Abdominoplasty with Unrestricted Liposuction, No Epigastric Flap Elevation, Transverse Plicature and Skin Graft Neoumbilicoplasty (TULUA) - Description of 100 Cases.

In the pursuit of safety and good results in lipoabdominoplasty several modifications have been proposed with the TULUA technique.^1-2 The experience with 100 patients operated between 2005 and 2017 is described.

Operative technique: tumescent liposuction without restrictions in the entire abdomen including the epigastrium, en-bloc dermolipectomy of the hypogastrium above the muscular aponeurosis, amputation of the umbilicus and umbilical ring closure, wide horizontal aponeurotic plication in two planes with nonabsorbable sutures from the umbilicus to the pubis and from one iliac spine to the other, suture by planes and suction drainage, finally neoumbilicoplasty with skin graft in the ideal position is performed.

Results: 97% were women, in 89% there were associated procedures such as mastopexy, gluteoplasty and belt dermolipectomy, the main indications were: umbilical hernia in 16, previous abdominoplasty in 11, postbariatric in 9, other indications were to avoid vertical scar when moderate redundancy of the epigastrium was present, obesity and other indications at the discretion of the author.

There were no fatal cases, nor pulmonary thromboembolism, there was no flap necrosis and any reoperations. Objective scoring of results in 48 was rated excellent, 50 as good and 2 bad. No epigastric bulge was noted. The scar was located 6.3 +/- 1.2 cm from the anterior vulvar commissure, and the umbilicus was placed in an ideal position when measured according to the gold standard proportion in 74%, although there was no graft integration of navel in 14%, the umbilical result was objectively measured as good in all but two cases, 8 seromas were treated by repeated punctures.

Conclusions: TULUA adds the liberal use of liposuction to the abdominoplasty demonstrating safety, which allows the flap to be molded in critical areas such as epigastrium, subcostal margins, and waist. In spite of not dissection of the flap in the epigastrium, transverse plicature corrects in an integral way the laxity of the wall.

Possible advantages: simplification of the abdominoplasty, preservation of more vessels and nerves, less suture line tension, less dead space and fewer seromas, no accumulation of skin and fat in the epigastrium, low scar location, freedom in the selection of the new umbilical position and navel of normal aesthetic appearance.

Disadvantages: does not address the diastasis recti in the epigastrium, the umbilicus can migrate up, especially in secondary cases.

TULUA incorporates several aspects of the historical evolution of abdominoplasty to expand indications, improve results, improve recovery periods and reduce costs and complications. It has widely passed the proof of concept, gaining diffusion as a logic and scientific innovation to add simplicity and safety to the plastic surgery of the abdomen.

References:
1- Villegas F. A Novel Approach to abdominoplasty: TULUA modifications (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar). Aesthetic Plast Surg 2014; 38(3):511-20
 2 - Villegas F. A paradigm shift for abdominoplasty: transverse hypogastric plication without supraumbilical dissection, unrestricted liposuction, neoumbilicoplasty, and low placement of the scar (TULUA). In: Di Giuseppe A, Shiffman AM, editors. Aesthetic Plastic Surgery of the Abdomen. Springer. 2016: p 171-193