Sociedad Colombiana de Cirugía Plástica

Estética y Reconstructiva

Body Contouring

Aesthetic Surgery Journal

2020, 1–18
TULUA Lipoabdominoplasty: No © 2020 The Aesthetic Society.
Reprints and permission:
Supraumbilical Elevation Combined With journals.permissions@oup.com
DOI: 10.1093/asj/sjaa183

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Transverse Infraumbilical Plication, Video www.aestheticsurgeryjournal.com

Description, and Experience With 164

Patients

Francisco Villegas, MD

Abstract
Background: TULUA (transverse plication, undermining halted at umbilicus, liposuction [without restrictions], um-
bilicoplasty with a skin graft, and abdominoplasty with low transverse scar localization) is a fundamentally different
lipoabdominoplasty technique intended to reduce the risk of vascular compromise, correct wall laxity through a unique
plication, allow freedom in choosing the umbilical position, reduce tension on closure, and keep the final scar low.
Objectives:  The objectives of this article were to describe the TULUA technique and its variations, delineate the indica-
tions and contraindications, show the expected results, and determine its safety profile.
Methods: A series of 164 patients is presented. The technique’s basic tenets were (1) infraumbilical wide transverse
plication; (2) no undermining above the umbilicus; (3) unrestricted liposuction, including the supraumbilical tissues; (4)
umbilical amputation and neoumbilicoplasty in the ideal position with a skin graft; and (5) low transverse scar placement.
Complications were recorded and tabulated. Results were evaluated utilizing Salles’ and the author’s graded scales.
Results:  Scores averaged 9.4 out of 10 on the Salles’ scale and 5.6 out of 6 on the author’s scale, demonstrating adequate
correction of the abdominal contour and the wall and skin laxity, with properly placed scars and umbilici, and without com-
pensatory epigastric bulging. Overall, 20% of the patients experienced a complication: 9.7% experienced a delay in either
the healing or graft take of the umbilicus, 0.6% developed skin necrosis, 0.6% experienced a wound dehiscence, 2.4% had
an infection, and 4.9% developed a seroma.
Conclusions:  The TULUA lipoabdominoplasty technique was found to improve abdominal wall laxity and aesthetics to
a degree that is similar to traditional abdominoplasty, based on the evaluated parameters. The complications associated
with the procedure are within the range of other abdominoplasty techniques, and the technique potentially has a reason-
able safety profile with less risk of vascular compromise.

Level of Evidence: 4 

Editorial Decision date: May 8, 2020; online publish-ahead-of-print June 29, 2020. Therapeutic

