COSMETIC

TULUA Lipoabdominoplasty: Transversal

Aponeurotic Plication, No Undermining,
and Unrestricted Liposuction. A Multicenter
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Study of 845 Cases

Francisco J. Villegas-Alzate,

Background: TULUA (transverse plication, no undermining, full liposuction,

M.D.
Guillermo Blugerman, M.D.
Javier Vera-Cucchiaro, M.D.
Lázaro Cárdenas-Camarena,
M.D.
Carlos O. Uebel, M.D., Ph.D.,
H.C.
Diego Schavelzon, M.D.
Ernesto Moretti, M.D.
Esteban Elena, M.D.
Ayman Elmeligy, M.D.
Stefan Danilla, M.D., M.Sc.
Tuluá, Colombia; Buenos Aires,
Salta, Santa Fe, and Mar del Plata,
Argentina; Zapopan, Jalisco, México;
Porto Alegre, Brazil; Cairo, Egypt; and
Santiago, Chile
neoumbilicoplasty, and low transverse abdominal scar) is the acronym for a
radically different lipoabdominoplasty, intended to add simplicity, improve
vascular safety, and attain good results. Modifications are unrestricted liposuc-
tion, no flap detachment, massive transverse infraumbilical plication, umbili-
cus amputation, neoumbilicoplasty, diminished tension wound closure, and
low transverse scar settlement. The objectives of this article are to describe the
technique and analyze a multicenter experience.
Methods: Sixty-eight plastic surgeons from 10 countries provided data for a
retrospective review of 845 patients. Aesthetic results were scored by each sur-
geon using the Salles scale and analyzed in combination with complications to
identify associations between patient and surgery characteristics.
Results: Of the patients, 95.5 percent were female, 19.7 percent were obese,
35.6 percent had prior scars, 10.4 percent had undergone previous abdomino-
plasty, 6.5 percent were postbariatric, and 6.6 percent were smokers. One patient
had a kidney transplant, and 16.5 percent had comorbidities. Surgery charac-
teristics varied widely, being on average as follows: lipoaspirate, 2967  ml; resec-
tion, 1388  g; and surgical time, 3.9 hours; 46.5 percent were not hospitalized.
Averaged results were 8.68 of 10 points, besides adequate positioning and pro-
portion of scar and umbilicus, without epigastric compensatory bulging (4.97 of
6 points). Overall complications were 16.2 percent, mostly seroma (8.8 percent);
vascular-related complications (i.e., necrosis, wound dehiscence, and infection)
constituted 2.7 percent. There were no fatalities. The logistic regression model
demonstrated that smoking and obesity duplicate the risk of complications; if age
older than 60 years is added, the risk of complication increases seven to nine times.
Reported indications were multiple; however, pathologic diastasis was excluded.
Conclusion: TULUA lipoabdominoplasty is a new reproducible procedure with
good quantified results and an acceptable complication rate.  (Plast. Reconstr.
Surg. 148: 1248, 2021.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

From the Plastic Surgery Department, Universidad del Valle
Cali; UCEVA, Central Unit of Valle del Cauca Tuluá;
Centro B&S Plastic Surgery; Aesthetic and Laser Surgery
Clinic; Innovare, Specialized Plastic Surgery Clinic;
Division Plastic Surgery, Pontifical Catholic University
of Rio Grande do Sul; Gamma Health Group, Hospital
Privado Rosario; Centro de Medicina y Cirugía Plástica
Esteban Elena; Plastic Surgery Department, Ain Shams
University; and Department of Plastic and Reconstructive
Surgery, University of Chile Clinical Hospital.
Received for publication April 11, 2020; accepted April 26,
2021.
Copyright © 2021 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000008577
C
ombination of liposuction and epigastric flap
elevation during abdominoplasty is prone to
vascular-related complications.1,2 In contrast,
liposuction with no flap undermining is considered
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
Related digital media are available in the full-text
version of the article on www.PRSJournal.com.

1248 www.PRSJournal.com
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 Volume 148, Number 6 • Transverse Plication Abdominoplasty

