 demonstrating epigastric
redundancy. Center: presurgical markings. Right: 18 months after
umbilical midline scar. Center: extrabdominal fat deposits are noted by
the patient grasp. Pathological diastasis was ruled-out during the presurgical examination. Right: 18months after TULUA abdominoplasty
TULUA abdominoplasty, epigastric redundancy has been corrected due
to unrestricted liposuction, massive hypogastric transverse plication,
wide pannus resection, and downward sliding of the epigastric skin
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F. Villegas
22.3.1 Complications
In the same series [23], no deaths were reported, and the
global complications were 16.2%, mostly seromas 8.8%, and
delayed umbilicus skin graft take 2.7%. Notoriously skin
necrosis was only 0.7%, and grouped vascular-related complications (necrosis, dehiscences, and infections) were 2.7%.
Although with TULUA modications to lipoabdominoplasty are expected a reduction of seromas, because of no
undermining, diminished tension, layered wound closure,
and reduced dead space [28], the author prefers to use suction drains because of the large amount of tumescent inltration and unrestricted liposuction. Additional studies could
conrm the expected reduction of seromas.
22.4 Discussion
TULUA is a radically different type of abdominoplasty; however, its evolution is according to the main historical currents of
the development of the abdominoplasty, to improve safety, add
simplicity, and maintain results. TULUA changes most of the
current paradigms; however, it maintains its alignment with the
current scientic plastic surgery reasoning and good sense.
It is well accepted that no elevation or direct dissection of
the epigastrium maintains its vascularity, as well as dimin-
ished tension in wound closure, avoids complications.
Following this line of thought, it is possible that the proposed epigastric no-detachment is safer from the vascular
point of view since it not only preserves the intercostal segmental vessels but the entire circulation of the deep epigastric artery coming from perforators from the rectus
abdominis muscles. Additionally, the traction exerted on the
abdominal muscles by the plication from the navel to the
pubis, gently advances the attached skin fat ap of the epigastrium downward, reducing tension on the skin suture
line, most of the tension is supported on the deep
structures.
Although initially the technique was indicated in selected
cases, today is the elective method in 92% of the author’s
cases; the rest 8% of patients who had pathological diastasis
or ventral epigastric hernias can be subjects of the vertical
and transversal plicature combined method.
Combining umbilical hernia repair with abdominoplasty
is a challenge solved in various ways, using special intrabdominal dissections, specically designed meshes, or laparoscopy [29–34]. In the authors’ practice, TULUA has
allowed to safely combine umbilical hernia correction
because the amputation of the umbilical stalk permits complete wall repair, while the neoumbilicoplasty avoids any
concern about umbilical stalk viability, deformation, or positioning (Figs. 22.20 and 22.21).
Fig. 22.20 Representative case 3: TULUA with umbilical hernia
repair. Left: female patient before abdominoplasty, a dotted line encir-
cles an incarcerated umbilical hernia 6cm in diameter. Center top: after
full liposuction of the upper abdomen and anks, en bloc resection of
the lower abdomen has been performed, then the hernia sac is being
dissected. No dissection above the hernia level is performed. Center
bottom: after hernia correction with sutures, a vertical plicature is
planned around the wall repair for reinforcement; a transverse plicature
10 × 30cm is depicted. Right: results 12months after TULUA and
umbilical hernia correction
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Fig. 22.21 Representative case 4: TULUA and simultaneous ven-
tral hernia repair. Left: female patient asking for an abdominoplasty
and ventral subumbilical hernia correction after abdominal hysterectomy. Center top: unrestricted liposuction of the upper abdomen and
anks has been performed, as well as “en bloc” resection of the lower
abdomen pannus. Three Allis forceps demonstrate hernial sac dissec-
Despite expected wide diastasis after massive weight loss,
the technique has been used in such cases when no pathological divarication is observed during presurgical evaluation, or it is not grossly observed during the periumbilical
dissection. The massive wide transverse plication of the
lower abdomen seems enough to integrally correct wall laxity; besides, the long and sometimes misplaced umbilicus is
amputated and created anew with acceptable results.