Dr Villegas is a Clinical Professor of Plastic Surgery, Universidad

In traditional abdominoplasty, wide undermining of the ab-
dominal flap up to the xiphoid and costal margins is performed
to allow inferior flap advancement and vertical plication from
the xiphoid to the pubis. The addition of liposuction allows
for thinning of the abdominal flap, as well as improving the
del Valle, Cali, Colombia, and Unidad Central del Valle, Tuluá, Valle,
Colombia.
Corresponding Author:
Dr Francisco Villegas, Carrera 34 # 26-09 Oficina 504, Tuluá, Valle
del Cauca, Colombia, 763021.
Email: fvillegastulua@gmail.com; Twitter: @fvillegastulua
2
Table 1.  TULUA Modifications Compared With Lipoabdominoplasty and Conventional Abdominoplasty
Conventional Abdominoplasty Saldanha’s Lipoabdominoplasty
Wide vertical plication Vertical plication
Wide dissection Supraumbilical tunnel dissection
Without liposuction or limited (“danger Liposuction
zones”)
Umbilicoplasty by stump exteriorization Umbilicoplasty by stump exteriorization
Abdominoplasty with scar location Low scar location limited by no supraumbilical
according to flap tension dissection
Modified from references6,18-21.
surrounding areas. However, the combination of extensive
elevation and liposuction of the flap itself has been associ-
ated with increased risks of necrosis, dehiscence, infection,
and seromas. This prompted Matarasso,1,2 in his classic pa-
pers on combining liposuction and abdominoplasty, to de-
lineate liposuction restriction zones, whereas Baroudi3 and
Rosenfield and Davis4 recommended postponing liposuction
after the initial procedure.
In 1995, Lockwood5 described safe liposuction during
abdominoplasty utilizing limited paramedian epigastric dis-
section and discontinuous undermining of the flap up to the
costal margins to preserve perforators. His paper changed
the general assumption that wide undermining is neces-
sary to advance the abdominal flap, adding the concept
that liposuction can be performed safely if no extensive
undermining is utilized. Despite these recommendations,
he reported 2 patients with minor wound border necrosis
and 1 patient with a 4 cm skin necrosis in his series of 50
patients (6%).
In 2001, Saldanha et al6 published a lipoabdominoplasty
technique that utilizes limited undermining of the
supraumbilical tissue and a vertical plication up to the
xiphoid through a central tunnel that preserves most of
the muscle perforator vessels, as Graf et al7 demonstrated.
Despite fairly limited dissection, the discontinuous under-
mining produced by liposuction allows the advancement of
the supraumbilical tissue so that it can reach the inferior clo-
sure line, which may be under significant tension because it
has to span the entire infraumbilical vertical distance.
Other key factors that a surgeon must take into account
in producing good results after abdominoplasty are the
low positioning of the scar and locating the umbilicus in
an aesthetic situation unhindered by undue tension or the
previous anomalous umbilicus stalk length, location, or de-
formity.8-13 Another important consideration is to diminish
tension on the closure, which can improve the perfusion of
the wound edges, decreasing the risk of dehiscence and
necrosis; where possible, this can help maintain the scar in
a low position.5,14-16
Aesthetic Surgery Journal
TULUA Abdominoplasty
T Transverse plication
U Undermining halted at umbilicus
L Liposuction (without restrictions)
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U Umbilicoplasty with a skin graft
A Abdominoplasty with low transverse
scar localization
To address all of the previously mentioned issues, in 2011
I17 published a series of abdominoplasty modifications, which
I  started making in 2005 in selected cases. These modifi-
cations included: no elevation of the supraumbilical flap,
combined with unrestricted liposuction of the entire flap,
treatment of wall laxity with an extensive transverse plication
of the infraumbilical abdominal wall, no vertical plication, am-
putation of the umbilicus, locating the abdominal scar very
low, and creation of a neoumbilicoplasty with a skin graft in
an ideal position (Table 1). I named this technique “TULUA”
(transverse plication, undermining halted at umbilicus, lipo-
suction [without restrictions], umbilicoplasty with a skin graft,
and abdominoplasty with low transverse scar localization),
and have published a number of articles regarding it.18-22
The purpose of this article is to familiarize the reader
with the latest advancements in technique and technical
variations to expand indications, delineate the indications/
contraindications, determine the effects of the proce-
dure on abdominal contour, and define the safety profile
for TULUA.
METHODS
From June 2005 to June 2018, I  performed 164
abdominoplasties that were included in this study. All of
the patients were informed about the surgeries and signed
an informed consent. Ethical and patient security protocols
were followed according to the national, local, and institu-
tional regulations for plastic surgery–accredited institutions.
The traditional TULUA technique, which is described
below, was utilized on the majority of patients. In 12 patients
(7.3%), transverse infraumbilical plication was combined with
a vertical supraumbilical plication through a central tunnel,
which was added to treat pathologic rectus diastasis in the
supraumbilical region. Secondary abdominoplasties that
utilized the TULUA technique were included.
The patients that were excluded from the study were
those with partial tissue resections in the infraumbilical
Villegas3
Table 2.  Patients’ Characteristics 
Characteristic Female Male Obese
Number 161 3 31
% 98% 2% 19%
TULUA, n = 164.
Table 3.  Patients’ Comorbidities
No comorbidities Abdominal Umbilical
scars hernia
Number 98 58 23
% 59.7% 35% 14%
TULUA, n = 164.
region, even if they had a transverse plication, which I call
“transverse plication mini-abdominoplasty”; had traditional
panniculectomies; had abdominoplasties without liposuc-
tion; required mesh wall repair; and had isolated vertical
plications.
Demographic characteristics, indications, details of the
operative technique, and complications were recorded.
I quantified the results according to the Salles et  al23,24
clinical scale. The Salles clinical scale is a 10-point scale
that includes 5 parameters, each of which is assigned 2
points. The parameters are (1) global abdominal volume;
(2) lateral contour; (3) skin redundancy; (4) umbilical ap-
pearance; and (5) abdominal scar quality. I compared the
preoperative and postoperative photographs and graded
the results based on the above parameters at an average
of 60 weeks (range, 3–500 weeks) postoperation. The
numbers attained for each of the 164 patients were then
averaged.
Additionally, I added my own 3-parameter scale, where
each parameter was also assigned 2 points each. These
parameters evaluated the following: (1) distance from the
vulvar commissure to the scar; (2) proportion between
that measurement and the distance from the scar to the
new umbilical position, compared with an ideal, hypothet-