safer because of the preservation of vessels.3–6 There
is an acceptance that liposuction combined with a
tunneled dissection in the midline maintains most
of the perforators in the upper abdomen, known as
lipoabdominoplasty.7 Appearance and positioning
of the scar and umbilicus are primary determinants
of abdominoplasty results.8,9
Following scientific reasoning, TULUA (trans-
verse plication, no undermining, full liposuction,
neoumbilicoplasty, and low transverse abdominal
scar), a radically different type of lipoabdomi-
noplasty, was described.10 The modifications are
as follows: unrestricted liposuction to the upper
abdomen, no undermining above the umbili-
cus, extensive transverse infraumbilical plica-
tion, umbilicus amputation, properly positioned
neoumbilicoplasty with a skin graft, and planned
low placement of the scar (Table 1). A multicenter,
multinational study is presented to describe the
procedure and to analyze indications, patients’
characteristics, surgery features, results, complica-
tions, and statistical associations.
PATIENTS AND METHODS
A retrospective series of 845 patients is
described. Sixty-eight plastic surgeons from
10 countries, including Mexico, Egypt, the
Caribbean, Central America, and South America,
provided patient data from June of 2018 to June of
2019.11,12 Every patient signed a consent form. The
principles outlined in the Declaration of Helsinki
have been followed.
Inclusion criteria consisted of primary and sec-
ondary cases with follow-up periods longer than 3
weeks and complete data regarding complications.
Patients were excluded if they had pathologic diasta-
sis, partial subumbilical resections, dissection above
the umbilicus, umbilicus transposition, combined
vertical and transverse plicatures, mesh repair, or
TULUA closure after DIEP flap surgery. Presurgical
pathologic diastasis was determined with the patient
lying down while contracting the anterior abdomen
during active flexion of the trunk. The patient was
not selected for isolated transverse plication if recti
muscle divarication is more than two fingerbreadths
(4 to 5 cm) or when the interrectus area bulges or
forms a midline sulcus.
Quantification of results was performed using
the Salles score.13 Scores were qualified 0 to 2
points to evaluate five items: abdomen volume,
lateral contour, skin excess, umbilicus appear-
ance, and scars. Three additional scores (0 to 2
points) were attained about residual epigastrium
laxity, positions of the umbilicus, and transversal
scar, besides their proportionality.
Statistical Analysis
Descriptive statistics were used for patient
characteristics and surgical details. For explor-
atory analysis, all systemic and local complications
were included. Excluded complications were
those attributed to associated procedures.
Statistical significance was set at p < 0.05.
Confidence intervals were set at 95 percent. Analyses
were performed using Stata v.12.0 (Stata Statistical
Software, Release 12; StataCorp LP, College Station,
Texas). The univariate analysis determined signifi-
cant associations between complications and the
following risk factors: sex, age, weight, body mass
index, diabetes, smoking, hypertension, connective
tissue disease, and drain use. Multivariable regres-
sion analysis was performed using significant vari-
ables found in the univariate analysis to determine
independent risk factors for complications.
Surgical Technique
The detailed technique has been pub-
lished.10,14,15 (See Figure, Supplemental Digital

Table 1.  TULUA Modifications Compared with Lipoabdominoplasty and Conventional Abdominoplasty*
Conventional Avelar- Saldanha
Abdominoplasty Lipoabdominoplasty TULUA Abdominoplasty
Plication Wide vertical plication Vertical plication T, Transverse plication
Dissection Wide dissection in epigastrium Supraumbilical tunnel U, Undermining (direct dissection)
dissection halted at the umbilicus level
Liposuction Without liposuction or limited Liposuction L, Liposuction (without restrictions)
(danger zones)
Umbilicoplasty Umbilicoplasty by stump Umbilicoplasty by stump U, Umbilicoplasty with a skin graft
exteriorization exteriorization
Abdominoplasty Abdominoplasty with scar location Low scar location limited by A, Abdominoplasty with low trans-
according to flap tension no supraumbilical dissection verse scar localization
*Modified from Villegas FJ. A novel approach to abdominoplasty: TULUA modifications (transverse plication, no undermining, full liposuction,
neoumbilicoplasty, and low transverse abdominal scar). Aesthetic Plast Surg. 2014;38:511–520; and Villegas-Alzate FJ. A paradigm shift for abdomi-
noplasty: Transverse hypogastric plication without supraumbilical dissection, unrestricted liposuction, neoumbilicoplasty, and low placement
of the scar (TULUA). In: Di Giuseppe A, Shiffman MA, eds. Aesthetic Plastic Surgery of the Abdomen. Cham, Switzerland: Springer; 2016:171–193.

1249
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 Plastic and Reconstructive Surgery • December 2021

Content 1, which shows TULUA lipoabdomi- Neoumbilicoplasty is made by an inverted-

