TULUA abdominoplasty can be applied to any patient; nevertheless as in the conventional surgery, it has relative contraindications in smokers, obese, and in the presence of comorbidities. It definitely cannot be used if there is significant diastasis recti above the navel and hernias or epigastric eventrations, which have been determined by physical examination or imaging. However, some cases of umbilical hernias or eventrations in the lower abdomen could be treated simultaneously with this technique.

TULUA is especially indicated in patients in whom flap detachment of the epigastrium is considered risky or inappropriate due to vascularity concern as well as in obese, smokers and in cases of previous liposuction. Obese patients in whom it is not possible or there is no indication of bariatric surgery are particularly benefited from this type of surgery, without having to deal with extensive dissection to reposition the umbilical stalk which is elongated and is hard to accommodate in some cases. For the same reasons, the technique has special advantages for massive weight loss patients. The modifications would have application when there is redundancy of skin and epigastric fat, where accumulation of tissue in the midline of the upper abdomen with vertical plication is anticipated. Probably some cases of vertical excess of skin, in whom a “fleur-de-lis” resection is considered to leave a final anchor-shaped scar, can be beneficiaries of TULUA, avoiding perhaps the vertical scar component (Fig. 15.3). In conclusion, TULUA technique can be applied to any patient who has no significant diastasis or hernia in the epigastrium, most of patients in whom has been used have been selected in an intuitive manner, in cases where is deemed inconvenient or unsafe a wide flap dissection (Table 15.2).

Once the patient has been selected and other surgical options discussed, informed consent for surgery is mandatory in which sufficient clarity about modifications to the technique is emphasized.

With the patient standing, demarcation is similar to conventional abdominoplasty, taking care to place the transverse incision as low enough at the time of surgical wound closure about 5–7 cm above the anterior vulvar commissure, and the incision should be planned sufficiently to avoid lateral dog ears.

In no case, the preexisting lower abdominal crease is used to plan the incision; subsequently, this leads to high location of the scar. By contrast during demarcation, the patient is asked to pull up firmly and symmetrically with both hands the skin and fat from the hypogastrium, noticing a shift of the mons veneris and the vulva to a higher and anterior placement; in this situation of transient traction, a midline mark point is placed 5–7 cm above the anterior vulvar commissure, bimanual traction is then released, and the outline proceeds all the way of the transverse incision starting from the central point to the most lateral end, frequently exceeding the anterior iliac spines. An ellipse is completed drawing a joining line between the lateral ends with the navel; the upper and lower outlines of the ellipse should be approximately of the same length to facilitate the closure without dog ears, rotation cones, or lateral deformities (Fig. 15.4).

Under general anesthesia, infiltration with saline and adrenaline 1: 500,000 is completed to achieve tumescence in the anterior abdomen and all areas in which there will be liposuction that usually involve the back, flanks, and medial thighs. Average infiltration of the abdomen is 2000 mL, which is complemented to 3000–8000 mL in all additional operative areas.

Through four ports of 5 mm in hypogastrium, one in the navel and two in the inframammary crease, full deep and superficial liposuction is carried out, above the navel, abdominal flanks, and mons veneris using cannulas of 5 mm. Liposuction is done without any restriction as recommended in other techniques, leaving the flap thin and uniform, about 2–3 cm in thickness with multiple crisscrossed cannula tunnels. Additional ports are used, according to the surgical plan, to complete liposuction in the back and remaining areas under treatment; liposuction of the hypogastrium is not considered necessary because it will be resected en bloc afterward (Fig. 15.5).

A bistoury skin incision is performed on the delineated transverse line, down to the subcutaneous fat. With an electrocautery, dissection in a surgical plane immediately above the muscular aponeurosis is carried out. The hypogastric flap is detached up as far as the umbilicus, halting at its level, creating a limit of upper dissection that unites the iliac spines with the navel in the midline. In no case, direct flap elevation must progress above the navel. It is recommended to leave a little fat over the pubic bone doing an oblique or step cutting after the initial skin incision, forming a subcutaneous triangle about 6 by 4 cm where the thinner part of the supraumbilical flap will be accommodated (Fig. 15.6).