ical golden proportion; and (3) residual redundancy of the
supraumbilical region. The numbers attained for each of
the 164 patients were then averaged.
Patient Selection
As a general rule, TULUA is contraindicated in obese pa-
tients, patients with uncontrolled diabetes or uncontrolled
hypertension, and active smokers. However, the study in-
cluded 31 patients (19%) who presented with a body mass
Not obese Primary case Previous abdominoplasty Previous liposuction
133 133 22 9
81% 81% 13% 6%
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Hypertension Other hernias Postbariatric Smokers Diabetes
11 7 7 5 5
6.7% 4.2% 4.2% 3% 3%
index over 30 and 5 patients (3%) who were active smokers
(Tables 2 and 3).
Although initially the TULUA technique was utilized
only in selected cases, currently it is performed in almost
all patients presenting for abdominal contour surgery,
except for those who have a pathologic rectus diastasis
in the supraumbilical region. Pathologic rectus diastasis
is considered to be greater than 5 cm, detected at a clin-
ical examination in which excessive bulging or marked
depression can be noted between the medial edges
of the recti muscles during active trunk flexion. In such
cases, a combined vertical and transverse plication was
performed.
Surgical Technique
In the standing position, the infraumbilical tissues are
manually elevated superiorly and a central point is
marked 5  cm to 6  cm from the anterior vulvar commis-
sure or the base of the penis (see Supplementary Video).
Next, the manual traction is released, and the markings
are extended laterally toward the sides, 3.5 cm above the
inguinal fold. The lateral limits of this line can reach the
posterior axillary line, extending as much as necessary to
avoid dog-ears and to correct lateral laxity.5 The end of
that marking is joined with another semi-elliptical line that
passes over the umbilicus, defining the amount of tissue
to be resected. The size of this resection may vary from
patient to patient, in some cases reaching a level above
the umbilical insertion. It is the intent of this marking
method to place the final scar at 6 cm above the top of
the vulvar commissure or the base of the penis. The lat-
eral extent of the scar positioning may vary somewhat ac-
cording to the criteria of each surgeon and the patient’s
wishes (Figure 1).
4
Video. Watch now at http://academic.oup.com/asj/
article-lookup/doi/10.1093/asj/sjaa183
All cases were performed under general anesthesia.
Infiltration with normal saline and adrenaline, 1:500,000,
is performed until tumescence and vasoconstriction is
achieved.
Circumferential liposuction of the trunk and extremities
is performed when indicated. Unrestricted liposuction of
the supraumbilical abdomen, in both the deep and super-
ficial planes, is completed, leaving behind a uniform flap 2
to 3 cm in thickness (Figure 2).
Next, the skin and fat of the lower abdomen are excised
by dissecting the tissues off the underlying rectus fascia ei-
ther en bloc or by starting inferiorly and advancing superi-
orly to the level of the umbilicus. The umbilical stalk is then
excised at its base, and the defect is closed with sutures.
With the operating table at 30° of flexion and the pa-
tient under skeletal muscle relaxation with neuromuscular
blockers; a depression maneuver of the lower abdominal
wall is performed by pressing down with 4 extended fin-
gers to measure the magnitude of the wall laxity. Based on
this maneuver, an ellipse of variable height is drawn that
can span from the umbilicus to the pubic bone and from an
inferomedial border of the external oblique muscle to the
other (Figure 3).
With 0-The United States Pharmacopeia (USP) polypro-
pylene, 4 key inverted sutures are placed, advancing the
external oblique muscles down and toward the midline,
and leading to a narrowing of the waistline that is noticed
immediately. Centrally overlying the rectus muscle fascia,
vertically oriented inverted sutures of the same kind are
placed in the same vector as the rectus muscle fibers, ex-
erting downward traction on the abdominal flap. A second
running suture layer is then placed, utilizing the same cal-
iber material.
The described transverse plication advances the fatty
tissues and skin, bringing together the edges of the wound
Aesthetic Surgery Journal
under diminished tension, which allows the careful closure
of Scarpa’s fascia, which is complemented by a multilay-
ered closure. Suction drains are either placed through the
mons pubis or are brought out through the incision. The
operating table is then extended to a flat position. At this
stage of the operation, the abdomen is flat, the waist is nar-
rowed, the scar is kept low, and no compensatory bulge of
the upper abdomen is noticed (Figure 4).
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Neoumbilicoplasty is performed by selecting a midline
point according to the golden proportions of 1:1.618, meas-
ured with a sterile ruler or with a Fibonacci caliper from the
xiphoid to the scar according to Visconti and Salgarello10
or from the anterior vulvar commissure according to my
technique.19 At the selected area for the new umbilicus,
an inverted U incision of 1.5 cm in diameter is made, and
defatting is performed 2.5 cm around the neoumbilical in-
cision, down to the fascia in the midline. Dermal fixation of
the edges of the inverted U to the aponeurosis of the linea
alba is performed with 6 stitches of 2-0 USP polyglactin,
leaving a raw area that is tunnel mouth–shaped, on which
a full-thickness skin graft is fixed with stitches of plain
catgut 3-0 USP (Figure 5).
For venous thromboembolism prevention, preopera-
tive risk stratification was performed according to Caprini’s
score.25,26 Patient warming devices and warming of the
intravenous and tumescent fluids were utilized in every
case. Below the knee, intermittent pneumatic compres-
sion devices were applied during surgery and during the
recovery room stay; assisted ambulation started 6 hours
after surgery, and subcutaneous enoxaparin or dalteparin
was administrated 12 hours after surgery and for 7  days
after surgery. As an antibiotic prophylaxis, 2 grams of in-
travenous cefazolin was utilized 1 hour before the skin inci-
sion and during every 4 hours of surgery.
A moderate-pressure compression garment was ap-
plied to the thighs and torso, and the patient was admitted
to the hospital for 1 day.
Variations of the Technique
TULUA With Umbilical Hernia Repair
The abdominal dissection is carried approximately 5  cm
above the umbilicus in a central tunnel, medial to the edge
of the recti muscles. The hernia sac is dissected and the
hernia defect is suture-repaired, and is reinforced with a
small vertical plication above the umbilicus, combined with
the transverse plication of the typical TULUA procedure
(Figures 6 and 7).
TULUA in the Treatment of Pathologic Supraumbilical
Rectus Diastasis
A central tunnel is dissected up to the xiphoid to perform
a supraumbilical vertical plication with continuous su-
tures in 2 layers of polyglactin 0 USP. Polypropylene is
Villegas5