noplasty. Technical details are geographically
outlined, including full tumescent liposuction,
transverse plication without supraumbilical under-
mining, neoumbilicoplasty, and planned scar and
umbilicus positioning, http://links.lww.com/PRS/
E685.)
Demarcation is similar to conventional
abdominoplasty, with emphasis on upper biman-
ual traction of the mons veneris to plan the lowest
midpoint of the incision 6 cm above the genitalia.
Under general, neuroaxial, or local anesthesia, a
tumescent infiltration of normal saline and epi-
nephrine 1:500,000 is used. Unrestricted deep,
and superficial liposuction of the upper abdomen
and complementary areas is performed. Care
must be taken not to excessively thin the midline
immediately above the umbilicus, and to leave
enough fatty tissue around the area where the
neoumbilicus will be reconstructed to avoid a flat
neoumbilicus. The lower abdomen is not liposuc-
tioned because it will be resected.
A beveled incision above the pubis is neces-
sary to avoid a step deformity after wound closure.
Hypogastric dissection in the plane above the
muscular fascia is halted at the umbilical level.
Dissection is not performed above the umbilicus.
The hypogastrium, including the umbilicus, is
resected en bloc, and the umbilical ring is closed
with sutures.
A horizontal ellipse is drawn on the abdomi-
nal fascia from one anterior iliac spine to the
other, and from the umbilicus to the pubis, mea-
suring 20 to 30 cm × 10 to 15 cm. Dimensions of
the plicature must be adjusted to each patient’s
wall laxity, avoiding overcorrection. With mild
flexing of the operating table, the transverse pli-
cation is made with a two-layered suture (0 U.S.
Pharmacopeia polypropylene). The plication
shortens the rectus muscles, imbricating them
inward to the abdominal wall cavity. The infero-
medial borders of the external oblique muscles
coincide with the superolateral borders of the
depicted ellipse, so that when the plicature is fin-
ished, a downward and medial advancement is
produced, and improvement of the waistline is
corroborated.
The wound is closed in layers, repairing the
Scarpa fascia with 2-0 U.S. Pharmacopeia polygla-
ctin. Closure starts laterally, avoiding dog-ears.
Umbilical position is determined, with the
operating table extended, according to the golden
proportion (1:1.62), where 1 is the distance from
genitalia to the incision, and 1.62 is the distance
from the incision to the neoumbilicus.
U–shaped incision 0.8 to 1.1  cm in length; after
defatting around it, a 2.5-cm-wide depression is
created. The dermis of the incised U is sutured to
the linea alba using 2-0 U.S. Pharmacopeia poly-
glactin suture, forming a tunnel-mouth–shaped
raw area on the fascia 1 to 1.5 cm in diameter. This
area is grafted with a full-thickness skin sutured
with 3-0 U.S. Pharmacopeia plain catgut sutures
(Figs. 1 through 4).
Some surgeons did not use drains [347cases
(42.3 percent)], although the corresponding
author (F.J.V.A.) used closed suction drainage.
Although most of the authors encourage and
used deep venous thrombosis prophylaxis accord-
ing to the Caprini risk factor assessment, no data
were collected about its use; nor was informa-
tion collected regarding the use of compression
garments, antibiotic prophylaxis, or postopera-
tive therapies. Two hundred eighty-one patients
operated on by two authors (G.B. and D.S.) had
echographic examination during the first post-
operative visit to detect seromas and to perform
ultrasound-guided punctures.
RESULTS
Forty patients had exclusion criteria. The final
analysis involved 845 patients. Most were women
Fig. 1. TULUA, surgical markings. A 39-year-old woman during
surgical markings. Upward manual traction is exerted to depict
the incision 6 cm from the anterior vulvar commissure. The blue
ellipse demonstrates the amount of resection planned; the red
ellipse delineates the transverse plication on the abdominal
aponeurosis; and the red arrows illustrate the direction of the
advance on the rectus muscles and external oblique muscles,
caused by the transverse plication.

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 Volume 148, Number 6 • Transverse Plication Abdominoplasty

Fig. 2. TULUA, unrestricted liposuction. (Left) A 47-year-old woman with a body mass index
of 31.2  kg/m2 on the operating table shown after tumescence and liposuction without
restriction in the epigastrium. The pinch test demonstrates flap thickness and mobility.
(Right) The entire hypogastric pannus is elevated for resection; there is no dissection in the
epigastrium; and the umbilical stalk is ready to be sectioned. The blue ellipse drawn on the
aponeurosis depicts the transverse plicature.

[807 cases (95.5 percent)], and 38 (4.5 percent)
were men. Age ranged between 18 and 89 years
(mean ± SD, 43.5 ± 0.7 years). Follow-up ranged
between 3 and 500 weeks (mean ± SD, 44.3 ± 64.7
weeks).
One-hundred forty-five patients (19.7 per-
cent) were obese, and six (0.8 percent) had a body
mass index greater than 40  kg/m2. Six-hundred
eighty-one patients (82 percent) had primary
abdominoplasty; however, a previous abdomino-
plasty was present in 87 (10.4 percent); preced-
ing liposuction was reported in 61 (7.3 percent),
antecedent abdominal scars were reported in 301
(35.6 percent), and bariatric surgery was reported
in 55 (6.5 percent).
General anesthesia was used in 672 (81.2 per-
cent), spinal or epidural anesthesia was used in
110 (13.3 percent), and local with intravenous
sedation was used in 45 (5.4 percent). The opera-
tive time ranged between 1 and 8 hours (mean ±
SD, 3.9 ± 1.4 hours).
Surgery was ambulatory in 386 patients (46.5
percent); 382 (46.0 percent) stayed overnight,
and 61 (7.3 percent) were hospitalized for more
than 1 day. Ranges, means, and standard devia-
tions of the rest of the variables fluctuated widely,
as follows: the amount of tumescence (range, 500
to 11,000  ml; mean ± SD, 3826 ± 2058  ml); the
amount of lipoaspirate (range, 100 to 10,700 ml;
mean ± SD, 2967 ± 1818 ml), the weight of resec-
tion (range, 150 to 12,230 g; mean ± SD, 1388 ±
1300  g), and plicature dimensions [height, 4 to
19  cm (mean ± SD, 10.8 ± 2.9  cm); width, 16 to
39 cm (mean ± SD, 26.1 ± 6.1 cm)] (Table 2).
TULUA was combined with other plastic sur-
gery operations in 642 patients (76 percent), such
as liposuction in other areas in 476 (56.3 percent),
breast operations in 258 (30.5 percent), gluteal fat
grafting in 253 (30 percent), and facial operations
in 39 patients (4.6 percent). An umbilical hernia
was repaired in 35 (4.1 percent), whereas medial
arm, medial thigh, and belt lipectomies were in
sum 30 (3.5 percent). Hysterectomy was associ-
ated with TULUA in four patients and with labia
minora reduction in two.
Three-hundred seventy-two patients (44 per-
cent) had no comorbidities, 69 (8.1 percent) were
hypertense, 56 (6.6 percent) were active smokers,
33 (3.9) had hypothyroidism, 27 (3.2 percent)
were diabetics, and one patient had a kidney
transplant. (See Figure, Supplemental Digital
Content 2, which shows that isolated TULUA
lipoabdominoplasty was performed in 24 percent
of patients. More than half of patients had lipo-
suction of areas other than the abdomen. Almost
one-third had breast surgery and gluteoplasty.