When hygienic reconstructive apronectomy is indicated,
TULUA can be performed to convert such reconstructive
procedures to true aesthetic abdominoplasties. A similar
experience has been reported by the author with the closure
of the donor area after a deep inferior artery perforator ap
for breast reconstruction [35, 36].
A very special group of patients with a moderate amount
of fat and skin laxity asking for high denition (etching) of
the abdomen have been operated combining safely differential liposuction with TULUA abdominoplasty (TULUA-HD)
[37–41].
Once the surgeon is trained with transverse plication
abdominoplasty, more indications will appear. In the author’s
experience, it is also very useful to solve secondary cases,
tion and wall defect, viscera have been reduced. Center bottom: vertical
closure of the hernia defect, a transverse plicature 10 by 28 cm, is
depicted to accompany the procedure. Right: 20 months after the
TULUA procedure. Note the integral correction of skin, fat deposits,
and wall laxity. The hernia has been cured without relapse
performing the surgery again to correct residual deformities
or complications [42, 43].
In general, TULUA widens the spectrum of indications.
22.4.1 Diusion oftheTechnique andGain
ofAcceptance
After its initial publication in 2011, the TULUA technique
has gained wide dissemination through scientic and social
networks, demonstrating that it is highly reproducible and
with a low learning curve; however, it is emphasized that it
must be performed by certied plastic surgeons in accredited
healthcare centers [44–47].
22.4.2 Animal Study
To reafrm the mentioned reasonings, an experimental study
in an animal model was designed to compare the wide
detachment conventional technique with TULUA lipoabdominoplasty. Using similar surgical techniques than in
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F. Villegas
humans, full liposuction was performed, followed by standardized skin resection, and vertical or transverse plication,
with or without upper abdomen ap detachment according to
each study group design. Measurements of tension necessary
to fascia and skin closure, plication size, and positions of the
scar and navel were annotated. Complications were described
and quantied. An external group blindly rated the scars
according to the Manchester scale. Euthanasia was performed at day 21 detailing the ndings [48, 49].
Flap necrosis was found to be more frequent and more
extensive in the vertical groups (p<0.01 and 0.04). In the postmortem examination, the permeability of epigastric perforators
was veried, despite extensive liposuction, in all the individuals in the transverse group and in none of the vertical groups.
The lack of union between the wall and the skin led to the
appearance of mesothelial cavities or seromas being more
frequent and with a greater area in the vertical groups.
The transverse lipoabdominoplasty had a greater area of
wall plication (p<0.000) and generated greater tension for
the closure of the wall (p<0.000), likewise decreasing the
tension of skin closure (p< 0.000) causing the horizontal
scar to remain low (p<0.05, p<0.03).
nancy and the pregnancy itself did not impair the aesthetic
outcome[50, 51].
22.5 Conclusions
The TULUA abdominoplasty technique incorporates a number of aspects of the historical, logical evolution of the
abdominoplasty to improve results, decrease recovery periods, and cut costs and complications. Surpassing the “proof
of concept” stage, TULUA is offered as an alternative with
technical, scientic, and historical evolutionary reasoning, as
a further step in the constant quest for excellence, simplicity,
and safety in plastic surgery.
Patient selection must follow appropriate criteria. Patients
must be well informed and with realistic expectations. The
surgeon performing TULUA for the rst time should choose
an easy case, without diastasis recti, and should be familiar
with conventional abdominoplasty, lipoabdominoplasty, and
the prevention and treatment of complications [52−55].
22.6 Summary
22.4.3 TULUA Advantages
The procedure allows full liposuction, corrects the abdominal wall integrally without supraumbilical detachment, and
there is the adequate placement of the scar and umbilicus
with good aesthetic results. Diminished tension in wound
closure with less wound dead space and nerve and vessel
preservation of the undetached ap are considered additional
advantages. Complications are low, and the learning curve of
the procedure is straightforward.
22.4.4 TULUA Disadvantages
The technique does not afford the rectus diastasis directly
and does not allow ventral epigastric hernia correction.