After complete dissection of the hypogastrium, a horizontal ellipse is drawn with a surgical marker on the anterior musculature of the abdomen from the iliac spine to the other, passing through the umbilicus and pubis. To determine if the size of the drawn ellipse is correct for the plication, an active maneuver is performed sinking the wall with four fingertips extended in the center of the elliptical mark, to observe how the top and bottom lines come together to almost touching; if there is some lateral redundancy over the oblique muscles on the iliac crest, the plicature could extend laterally about 4 cm more on each side.

With the patient under muscle relaxation and the operating table in a position of moderate flexion, transverse plication of the anterior wall of the abdomen is carried down joining the edges of the drawn ellipse, with interrupted 0 polypropylene stitches with inverted knots, which are reinforced by running suture of the same suture type (Fig. 15.7).

This plication reaches 30 per 10 cm, and it can be extended while it is made if, laxity or on the contrary, excessive tension is observed. This surgically created fold produces umbilical descent reaching the pubis in some cases. The navel is then amputated, and its abdominal wall opening is closed with 0 polypropylene stitches.

The fat and skin previously elevated of the hypogastrium are resected, which in all cases is a similar block of tissues than is resected in conventional surgery. The wound is closed by planes emphasizing to avoid dog ears using additional liposuction and lateral prolongation of the incision as necessary. This wound closure is much easier and under less tension than in conventional abdominoplasties as tension on the suture line is not exerted directly on the skin, but it is mitigated by the pulling effect of the aponeurosis and the accompanying downward displacement of all tissues during the transverse plication.

The wound closure is done with 2-0 polyglactin stitches at the subcutaneous planes, superficial aponeurosis, and dermis. The skin is sutured with 3-0 poliglecaprone or 3-0 polypropylene intradermal continuous suture. Wound dead space is reduced performing this careful closure, and the flap gently reaches almost without tension to the bottom edge of the wound (Fig. 15.8).

A closed suction drainage is left in place for 7 days through two incisions at mons veneris.In secondary cases, the subcutaneous tissues and superficial fascia of the upper border of the incision, are set with slowly absorbable sutures to firm pubic spots and iliac spines to prevent, or correct the superior migration of the scar.

At this moment in surgery, there have been significant changes in the anterior abdominal wall, which must be seen flat, without irregularities, with tense aponeurosis due to transverse plication and the skin without redundancies or abnormal accumulations (dome effect), as sometimes seen in cases of abdominoplasties with plication in the midline.

On the abdominal skin now sutured, a vertical midline is drawn from the xiphoid to the vulva. The measured distance from the surgical wound to the top part of the vulvar commissure must continue being 5–7 cm (distance V) as was planned, this distance is multiplied by 1.5–2, and the measurement is translated in the midline above the abdominal incision to help to choose the best position of the new umbilicus 7.5–14 cm (distance H). Once determined the ideal umbilical position, an inverted U incision, is made 1.5 cm in diameter; fat trimming with scissors is performed down its periphery to the muscular fascia and linea alba, creating a depression of 2.5 cm.

For best viewing of the linea alba, curettage of fat can be performed with a Yankauer cannula with its olive tip temporarily removed by hand unscrew. Sloped walls of the umbilicus are formed joining the dermis of the inverted U incision to the abdominal aponeurosis, with six to eight polyglactin 2-0 sutures. Senn-Miller retractors are used for easier setting of sutures in such a small space; traction from the bottom of the wound with a temporary suture can also help during the process; stitches are placed all first, leaving them unknotted and repaired with mosquito forceps, to be all tied to the end, resulting in a closure with lost inverted knots between the fascia and skin.

A full-thickness skin graft, triangular shaped of 1.5 cm, perfectly defatted, is harvested from the hypogastrium-resected specimen, to be attached to the abdominal wall with three sutures of 3-0 plain catgut, to create the bottom of the neoumbilicus. The skin graft must be in intimate contact for its dermal side with the aponeurosis of the abdominal midline. Additional sutures can be placed if necessary. Graft must be flat; in no case it is tubular, and the recipient area is never a fatty tissue. An antibiotic ointment dressing is used forming a ball of 1.5 cm to help give form to the new navel (Figs. 15.9 and 15.10).

After the surgery is completed, a postsurgical elastic garment is worn to produce moderately elastic compression of the abdomen and operated areas. The patient is transferred to standard postoperative room to be discharged the next day with home care of wound and drain. The drain is usually removed after a week regardless of their production; in the few cases that seromas are seen, they are drained aseptically by needle and syringe puncture during postoperative consultations once or twice a week until complete remission of the collection (Table 15.3).