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 Plastic and Reconstructive Surgery • December 2021

Fig. 3. TULUA, transverse plicature. (Left) The same patient as in Figure 2. Extensive en bloc
resection of the hypogastric pannus (2600  g) and umbilicus amputation has been per-
formed. There is no dissection above the umbilicus. Blue lines depict massive transverse plica-
tion, and yellow arrows demonstrate the advancement of the inferior borders of the external
oblique muscles. (Right) After two-layer plication, before wound closure. The wound bor-
ders lie together without tension and diminished dead space. Black arrows indicate waistline
change attributable to the oblique muscles advanced to the midline, and flank liposuction.

Fig. 4. TULUA, neoumbilicoplasty. (Left) The same patient as in Figures 2 and 3. Tension-free
wound closure with a very low scar placement has been performed. Suction drains have
been left in place; a divine proportion caliper (Fibonacci) is used to determine the neoum-
bilicoplasty position. (Right) Neoumbilicoplasty in the midline is 9.5 cm above the incision.
Observe how low the scar is placed; a full-thickness skin was grafted on the midline fascia
after an inverted-U incision and defatting were performed.

Facial plastic surgery operations were performed Content 3, which shows that 44 percent of patients
simultaneously in 4.6 percent, http://links.lww. did not report comorbidities. Previous abdominal
com/PRS/E686. See Figure, Supplemental Digital scars were seen in 35.6 percent. Notoriously, 6.6

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 Volume 148, Number 6 • Transverse Plication Abdominoplasty

Table 2.  Patients and Surgery Characteristics for 845 Patients Undergoing TULUA Abdominoplasty
Characteristic (Data Entries) No. of Patients (%) Mean SD Range
Sex (n = 845)
 Female 807 (95.5)
 Male 38 (4.5)
Age, yr (n = 833) 43.5 10.7 18–89
BMI status (n = 736) 27 4 18–41
 BMI <30 kg/m2 585 (79.5)
 BMI >30 kg/m2 145 (19.7)
 BMI >40 kg/m2 6 (0.8)
Case type (n = 829)
 Primary case 681 (82)
 Previous abdominoplasty 87 (10.4)
 Previous liposuction 61 (7.3)
 Postbariatric 55 (6.5)
Anesthesia type (n = 827)
 General 672 (81.2)
 Spinal or epidural 110 (13.3)
 Local plus IV sedation 45 (5.4)
Hospital stay (n = 829) 1.27 0–12
 Ambulatory 386 (46.5)
 Overnight 382 (46.0)
 >1 day 61 (7.3)
Drains days (n = 820) 3.3 0–15
 No drains used 347 (42.3)
 1–6 days 205 (25)
 7 days 167 (20.4)
 8–10 days 92 (11.2)
 11–15 days 9 (1.1)
Tumescence, ml (n = 820) 3826 2058 500–11,000
Lipoaspirate ml (n = 814) 2967 1818 100–10,700
Resection, g (n = 476) 1388 1300 150–12,230
Plicature height, cm (n = 506) 10.8 2.9 4–19
Plicature width, cm (n = 504) 26.1 6.1 16–39
Operative time, hr (n = 819) 3.9 1.4 1–8
Follow-up, wk (n = 812) 44.3 64.7 3–500
BMI, body mass index; IV, intravenous.