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Figure 1.  TULUA preoperative surgical markings. (A) With this 42-year-old woman in a standing position, strong upward manual
traction was exerted to determine a central point 5 cm to 6 cm above the anterior vulvar commissure. (B) Resection marks were
completed utilizing black lines. Her EOMs and rectus muscles were delineated with parallel red lines. Black and red arrows
demonstrate the direction of the plication. This marking method is utilized to place the final scar at 6 cm above the vulvar
commissure. EOM, external oblique muscle.

not utilized because the skin graft of the neoumbilicus will
lie on this suture line and there may be extrusion of this
unabsorbable suture material. The transverse plication is
then done in the typical TULUA fashion. I  call this tech-
nique “TULUAnha,” because it is a combination of TULUA
and Saldanha et  al’s6 lipoabdominoplasty technique
(Supplemental Figures 1 and 2).
infraumbilical resection will be utilized. In some pa-
tients, this will necessitate a degree of umbilical de-
scent. Alternatively, a neoumbilicoplasty is performed
after amputation and closure of the old umbilical defect,
much like a secondary mini-abdominoplasty, to cor-
rect an umbilical and scar malposition (Supplemental
Figures 3 and 4).

TULUA in Secondary Cases RESULTS

En bloc resection is not performed in secondary cases.
The flap is raised from inferior to superior, up to the um-
bilicus, and the transverse plication is performed. Flap re-
section is tailored based on flap mobility and the desired
low position of the scar. Sometimes this requires leaving
behind a small inverted T.
In some secondary cases, the complete resection of
tissues below the umbilicus is impossible, so a partial
I operated on 164 patients, whose ages ranged between
18 and 64 years (mean, 40.6 y ± standard deviation, 9.9).
The follow-up time varied widely, between 3 and 500
weeks (mean, 59.9 weeks ± standard deviation, 101.8).
Among these 164 patients, there were 161 women and 3
men. There were 133 primary cases; 22 secondary cases
due to complications or unsatisfactory results of previous
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Figure 2.  TULUA: unrestricted liposuction of the supraumbilical tissues. (A) This 42-year-old woman is shown under general
anesthesia, after tumescence, and before liposuction; a pinch test shows the flap thickness. (B) Unrestricted liposuction was
performed in the deep and superficial planes from different ports in the epigastric area. Liposuction is not performed in areas
to be resected below the umbilicus. (C) Uniform flap thinning was performed after crisscrossed liposuction tunnels.

A B C

Figure 3.  En bloc resection of the infraumbilical tissues. (A) This 44-year-old woman is shown during TULUA surgery, with her
infraumbilical tissues being resected en bloc. The umbilicus stalk is going to be sectioned. Continuous dissection is halted at
the umbilicus. There is no continuous undermining of the supraumbilical tissues. (B) The 4 extended fingers of the left hand
test the laxity of the anterior abdominal wall (“furrow test”) to plan the extent of the transverse plication. (C) An ellipse, 30 cm
x 12 cm, has been marked. The superolateral borders of the planned plication coincide with the inferomedial borders of the
external oblique muscles (arrow).
Villegas7

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Figure 4.  During TULUA, the advancement of the external oblique muscles narrows the waistline. (A) This 44-year-old
woman is shown during TULUA surgery. The inferomedial border of the external oblique muscle has been advanced inferiorly
and toward the midline with 2 sutures. The purple arrow on the skin demonstrates the vector of the advancement. (B) The
infraumbilical abdominal wall is shown after completion of a 2-layered transverse plication and closure of the umbilical defect.
No compensatory bulge of the epigastric area is detected. (C) After Scarpa’s fascia advancement in the same direction of the
arrows, I perform skin closure in layers and a neoumbilicoplasty in my preferred position.