The creation of a new umbilicus is the most challenging
technical step and is prone to prolonged wound healing and
delayed graft take. Improper placement of the umbilicus in
the midline or very high setting is possible if attention is not
addressed to surgical details and anthropometric proportions. Some elongation is expected of the abdominal wall
after plicature, so the scar can migrate upwards with time
1cm and the umbilicus between 1 and 3cm.
There is some concern about the possible unfavorable
effects of the plicature on nerves and on the groins.There is
a report about a successful pregnancy and delivery after a
TULUA abdominoplasty, in this particular case the abdominoplasty did not interfere with the normal evolution of preg-
Lipoabdominoplasty is not exempt from complications such
as necrosis, wound dehiscence, epigastric redundancy, high
transverse scar, low positioning of the umbilicus, and seroma.
Since 2005 a modied lipoabdominoplasty has been performed in selected cases, modications are transverse elliptical
plication across the lower abdominal wall, no detachment of the
ap above the umbilicus, unrestricted liposuction of the abdominal ap including midline, anks, and epigastrium; direct
resection of skin and fat in the lower abdomen from the navel to
the pubis and from an anterior iliac crest to the other; umbilicus
amputation and immediate reconstruction in the ideal position
with a skin graft, and low transverse scar placement (TULUA).
It is believed that TULUA has advantages in terms of vascular safety, recovery of sensitivity, position, and quality of
the neoumbilicus, and location of the transversal scar, with
normal or superior aesthetic results, which could expand the
indications to a larger group of patients as obese, secondary
cases, umbilical hernias, ventral hernias of the hypogastrium
and those with massive weight loss due to bariatric surgery.
It could also be used for donor area closure of free aps of
the lower abdomen.
The main drawback of the technique is that no affords
directly de diastasis; however, a combination of vertical plicature in the midline with wide transverse plications of the
lower abdomen is used about 8% of the cases.
It is recommended as a useful tool to be performed by
plastic surgeons with experience in conventional abdominoplasty and lipoabdominoplasty who know the details of the
TULUA technique in patients with adequate indications.
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164 Patients. Aesthet Surg J. 2021;41:598–602.
55. Roseneld LK. Second Thoughts on First Thoughts. Aesthet Surg
J Open Forum. 2020;3(1):ojaa044. https://doi.org/10.1093/asjof/
ojaa044. PMID: 33791665; PMCID: PMC7954381
Secondary Abdominoplasty
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GuillermoBlugerman, DiegoSchavelzon,
VictoriaSchavelzon, andGuidoBlugerman
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23.1 Introduction
Patients coming in for revision surgery due to surgical
sequelae caused by previous abdominoplasties are becoming
more frequent in our consultations. The increase in the popularity of this type of surgeries is due to the simplication of
the techniques after the pioneering work of Avelar and
Saldanha, in addition to the increased number of patients
coming to us due to changes in the body secondary to bariatric surgery. Additionally, we do a large number of patients
who wish to correct unfavorable results achieved from the
primary procedure.
When one is faced with such a case, having not participated in the previous procedure, one is at a disadvantage
about information on the type of procedure our surgical colleague has performed on that patient and that makes the corrective surgery plan more conservative than we would plan
in a primary case or in a review of a patient of our own.
The TULUA technique developed by Dr. Francisco
Villegas consisting of upper ap liposuction along with a
transverse plication of the anterior rectus muscle of the abdomen [1, 2] is easy to execute and the versatility of neoumbilicoplastia allows to solve very safely most of the problems
that afict this type of patients.
23.2 Classication ofDefects
Consultations are usually by one or more of these factors: (1)
the scar, (2) the adipose content, (3) the skin continent, (4)
the aponeurotic muscle wall, and (5) the navel.