percent were reported as active smokers, http://
links.lww.com/PRS/E687.) Aesthetic scores for
abdominal volume correction, lateral contour
improvement, residual skin sagginess, neoumbili-
cus appearance, and scars averaged 8.68 points,
according to the Salles13 scale (0 to 10). The low-
est score was 1.47 (of 2) for abdominal scars,
where 20 (2.3 percent) had poor scars; however,
50 percent scored 2 of 2 points (“scars of good
appearance”).
An additional evaluation regarding scar posi-
tioning, umbilicus proportionality, and residual
epigastric bulging was qualified 4.97 (maximum
possible, 6). Umbilicus proportionality was 1.58
(of 2), because 37 (4.3 percent) were placed
excessively high or low (Tables 3 and 4).
Global complications were 16.2 percent; no
deaths were reported. Seromas constituted 8.8
percent, delayed umbilicus skin graft take con-
stituted 2.7 percent, skin necrosis constituted
0.7 percent, and vascular-related complications
(i.e., necrosis, dehiscences, and infections) con-
stituted 2.7 percent. Nonlethal pulmonary embo-
lism, inguinal hernia, and pneumothorax were
reported as individual occurrences. Ten patients
(1.1 percent) had hospital readmission for surgi-
cal complications (Fig. 5).
In a group of 281 patients (33.2 percent)
reported by two of the authors (G.B. and D.S.) in
which no drains were used and ultrasound exami-
nation was performed during the first postopera-
tive visit, seromas were diagnosed and treated by
unique or multiple punctures in 42 cases (15 per-
cent), accounting for 56 percent of the 75 total
reports of seromas in the entire series. Univariate
analysis of complications demonstrated that the
risks increasing complication rates were: age, body
mass index, active smoking, diabetes, and hyper-
tension. A 1-year increase in age augments the
complication risk by 1.2 percent; each kilogram
of weight increases the risk by 4.3 percent; and
each incremental body mass index point expands
complication chances by 12.8 percent.
Diabetes, smoking, and hypertension increased
the total risk of complications four, three, and two
times, respectively (415, 312, and 246 percent). No
significance was found on the total complication
rate for connective tissue disease and drain use.
In this series, female patients have fewer complica-
tions compared with male patients (Table 5).

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 Plastic and Reconstructive Surgery • December 2021

Table 3.  Evaluation of Aesthetic Appearance of TULUA Abdominoplasty*

Score Evaluated Parameter (score range, 0–2) No. of Cases Average
1. Volume of the abdomen 1.82
(717 entries)
 0 Large amount of fat in the abdomen, large bulging 14
 1 Moderate amount of fat in the abdomen, some bulging 94
 2 Adequate amount of fat in the abdomen, without bulging 609
2. Lateral contour (716 entries) 1.78
 0 In anterior view, abdominal waist at the navel level, with bulging 17
 1 Abdomen with straight lateral contour, without defining the waist 118
 2 Well-defined abdominal waist, with concavity 581
3. Skin excess/sagging (715 entries) 1.83
 0 Large skin excess, with sagging and stretch marks 16
 1 Moderate amount of skin excess, with sagging 86
 2 Without skin excess and/or sagging 613
4. Umbilicus appearance (715 entries) 1.78
 0 Umbilicus scar with deviation, retraction, hypertrophy, 19
or adjacent skin excess
 1 Acceptable appearance, with or without discrete deviation, 119
retraction, skin excess, or scarring
 2 Umbilicus scar of natural appearance 577
5. Scars on the abdominal wall (714 1.47
entries)
 0 Hypertrophic or keloid, hyperchromic, hypochromic, 20
depressed, or in an awkward position
 1 Poor scar appearance 334
 2 Scar of good appearance 360
Global score 0–10 8.68
*Scored results (range, 0–10) (Salles AG, Ferreira MC, do Nascimento Remigio AF, Gemperli R. Evaluation of aesthetic abdominal surgery
using a new clinical scale. Aesthetic Plast Surg. 2012;36:49–53).
†H = Distance from the scar to the umbilicus in centimeters; V = distance from the anterior vulvar commissure in females or the base of the
penis in males to the transverse scar; H/V = ratio between distance H (cm) and distance V (cm).

The final logistic regression model of multi-
variable analysis for combined risk factors (i.e.,
female, age, body mass index, smoking, diabe-
tes, and hypertension) demonstrated that being
an active smoker and having a body mass index
greater than 30 kg/m2 were independent risk fac-
tors for increased complication rates. The pre-
dictive properties of the final statistical model
revealed a sensitivity of 4.6 percent and a specificity
of 99.6 percent, and correctly classified subjects in
85.56 percent.
The logistic regression calculated the prob-
ability of having complications associated with
age older than 60 years, obesity, and smoking sta-
tus. Calculated probabilities were similar to those
observed in the study; smoking and obesity sepa-
rately duplicate the risk of complications, whereas
the combination of the three variables increases

Table 4.  Location of the Scar Distance for TULUA Abdominoplasty*

No. of
Score Evaluated Parameter (score range, 0–2) Cases Average
1. Location of the scar distance V. Distance from the anterior 1.64
vulvar commissure to the transverse scar (640 entries)
 0 >10 cm 24
 1 9.9–7.1 cm 179
 2 <7 cm 437
2. Proportionality between umbilicus and scar 1.58
positions H/V* (646 entries)
 0 High or low umbilicus (H/V >2 or H/V <1.5) 37
 1 Close to the ideal position (H/V = 1.5–2.0) 195
 2 Ideal position.; golden proportion (H/V = 1.62) 414
3. Epigastric bulging due to residual muscle 1.75
wall laxity (685 entries)
 0 Visible bulge while standing 22
 1 Visible bulge while sitting 122
 2  Flat epigastrium 541
Global score 0–6 4.97
*Score results (range, 0 to 10) (Salles AG, Ferreira MC, do Nascimento Remigio AF, Gemperli R. Evaluation of aesthetic abdominal surgery
using a new clinical scale. Aesthetic Plast Surg. 2012;36:49–53).
*H = distance from the scar to the umbilicus in cm; V = distance from the anterior vulvar commissure to the transverse scar; H/V = ratio between
distance H (cm) and distance V (cm).

