Plastic and Reconstructive Surgery • March 2020
Correspondence to Dr. van der Lei neo-umbilicus is chosen and made through the use of a skin
Department of Plastic Surgery
University Medical Centre of Groningen
Hanzeplein 1, P.O. Box 30.001
9700 RB Groningen, The Netherlands
b.van.der.lei@umcg.nl
DISCLOSURE
The authors have no financial interest to declare in rela-
tion to the content of this communication.
REFERENCES
1. Guyuron B, Son JH. String fat/dermis graft for correction of
wrinkles and scars. Plast Reconstr Surg. 2019;144:93–96.
2. Carraway JH, Mellow CG. Syringe aspiration and fat concen-
tration: A simple technique for autologous fat injection. Ann
Plast Surg. 1990;24:293–296; discussion 297.
3. Stenekes MW, Van Der Lei B. Nasolabial fold augmenta-
tion with SMAS graft. J Plast Reconstr Aesthet Surg. 2012;65:
1618–1621.
Secondary Abdominoplasty: Management of the
Umbilicus after Prior Stalk Transection
Sir:
E very time, we are going to face an increased demand
from patients requesting secondary abdominoplas-
ties who had previously undergone a mini-abdomi-
noplasty with supraumbilical detachment and navel
detachment.1 The reasons are that the abdominal
area is increasingly more exposed, there are more fre-
quent changes in partners, and a there is a greater aes-
thetic demand from society, thereby causing a greater
demand for this type of treatment.
Personally, I have had nine cases of mini-abdom-
inoplasty treated using the supraumbilical diastasis
with umbilical transection and three cases of previous
treatment of umbilical hernia. In those 12 cases, a sec-
ondary abdominoplasty was performed (until 2015)
without any suffering or vascular damage to the umbi-
licus. The probable explanation is that the umbilical
pedicle behaved like a randomized flap 21 days after
primary surgery, and in the worst-case scenario, partial
or total necrosis with closure by secondary-intention
healing would be acceptable from an aesthetic point
of view.
In my opinion, these cases would be an accurate
indication for a transverse plication, no undermining,
full liposuction, neoumbilicoplasty, and low transverse
abdominal scar, or TULUA abdominoplasty, as published
by Dr. Villegas in 2014. I incorporated the TULUA pro-
cedure into my routine for secondary abdominoplasty
in 2016, and I have operated on 36 patients using this
technique. The TULUA technique allows for vigorous
and wide liposuction of the supraumbilical area since
it will not be detached, a trans-infra-umbilical wide pli-
cation, and amputation of the patient’s original navel.
At the end of the operation, the new location of the
654e
graft.
Our approach is to use epidural anesthesia per-
formed by the anesthesiologist and tumescent infiltra-
tion with lidocaine for its bacteriostatic power. Of the 36
patients I have operated on, 14 had previous unsuccess-
ful tummy tucks and 22 patients had extensive lipoaspi-
ration of the anterior abdomen, with adhesions or little
elasticity of the supraumbilical flap with which to per-
form the infraumbilical portion. The TULUA technique
allowed us to incorporate a new niche of patients who
were dismissed because their cases were complicated.2
TULUA offers a high degree of safety in its execution. It
also allows us to combine other procedures in the same
patient without extending the surgical time exceedingly.
With vigorous and extensive lipoaspiration of the
supraumbilical flap, it is possible to perform a high-
definition liposuction in that area and combine it with
the infraumbilical transverse plication of the TULUA,
allowing us to offer a very safe high-definition lipoab-
dominoplasty to our patients.
In the last 2 years, this technique has been dissemi-
nated worldwide, beginning in South America. Several
colleagues are practicing it and have it within their
therapeutic arsenal, allowing us to solve complicated
cases of our own or from colleagues who are not spe-
cialists in plastic surgery.
DOI: 10.1097/PRS.0000000000006581
Javier Vera Cucchiaro, M.D.
Javier Vera Cucchiaro Aesthetic and Laser Clinica
Avenue Entre Rios 220
Salta, Argentina
jvc@centrocirugiaestetica.com
Instagram: @javierveracucchiaro
Facebook: @DrJavierVCucchiaro
DISCLOSURE
The author has no conflict of interests to report.
REFERENCES
1. Dean RA, Dean JA, Matarasso A. Secondary abdominoplasty:
Management of the umbilicus after prior stalk transection.
Plast Reconstr Surg. 2019;143:729e–733e.
2. Villegas F. A novel approach to abdominoplasty: TULUA.
Aesthetic Plast Surg. 2014; 38:511–520.
Reply: Secondary Abdominoplasty: Management
of the Umbilicus after Prior Stalk Transection
Sir:
Managing an umbilicus when the stalk has been
previously transected and now requires circumscrip-
tion (i.e., for a full abdominoplasty) can theoretically
lead to ischemia.1,2 Our report3 about delaying the
umbilicus represents a potential solution and preserves
the patient’s intrinsic umbilical appearance. Neoumbi-
lization, as Dr. Javier Vera Cucchiaro and others have

Volume 145, Number 3 • Letters
described, obviates the need for a delay and offers an
alternative for surgeons and patients to discuss.