abdominoplasties or mini-abdominoplasties; and 9 cases 5 of them (3%) were unacceptable, 3 (1.8%) cases had very
due to liposuction sequelae (Tables 2 and 3). high umbilici, and 25 (15%) cases were placed slightly high;
Almost all of the abdominoplasties were associated in 5 patients, it was necessary to perform revisional sur-
with other body contouring procedures: liposuction of gery for scars and umbilici (Tables 7 and 8).
other areas (95%), gluteoplasty with fat grafts (72%), and
breast surgeries (62%). Facial surgeries were performed
simultaneously in 19 out of the 164 patients (11.5%). On Complications
average, 2.5 procedures were performed per patient.
Overall, the percentage of complications was 20%, mostly
One patient had an isolated TULUA lipoabdominoplasty
due to skin graft loss and delayed umbilical healing (9.7%).
(Tables 4 and 5).
One patient presented with distal flap necrosis and another
The average width and height of the transverse plica-
had partial dehiscence of the transverse wound. Both were
tion were 10.4 cm and 27.2 cm, respectively. The amount of
treated medically without surgery. There were 4 patients
tumescence utilized was 6025 cc on average, varying be-
who developed a wound infection, and 1 of them required
tween 600 cc and 10,000 cc. The amount of lipoaspirate was
a 7-day hospitalization and treatment with intravenous anti-
4063 cc on average, varying between 100 cc and 7200 cc.
biotics; no additional surgery was performed because of
The maximum resection weight was 12,230 grams and the
the infections. There were 2 patients who developed deep
minimum weight was 150 grams, with an average of 1435
vein thrombosis between 1 and 2 weeks after surgery. They
grams. Red blood cell transfusion was utilized in a single
were diagnosed by ultrasound after clinical suspicion and
case. The duration of surgery varied between 1 and 8 hours,
treated with systemic oral anticoagulation without hospital-
with an average of 5.6 hours. A total of 158 patients had a
ization. No fatal complications or pulmonary emboli were
hospital stay for 1 day, 1 stayed for 3 days, 1 stayed for 4 days,
encountered (Table 9).
1 stayed for 5 days, and 3 required stays of 7 days (Table 6).
According to my measurement, the aesthetic results
utilizing the Salles clinical scale were determined to be 9.4 DISCUSSION
points out of 10 for the 164 patients studied and 5.65 points
out of 6 points for the additional 3 parameters that I added. Abdominoplasty techniques have remained relatively un-
However, 17 umbilici (10.3%) were classified as suboptimal, modified over many decades, with the most noticeable
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Figure 5.  Neoumbilicoplasty in the planned position. (A) After wound closure, the new umbilical position is determined in the
midline. The golden rule proportions can be helpful to place the new umbilicus, utilizing the anterior vulvar commissure as a
guide for the golden ratio of 1:1.618. In this case, a 6:9.7 cm ratio is demonstrated with the Fibonacci caliper. (B) An inverted U
incision has been defatted around its periphery and firmly sutured to the linea alba; a full-thickness skin graft will lie directly
over the midline aponeurosis.

changes being the addition of liposuction, improvements
in safety, better patient selection, and improvements in the
quality of results.27-30
The TULUA technique brings together the greatest his-
torical trends in abdominoplasty to improve safety while
maintaining aesthetic results, making surgery simpler
(Figures 8 and 9). No undermining or selective detach-
ment of the flap makes lipoabdominoplasty safer than the
traditional elevation up to the xiphoid and costal margins.
TULUA magnifies this concept, because there is no under-
mining at all above the umbilical level.
In a systematic review and meta-analysis by Xia et al31 on
the safety of lipoabdominoplasty versus abdominoplasty,
a total of 17 studies were selected among 483 eligible ar-
ticles, which provided data from 14,061 patients, including
42 TULUA cases described in my 2014 publication.19 The
review demonstrated that lipoabdominoplasty is a valu-
able tool in body contouring, without evidence of having
more complications than conventional abdominoplasty.
In 1990 and 1992, Illouz32,33 described his abdomin-
oplasty technique without undermining, allowing un-
restricted liposuction. Although no treatment of the
musculoaponeurotic layer was performed in his de-
scriptions, the results were acceptable. However, com-
plaints of high scar positions and poor location of the
neoumbilicoplasty were reported.
Because the abdominal wall laxity is multivectorial, both
horizontal and vertical shortening are desirable for the
wall’s integral correction during abdominoplasty. Some de-
gree of a vertical decrease in length is possible by utilizing
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C