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 Volume 148, Number 6 • Transverse Plication Abdominoplasty

Fig. 5. Bar graph of complications observed in 845 TULUA cases; 83.8 percent had no complications.

complications seven to nine times. (See Table, 100 percent increased risk of complication, http://
Supplemental Digital Content 4, which shows that links.lww.com/PRS/E688.)
active smoking status, age older than 60 years, and
obesity were complications predictive of the global
DISCUSSION
complication rate. The presence of one predictor
increases the risk from 15 percent to 25 percent. TULUA is a technique that modifies tradi-
The presence of two predictors increases the risk tional abdominoplasty to maximize outcomes and
from 31 percent to 48 percent. The presence of safety. Its rationale is, first, preserving the vascular
three predictors was associated, in one case, with a anatomy of the abdominal wall because there is
no direct undermining; and second, diminishing
tension in wound closure because of the extensive
Table 5.  Univariate and Multivariate Analysis for transverse plicature. Additional reasoning is the
Total Complications creation of an umbilicus adequately placed, and
No. of a transverse scar in a low location to improve the
Risk Factor Observations OR 95% CI p aesthetics. The modifications are easily reproduc-
Univariate analysis ible for plastic surgeons everywhere, as demon-
 Female sex 830 0.413 0.19–0.85 0.018* strated in this work, in which 68 plastic surgeons
 Age 833 1.021 1.00–1.03 0.013*
 Weight 771 1.043 1.02–1.05 0.000* contributed. Comments about the technique
 BMI 721 1.128 1.07–1.18 0.000* and its growing indications have been published
 Diabetes 835 4.153 1.80–9.56 0.001* by well-known authors.16–23 Although not directly
 Smoker 835 3.123 1.73–5.62 0.000*
 Hypertension 835 2.460 1.40–4.29 0.002* applicable to humans, it has been demonstrated
 Connective tissue 835 5.507 0.34–88.62 0.229 in an animal comparison study that TULUA
disease diminishes tension in wound closure, preserves
 Drain use 820 0.984 0.93–1.03 0.574
Multivariate analysis perforator vessels, and has less vascular-related
 Age 720 1.017 0.99–1.03 0.068 complications.24
 BMI 720 1.123 1.07–1.18 0.000*
 Smoker 720 2.844 1.43–5.65 0.003* The combination of liposuction and abdomi-
BMI, body mass index. noplasty has been performed since 1985.25,26 By
*Statistically significant. 1996, large-volume liposuction combined with