When possible, I prefer avoiding umbilical transec-
tion (e.g., at the primary procedure), because there
can be a tendency to lower the umbilicus more than
the 1- to 2-cm distance that is acceptable. This maneu-
ver might be considered in a modified type III, limited
abdominoplasty, which is an uncommon operative
choice in abdominal contour surgery patients. Postop-
erative patient dissatisfaction with these less invasive
alternatives to a full abdominoplasty can result unless
the patient is an ideal candidate for a limited abdomi-
noplasty and is fully aware of the procedure and its limi-
tations (e.g., less skin removal than an abdominoplasty,
persistent upper rectus muscle diastasis, and so on).
My coauthors and I thank Dr. Javier Vera Cucchiaro
for reporting his experience with the Villegas technique.
DOI: 10.1097/PRS.0000000000006582
Alan Matarasso, M.D.
Department of Plastic Surgery
Zucker School of Medicine at Hofstra/Northwell Health
New York, N.Y.
Correspondence to Dr. Matarasso
1009 Park Avenue
New York, N.Y. 10028
amatarasso@drmatarasso.com
DISCLOSURE
The author has no financial interest to declare in relation
to the content of this communication. No funding was received
for this communication.
REFERENCES
1. Matarasso A, Schneider LF, Barr J. The incidence and manage-
ment of secondary abdominoplasty and secondary abdominal
contour surgery. Plast Reconstr Surg. 2014;133:40–50.
2. Matarasso A, Matarasso DM, Matarasso EJ. Abdomino-
plasty: Classic principles and technique. Clin Plast Surg.
2014;41:655–672.
3. Dean RA, Dean JA, Matarasso A. Secondary abdominoplasty:
Management of the umbilicus after prior stalk transection.
Plast Reconstr Surg. 2019;143:729e–733e.
Oral Surgeons as Cosmetic Surgeons and Their
Scope of Practice: A Letter to the Editor
Sir:
A fter reading the article by Davison et al1 in the
April 2019 edition of the Journal, I was disap-
pointed by their overt misrepresentation of oral and
maxillofacial surgeons in regard to the training and
experience of contemporary oral and maxillofacial
surgeons.
The claim is made that “Oral surgeons have
sought to expand their scope of practice into areas
that, until now, have been restricted to physicians.”
Dentists, specifically, oral and maxillofacial surgeons,
1
have played an intimate role in the advancement of
medicine and dentistry. A review of history reveals
that dentists were the first to administer general
anesthesia, revolutionize facial trauma and recon-
struction, and make strides in tissue healing and
regeneration. It wasn’t until 1942 that the word “oral”
was dropped from what is known today as the Ameri-
can Association of Plastic Surgeons. In fact, prior to
1923, all “oral and plastic surgeons” were required to
have a dental degree.2
Further assertions are made that “the training and
educational background of a specialty physician is far
more comprehensive to that of an oral and maxillofa-
cial surgeon.” Graduates of American oral and maxil-
lofacial surgery programs must complete at least 175
major surgical procedures of the face, head, and neck.
All of these procedures must be completed in the final
year (year 4 or 6) of training.
Diepenbrock and Suihkonen assessed the expe-
rience of oral and maxillofacial surgery graduates in
regard to facial cosmetic surgery. It was found that
graduating oral and maxillofacial surgeons (2011 to
2016) completed an average of 20.3 facial cosmetic
procedures (excluding orthognathic surgery), with the
most robust program completing, on average, 107 pro-
cedures per graduate.3
Facial cosmetic surgery is a core tenet of oral and
maxillofacial surgery. It is required for graduation, is
part of the residents’ annual in-service examination,
is tested on both the written and oral board examina-
tions, and is an optional covered benefit provided by
malpractice carriers.
The authors conclude by stating physicians have
been “ineffective in proving the inadequacy of oral and
maxillofacial surgery education and training” and are
“without objective data.” This is because, as much as
some have tried, there are no supporting data. It would
be prudent for legislators and the public to review the
morbidity and mortality rate of all specialties!
The term “dentist” is often used by competing spe-
cialties as a derogatory term for oral and maxillofacial
surgeons. It does not fit the experience or scope of an
oral and maxillofacial surgeon. It is analogous to say-
ing a “surgeon” wants to do a face lift, without speci-
fying the specialty of the surgeon. Is that surgeon a
vascular surgeon, an orthopedic surgeon, a neurosur-
geon? These surgeons are not trained to do cosmetic
procedures, just as a periodontist, endodontist, or a
general dentist is not trained to do so. Lumping oral
and maxillofacial surgeons as “dentists” is no differ-
ent than saying a “physician” can’t perform cosmetic
procedures.
It is time for professional societies, state govern-
ments, dental and medical boards, and the public to be
thoroughly educated in the training and safety record
of contemporary oral and maxillofacial surgeons, as
well as the experience and training of all specialists
performing facial cosmetic surgery.
DOI: 10.1097/PRS.0000000000006582
655e