Figure 6.  TULUA abdominoplasty and umbilical hernia repair. (A) This 47-year-old woman requested an abdominoplasty and
umbilical hernia repair. (B) The hernia sac is dissected. Transverse plication and hernia repair are depicted. (C) After hernia
repair, a small vertical periumbilical plication and a wide transverse plication are performed. (D) At 53 weeks after surgery, note
the wall laxity correction and no evidence of hernia relapse or compensatory bulging in the supraumbilical region. There is
good shape and position of the umbilicus and waistline improvement.

mattress triangular sutures34 or adding a transverse com-
ponent to the plication, forming an “L.” 35
Other types of single or multiple sutures have been
described to improve the waistline and vertical sagging,
with “customized” oblique, semilunar, H, L, J, and epigas-
tric transverse sutures that require ample flap dissection,
which would have a negative effect on vascularization.36-39
Although conventional vertical plication and transverse or
anchor plications can be performed with limited detach-
ments, they may have greater technical difficulty.40,41
The idea of semi-elliptical transverse plication in the
infraumbilical region, as described by Cárdenas Restrepo
and Muñoz Ahmed42 for mini-abdominoplasty, is ex-
tended with the TULUA technique, which increases the
area of plication to the entire infraumbilical area, with
the added advantage of preserving the vascularity of the
supraumbilical tissues by avoiding flap undermining in
the epigastrium.
TULUA treats multivectorial abdominal wall laxity with a
wide transverse plication from the umbilicus to the pubis
and from an external oblique muscle to the other, folding
on itself the musculoaponeurotic layer of the anterior and
lateral wall of the abdomen in the same physiological
direction of its contraction. Transverse plication advances
external oblique muscles down and toward the midline,
creating a narrower waist and shortening the rectus mus-
cles in the same direction of their muscle fibers (Figure 4).
The wide transverse plication decreases the tension on
wound closure, which can have additional positive effects
on flap circulation, reducing marginal necrosis and dehis-
cence. Because the supraumbilical tissues are essentially
advanced inferiorly by the plication, not by undermining, it
is less likely to compromise the blood supply of these tis-
sues while also allowing easy, direct closure, which signifi-
cantly decreases the dead space that could have an effect
on decreasing the number of seromas.
Proper location of the umbilicus and the transverse
scar are key factors in obtaining good results in abdo-
minoplasty. According to Martínez-Teixido et  al43 and
Hoyos et  al,9 immediate or delayed neoumbilicoplasty
allows the surgeon the freedom to choose the best pos-
sible location without concern for the original position of
the umbilicus. The final position of the abdominoplasty
transverse scar is affected by a number of factors, in-
cluding the tension on closure. In traditional abdomino-
plasty, the superior flap has to travel a long way to the
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C D

Figure 7.  The results of the same patient shown in Figure 6 who presented for TULUA abdominoplasty and umbilical hernia
repair. (A, C, E) The preoperative photographs of this 47-year-old woman showed an umbilical hernia and abdominal wall laxity,
accompanied by subcutaneous fat deposits. (B, D, F) At 53 weeks after surgery, the umbilicus and scar are well positioned (a
Fibonacci caliper demonstrates a 1 to 1.618 proportion), her hernia has been repaired, the wall laxity has been corrected, the
waistline has diminished, and the neoumbilicoplasty is quantified as 2 points (good) according to the Salles score. The relaxed
lateral view demonstrates no compensatory bulging in the epigastrium or hernia relapse.
Villegas11

E F

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Figure 7.  Continued.

Table 4.  Type of Procedures Associated With TULUA 

Surgery Liposuction of Other Areas Gluteoplasty Breast Surgery Facial Aesthetics

Number 156 118 102 19

% 95% 72% 62% 12%

n = 164 patients.

Table 5. Number of Simultaneous Procedures Associated
With TULUA
Number of Associated Number of
Procedures Per Patient Patients
0 1
1 17
2 59
3 67
4 19
5 0
6 0
7 1
Average
n = 164 patients.
inferior edge of the resection, which can pull up the final
scar position to an undesirable superior position. This
difficulty is worse in the Saldanha et  al6 technique be-
%
cause of the limited dissection and the remaining re-
taining septa with perforators in the periumbilical area.
0.6%
TULUA reduces the tension of the superior tissues on
10.4% the final scar position, because the transverse plica-
tion moves down the superior tissues with it, with the
36,0%
added benefit of minimal vascular compromise because
40.9% of the diminished tension on closure and perforator
preservation.
11.6%
Initially, TULUA was only utilized in special situations.
0.0% Currently, however, I utilize the TULUA technique in almost
0.0%
all abdominoplasty cases. It is especially advantageous in
patients who present with umbilical hernias, postbariatric
0.6% patients, secondary cases, patients with malpositioned pre-
2.6%
vious scars, and in general when there are doubts about
perfusion and the vascular supply of the supraumbilical tis-
sues (Supplemental Figures 5 and 6).
12 Aesthetic Surgery Journal