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Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • December 2021
abdominoplasty was published as a feasible pro-
cedure27 but with avoidance of liposuction of the
abdominal flap. Avelar alerted against the combi-
nation of liposuction with flap elevation. Instead
of flap detachment, he conceptualized the “closed
vascular system” to add liposuction safely because
there was no flap undermining28; however, the
wall laxity correction was not addressed, or was
considered unsafe or unnecessary.
Extensive liposuction without wall correction
was considered safe after Illouz’s description,
although he wrote: “The scar was not placed low
enough,” and “disproportion of the umbilicus
placement.”29 Lockwood described discontinuous
detachment to associate liposuction safely, chang-
ing the assumption that extensive dissection was
necessary to close the wound. A tunneled epigas-
tric dissection was required to perform the vertical
plicature, and the “high lateral tension” dimin-
ished closure tension in the pubic area.3 Later,
the term “lipoabdominoplasty” gained worldwide
acceptance.30–32 There seems to be a consensus:
decreased detachment enhances vascular safety,
but at the same time, it is more challenging to
perform the plication. TULUA affords both con-
cepts because there is no undermining in the
upper abdomen, and the wall laxity is corrected
by the massive transverse plication and allowing
unrestricted liposuction to complement contour
correction. Our findings corroborate these ideas,
because skin necrosis was observed in six of 845
cases (0.7 percent), and the three variables to
evaluate the abdominal shape—volume, lateral
contour, and postoperative epigastric—bulging
scored very high (1.82, 1.78, and 1.75, respec-
tively, of 2, the maximum possible scoring).
Some concerns can be raised about the con-
sequences of imbricating the lower abdominal
muscles in the transverse direction; however, short-
ening the elongated recti muscles and advancing
the receded external oblique muscles could be
beneficial to repair the lax abdominal wall.22,23,33
This shortening has been produced using cross-
stitches, combining vertical and transverse plica-
tions to conform an anchor, H, L, or inverted L;
also, customized multilevel transverse plicatures
have been reported.34–39
Isolated transverse plication has been used
previously by other authors.40,41 In a previous
TULUA report,10 postoperative magnetic reso-
nance imaging demonstrated noticeable anatomi-
cal changes after transverse plication consisting of
a 2-fold increase of the muscle thickness, without
mass or tumor in the lower abdomen, and without
bulge in the epigastrium. The mentioned studies
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Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
do not report deleterious consequences of the
transverse plication.
We did not observe chronic pain or walk
impairment. A well-conducted study of these top-
ics and concerns must be performed.
The transverse plicature integrally corrects
wall laxity and gives additional contour improve-
ment in the waistline. In most of the cases, no
compensatory enlargement, no bulging, and no
hernia were observed in the epigastrium.
Although not addressed in this study, a previous
description demonstrates waistline improvement
because of external oblique muscle advancement
and full liposuction with TULUA.42 The durability
of plicature and physiologic changes in intraab-
dominal pressure, the possible weakening of the
groin area, the possibility of nerve injury, and
biomechanics are still investigation questions to
explore43 (Figs. 6 through 8).
In a meta-analysis44 enrolling 14,061 patients,
including 42 undergoing the TULUA procedure,10
fewer complications were found in the lipoab-
dominoplasty group when compared to conven-
tional abdominoplasty. Our study describes a
global complication rate of 16.2 percent, where
the vascular-related problems [necrosis (0.7 per-
cent), dehiscence (0.9 percent), and infection (1
percent)] were in sum 2.7 percent.
Age older than 40 years, obesity, and smoking
are described risk factors45; our findings predicted
a 77 percent rate of complications when obesity,
smoking, and age older than 60 years coincide in
one patient. Despite the possible protective effect
on vascular complications, TULUA is not indi-
cated in such patients.
Complications can be explained by the com-
plexity of the procedures and patient charac-
teristics; a complication rate of 23 percent is
reported on 779 patients that had five types of
abdominoplasty, including 12 percent subumbili-
cal resections.46 Liposuction in the upper midline
was performed in 18.1 percent, and concurrent
procedures were performed in 49.3 percent of
the patients. Complications grouped as vascular-
related were 7.7 percent (2.85 times greater than
our 2.7 percent); our global rate of complications
was 30 percent less. It must also be noticed that
the studies are different because we involved 68
plastic surgeons, midline liposuction in all of the
cases, and concurrent procedures in 76 percent.
There is still concern about the aggressiveness
of liposuction in the central epigastrium. The tun-
nel detachment and the vertical plicature bring
tissues toward the midline, causing a “dome-like”
effect. The remaining septa above the umbilicus
 Volume 148, Number 6 • Transverse Plication Abdominoplasty

Fig. 6. Preoperative and postoperative photographs. (Left) A 52-year-old woman

with a body mass index of 31.08 kg/m2, before TULUA. (Right) The same patient 18
months after surgery. The patient received lipoaspirate (2500 cc) and underwent
panniculectomy (7.5 kg) and a massive transverse plicature (14 × 26 cm). Note low
scar placement without wound complications. There is a well-shaped umbilicus, in a
proportionate location, with adequate skin graft color matching.

Fig. 7. Preoperative and postoperative photographs. The same patient as in Figure 6.

Oblique views before (left) and after (right) TULUA. Note the global improvement of
the abdomen and waistline.

hinder wound closure in the proper position, is possible that the absence of a tunnel in TULUA
favoring dehiscence, or depressed or highly placed preserves more vessels and nerves. The trans-
horizontal scars with a relatively low umbilicus. It verse plication brings with it the attached tissues,

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Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • December 2021

Fig. 8. Epigastric correction in a patient with a previous miniabdominoplasty. (Left)

A 32-year-old patient with a body mass index of 30.8  kg/m2. She had compensa-
tory bulging, residual skin laxity, and parietal fat deposits in the epigastrium after
a miniabdominoplasty with infraumbilical vertical (no transverse) plication. (Right)
The same patient 8 weeks after TULUA; no undermining above the umbilicus was
performed. Unrestricted liposuction above the umbilicus and massive transverse
plication complemented the procedure. Note the correct positioning of the scar and
umbilicus, besides epigastric flattening.