1. The scar may be
(a) Asymmetrical
(b) Poorly placed
G. Blugerman (*) · D. Schavelzon · V. Schavelzon · G. Blugerman
B&S Center of Excellence in Plastic Surgery,
Buenos Aires, Argentina
• Very high
• Very low
(c) Hypertrophic
(d) Keloidal
(e) Atrophic or dehiscent
(f) Attached to deep planes
(g) Poorly compensated
• Dog ears
• Displaced midline
(h) T inversion in the center for lack of ap descent
2. Adipose content may be
(a) Excessive
(b) Decient
(c) Asymmetrical
(d) Fibrous
3. The skin component may present the following
concerns:
(a) Excess
(b) With decit
(c) With scar adhesions
(d) With post-necrotic scars
(e) With residual stretch marks
4. The aponeurotic muscle wall may present with
(a) Hernias
(b) Eventrations
(c) Palpable sutures
(d) Diastasis
• Unresolved primary
• Secondary
5. The navel may have the following concerns:
(a) Absent
(b) Cicatricial
• Hypertrophic
• Keloidal
• Atrophic
(c) Very large
(d) Very small
(e) Misplaced
© 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_23
359
360
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G. Blugerman et al.
• Very high
• Very low
• Off the midline
(f) Shallow
23.3 Treatment Options
The treatment of the residual scar of a previous abdominal
dermolipectomy will depend on the expectations and desires
of the patient that must be correctly evaluated in the rst consultation to assess the existence of realistic expectations
about the results that we can achieve. It is not the same when
the tailor is stitching with a piece of virgin cloth versus when
they brought him a poorly cut and ill-tting garment to alter.
23.3.1 Asymmetrical Scar
Intervention in an asymmetric scar (Fig.23.1) should usually
be undertaken with adequate planning and study of the
stresses to which the skin of both edges of the scar is subjected. The presence of scoliosis that is often the cause of
these deformities as well as scars present before or after primary surgery should be taken into account.
to be lowered without taking off much and at the same time
transfers the forces and tensions to the deep planes allowing
the presence of more delicate scars and with less distortion at
the pubic level.
TULUA’s technique for scarring can even be performed
under local tumescent anesthesia and at the time of the surgery Klein tumescent solution inltration is performed using
a cannula into the sheath of each anterior rectus muscle and
oblique muscles simulating anesthetic TAP Block
technique.
If possible, scarpa [3, 4] fascia aps are separately raised
to further decrease the force that could be exerted on the
upper ap.
In very low-placed scars that usually manifest as a major
depression and loss of volume at the pubic level, the solution
could be the use of the scar substitution technique, taking off
its adhesions to the deeper layers and liposhifting [5] maneuvers at the edges of the incision if the volume of fat is adequate or lipograft at the level of the mount of Venus if it has
been too attened. This can even cause dyspareunia in some
cases due to lack of cushioning on the pubic symphysis during sexual activity. Carbopneumodissection [6] is a very useful assistant when grafting adipose tissue in the pubis as it is
a highly trabeculated adipose tissue and difcult to obtain a
harmonious distribution in all cases.
23.3.2 Poorly Placed Scar
In very high scars (Fig.23.2) TULUA’s technique with its
transverse stitch is the choice, since it allows the upper ap
Fig. 23.1 Asymmetric scar 3months postoperative. The patient had
dehiscence and secondary closure at 10cm in the center of the scar
23.3.3 Hypertrophic or Keloid Scar (Fig.23.3)
Local inltrations can be used with a solution including
0.1mL of Triamcinolone of 20mg/mL and 0.9mL of 5FU
(5Fluorouracile) of 50mg/mL [7, 8]. Intralesional inltration into the center of the scar until blanching or papule
formation occurs with a separation of 4 or 5mm between
one papule and the next. The frequency of inltration will
depend on the reaction of the scar to the treatment
individually.
At the time of correction of the residual scar after inltrations and to prevent relapses, the application of a gauze
embedded in 5FU may be used for 3min prior to the closure
of dermis [9], in addition to the other prevention measures
already known. It is very important especially in patients
with keloidal tendency to be explained very clearly that local
itching is one of the rst symptoms that usually occur in this
type of pathological healing. So when they start experiencing
itching they should schedule a check-up to assess the require-
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