Table 6.  TULUA Surgery Characteristics 

Age, years BMI, kg/m2 Operative Tumescence, mL Lipoaspirate, mL Resection, g Plicature Plicature
Time, hr Height, cm Width, cm

Min 18 20 1 600 100 150 5 15

P25 33 25 5 5000 3000 800 9 26

P50 41 27 6 6000 4000 1200 10 28

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P75 47 29 6 7000 5000 1605 12 30

Max 64 40 8 10000 7200 12230 14 37

Aver 40.6 27 5.6 6026 mL 4063.5 1435.4 10.4 27.2

n = 164 patients. Aver: average; BMI, body mass index; Max, maximum value; Min, minimum value; P25, P50, and P75: 25th, 50th, and 75th percentiles.

Table 7.  Evaluation of Aesthetic Appearance Using Scored Results in TULUA Abdominoplasty

Score Evaluated Parameter Number of Cases Average

1. Volume of the abdomen, range 0–2 1.98

0 Large amount of fat in the abdomen, large bulging 0 –

1 Moderate amount of fat in the abdomen, some bulging 3

2 Adequate amount of fat in the abdomen, without bulging 161

2. Lateral contour, range 0–2 1.98

0 In anterior view, abdominal waist at the navel level, with bulging 0 –

1 Abdomen with straight lateral contour, without defining the waist 3

2 Well-defined abdominal waist, with concavity 161

3. Skin excess/sagging, range 0–2 1.97

0 Large skin excess, with sagging and stretch marks 0 –

1 Moderate amount of skin excess, with sagging 4

2 Without skin excess and/or sagging 160

4. Navel appearance, range 0–2 1.86

0 Navel scar with deviation, retraction, hypertrophy, or adjacent skin excess 5 –

1 Acceptable appearance, with or without discrete deviation, retraction, 12

skin excess, or scarring

2 Naval scar of natural appearance 147

5. Scars on the abdominal wall, range 0–2 1.60

0 Hypertrophic or keloid, hyperchromic, hypochromic, depressed, or in awkward position 6 –

1 Poor scar appearance 53

2 Scar of good appearance 105

Global score 0–10 9.4

n = 164; range, 0–10; Salles et al.23

Villegas13

Table 8.  Evaluation of Aesthetic Appearance Using Scored Results About Scar–Umbilicus Positioning and Epigastrium Quality
in TULUA Abdominoplasty

Score Evaluated Parameter Number of Cases Average

1. Location of the scar distance V, range 0–2. Distance from the anterior vulvar commissure to the transverse scar. 1.95

0 More than 10 cm 0

1 Between 9.9 cm and 7.1 cm 8

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2 Less than 7 cm 156

2. Proportionality between navel position and scar, H/V, range 0–2 1.81

0 High or low navel: H/V greater than 2 or H/V less than 1.5 3

1 Close to the ideal position: H/V = 1.5 to 2.0 25

2 Ideal position. Golden rule: H/V = 1.62 136

3. Epigastric bulging due to residual muscle wall laxity, range 0–2 1.89

0 Visible bulge when standing 0

1 Visible bulge when sitting 18

2 Flat epigastrium 146

Global score 0–6 5.6

n = 164; range, 0–6. H, distance from the scar to the navel in cm; H/V, ratio between distance H (cm)/distance V (cm); V = distance from the anterior vulvar commissure
to the transverse scar.

Table 9.  Complications From TULUA  Although contraindicated in cases of pathological

diastasis, TULUA has been combined with vertical plica-
Complication Value %
tion through a central tunnel in the supraumbilical region
Total number of complications 33 20% (12 out 164 patients [7.3%]) to add the advantages of de-
Skin graft failure in the umbilicus 16 9.7% creased dead space and diminution in the tension of the
wound closure with total autonomy in the location of the
Seroma 8 4.9%
umbilicus. The term “TULUAnha” has been proposed as a
Reinterventionsa 5 3% combination of Saldanha et al’s6 widely known technique
with TULUA.
Wound infectionb 4 2.4%
A special group of patients who want high-definition
Deep vein thrombosisc 2 1.2% liposuction could benefit from the described approach,
Blood transfusion 1 0.6%
because more aggressive modification of the flap can
be made to demarcate the midline and semilunar line,
Keloid in umbilicus 1 0.6%
and to define supra-umbilical etching, utilizing conven-
Skin necrosis in the hypogastriumd 1 0.6% tional liposuction or vaser and laser energies.44 At the
2019 American Society of Plastic Surgeons meeting in
Wound dehiscence 1 0.6%
San Diego, Babaitis45 presented experience with 30 pa-
Death 0 – tients—9 of them males combining full-plication transverse
Pulmonary embolism 0 –
abdominoplasty with high-definition liposculpture—which
he named “TULUA-HD.”
Blood transfusion (1) and reinterventions (5) were not summed in the total The aesthetic closure of the abdominal wall after infe-
number because they were part of the treatment of other complications.
n  =  164. aDue to umbilicus and scar revisions. bOf the 4 wound infections, 1
rior deep epigastric artery perforator flap harvesting has
patient required a 5-day readmission for intravenous antibiotics. cAmbulatory been previously described by Visconti and Salgarello.10 It
treatment. dNo surgery required. was accomplished utilizing TULUA for the closure of the
14 Aesthetic Surgery Journal