allowing the fat and skin to distribute evenly on
the new abdominal contour without midline accu-
mulation. Besides, it avoids the other undesirable
consequences (e.g., pit deformities produced by
the retaining effect of the septa during traction
for wound closure).
Low placement of the scar and correct posi-
tioning of the umbilicus are crucial points in
results.8,47,48 These characteristics were evalu-
ated, and good scores were obtained (1.64 and
1.58 of 2).
Neoumbilicoplasty has been reissued as use-
ful to improve results in modern abdominoplasty,
with better outcomes than transposition umbili-
coplasty.49,50 In our series, good umbilicus and
scar positioning without epigastric bulging were
demonstrated. Despite the delay in graft healing
(2.7 percent), high scores were attained when
umbilicus issues were evaluated (1.78 and 1.58
of 2 points). Expected color mismatch or scar-
ring after skin grafting was not a problem because
they occur in the depth of the new umbilicus in a
relatively invisible area. The ideal position of the
umbilicus to achieve the golden ratio (1:1.62) was
also reaffirmed51–53 (Fig. 9).
Some surgeons perform variations of neoum-
bilicoplasty using triangular, rectangular, or
U-shaped unique or multiple flaps; however, these
modifications are beyond the scope of this study.
Publications about these variations could appear
as the technique gains acceptance.
Seroma is currently associated with flap eleva-
tion.54,55 Despite the expected reduction because
of no dissection and reduced dead space, it was
8.8 percent. One subgroup of patients (281 of
845), in which seromas were diagnosed in 15
percent using postoperative ultrasound examina-
tion, deserves special consideration; this rate is 1.7
times larger than the global rate. Undercorrected
bulging in the epigastrium because of abundant
visceral and subcutaneous fat deposits were noted
in 3.2 percent; however, wall herniation or com-
pensatory bulging was not observed (Fig. 10).
The main strength of this study lies in the
multinational origin of data, avoiding a single
surgeon’s perspective. However, there are limita-
tions, such as its retrospective design. Omission
of complications is possible because the surgeons
uploaded their data; they also scored their own
results. Although the shortest follow-up was 3

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Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 148, Number 6 • Transverse Plication Abdominoplasty

Fig. 9. Umbilicoplasty evolution and final appearance. (Left) A 45-year-old woman, 3 weeks after
TULUA. The transverse scar is positioned low, without signs of vascular compromise or dehis-
cence. There is a delay in umbilical healing. Observe the erythema, treated with dressing changes,
and topical medication. (Right) Twelve months after TULUA, note umbilicus form, with the scars
adherent to midline aponeurosis, proper color matching, and adequate umbilicus positioning
demonstrated with a Fibonacci caliper.

weeks, it is considered adequate time to see most
of the complications. Despite the fact that most
surgeons were in the initial phase of the learn-
ing curve of an innovative procedure, the total
number of complications remained 16.2 percent.
This series reveals the broad and safe span of
applications of the technique and proposes indi-
cations for every abdominoplasty patient without
pathological diastasis, secondary cases, previous
liposuction, scars, umbilical stalk section, umbili-
cal hernia, redundant fat deposits in the upper
abdomen, and postbariatric cases. A combination

Fig. 10. Undercorrected bulging in the epigastrium of a (left) 52-year-old woman

with a body mass index of 30.7 kg/m2, who requested abdominoplasty; there was no
pathologic diastasis. Abundant visceral and subcutaneous fat deposits were noted.
(Right) Twelve weeks after TULUA accompanied by 2700-cc abdominal and flank
liposuction. Note epigastric residual bulging without herniation or protrusion; simi-
lar results were observed in 3.2 percent (Tables 3 and 4).

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Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • December 2021
of vertical and transverse plicature through a tun-
neled dissection is being used, although it is not
included in the present study (TULUANHA).
In a previous publication, 14 of 176 patients
(7.9 percent) had combined vertical and trans-
verse plication because of pathologic diasta-
sis.42 Because of hypothetical improved vascular
safety, the technique is starting to be used for
abdominal etching (TULUA-HD).18,56 The cor-
responding author (F.J.V.A.) has been using
TULUA to close donor DIEP57 flap areas and
to convert hygienic panniculectomies in full
abdominoplasties.
Although not scientifically compared, the
authors attest that TULUA is more simplified
and takes less operative time, which can improve
safety. Controlled blinded studies of this tech-
nique compared to standard abdominoplasty in
matched patients are encouraged.
CONCLUSIONS
TULUA lipoabdominoplasty is a reproducible
technique, adding a set of modifications to con-
ventional abdominoplasty with sound scientific
reasoning. The lack of detachment preserves per-
forator vessels. Transverse plicature integrally cor-
rects abdominal wall laxity, without compensatory
bulging, improving waistline, diminishing ten-
sion in wound closure, diminishing dead space,
and locating the scar in a low position. A good-
looking neoumbilicus is created in an adequate
position. Such sum modifications should improve
results and safety. There are advantages of simplic-
ity, vascular safety, unrestricted liposuction, and
improved aesthetics. We envision a worldwide dif-
fusion of this well-sounding technique supported
on comprehensive, blinded, prospective, multi-
centric studies.
Francisco J. Villegas-Alzate, M.D.
Carrera 34, #26-09 Oficina 504
Tuluá, Valle del Cauca, Colombia 763021
fvillegastulua@gmail.com
Facebook: Dr Francisco Villegas
Instagram: @dr.francisco.villegas
Twitter: @fvillegastulua
ACKNOWLEDGMENTS
The authors express their sincere thanks to the 68
surgeons who contributed their cases, and to Carlos
Echandía-Alvarez, M.D., M.S.C.E., Ph.D., at the
Universidad del Valle, and Victor Cardona Stat, at the
Universidad Libre, Cali, Colombia. They also thank
Robert X. Murphy, Jr., M.D., M.Sc., for support during
the redaction of the article.
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Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
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