A B D

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C

Figure 8.  TULUA results: example patient. (A) This 51-year-old woman who had 2 pregnancies and a body mass index of
31 requested an abdominoplasty. (B) Epigastric extra-abdominal fat redundancy is demonstrated by the patient. (C) After
unrestricted liposuction of the supraumbilical region, tissues of the lower abdomen have been resected; there was no
dissection above the umbilicus. A transverse plication will be performed, and a layered wound closure and neoumbilicoplasty
are also necessary to complete the procedure. (D) At 16 months after surgery, adequate aesthetic results were attained.

donor defect. I  have called this technique “TULUA-Deep
Inferior Epigastric artery Perforator flap” 46 (Supplemental
Figure 7).
It is important to note that there are some potential dis-
advantages to the TULUA abdominoplasty. First, the tech-
nique requires sacrifice of the umbilicus and the creation
of a neoumbilicoplasty. Most of the complications and low
aesthetic scores were due to problems with the umbilici.
Neoumbilici can be erroneously placed in high positions;
additionally, they can migrate upwards 1 cm to 3 cm with
time, because of some skin stretching and transverse pli-
cation relapse, especially in secondary cases. I encoun-
tered these problems more frequent in my early cases,
but the issues have diminished with experience.
Additional disadvantages of the TULUA technique are that
it does not directly address the vertical diastasis of the rectus
abdominis and does not allow the correction of supraumbilical
hernias without the described TULUAnha modification.
At this stage, it is not clear what the physiologic effect
of transverse plication is on intraabdominal pressure. It is
also unknown what effects, if any, this type of plication has
on the inguinal canals47 and the biomechanics of standing
and walking.
This study has a number of shortcomings that I acknowl-
edge and hope can be addressed in the future. First and
foremost is that the judging of results that I  achieved can
certainly be criticized as biased. Second, it is not clear
how the results of the TULUA abdominoplasty will differ
from the results of traditional vertical plication procedures.
It appears that the results are comparable, but this needs
to be confirmed in studies that compare these techniques
head-to-head.
Villegas15

A B

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C D

Figure 9.  TULUA results: follow-up of the same patient from Figure 8. (A, C, E) This 51-year-old woman who had 2 pregnancies
and a body mass index of 31 is shown before an abdominoplasty. A large extra-abdominal pannus and wall laxity are observed.
(B, D, F) At 16 months after TULUA surgery, the umbilicus and scar are properly placed, and there is global improvement of the
abdomen. Note the epigastrium flattening despite no supraumbilical plication.
16
E F
Figure 9.  Continued.
CONCLUSIONS
The TULUA abdominoplasty technique is designed to re-
duce the risks associated with elevation of the abdominal
flap and to treat abdominal wall laxity through a wide trans-
verse infraumbilical plication, and usually does not require
vertical plication. This is combined with amputation of the na-
tive umbilicus, which affords the surgeon the ability to place
the neoumbilicus in an ideal position, regardless of its original
position. In this study, I found that the abdominal contour was
dramatically improved based on 8 different parameters as de-
lineated by Salles and me. The safety profile of the procedure
was found to be acceptable, with most of the complications
occurring due to the neoumbilical skin graft not taking. I feel
that this approach is a viable alternative to traditional abdo-
minoplasty techniques. However, more studies need to be
undertaken to directly compare the results of TULUA with
traditional abdominoplasty techniques. Overall, TULUA poten-
tially offers a simple abdominoplasty technique that produces
good aesthetic results with a reasonable complication profile.
Supplementary Material
This article contains supplementary material located online at
www.aestheticsurgeryjournal.com.
Acknowledgments
I thank Dr Al Aly for his great contribution made through con-
structive comments and the generous donation of time for the
editing of this writing.
Aesthetic Surgery Journal
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Disclosures
The author declared no potential conflicts of interest with re-
spect to the research, authorship, and publication of this article.
Funding
The author received no financial support for the research,
authorship, and publication of this article.
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