Discussion: TULUA Male High-Definition Abdominoplasty
By James Schmidt on March 08, 2022
In “TULUA Male High-Definition Abdominoplasty,” renowned South American body sculpting plastic surgeons Alfredo Hoyos and Ricardo Babaitis and their colleagues, inspired by Francisco Villegas, present a 24-consecutive-patient retrospective analysis.1 They conclude that high-definition TULUA (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar) “is a safe and reproducible technique for the male patient.
It offers higher aesthetic results in line with modern beauty ideals.”
The surgical indication was feminizing adiposity with treatable skin and fascial laxity absent diastasis recti. Patients who met inclusion criteria were male patients who underwent high definition liposculpture and abdominoplasty with low transverse wide fascial plication. Excluded were patients who underwent conventional vertical plication abdominoplasty, medically compromised patients, and smoking patients. The fundamental technique includes indirect liposuction under- mining of the epigastrium, excision of skin and fat between the umbilicus and pubis, wide transverse imbrication of the hypogastric muscular fascia, two-layer skin flap closure, and neoumbilicoplasty. The masculine musculoskeleton is accentuated through high-definition VASER Lipo (Solta Medical–Bausch Health Companies, Inc., Bridgewater, N.J.) and lipoaugmentation. Detail is provided on marking and performing advanced liposuction, including selecting obscure access, infusing appropriate fluid, sighting landmarks, applying ultrasound, and layered fat aspiration. Accurate sighting and performance of previously described neoumbilicoplasty are emphasized.
Patients had a mean body mass index of 29.1 and average age of 33 years. The reasonable 4-hour mode operative time included 360-degree high-definition liposculpture averaging 4000 cc of lipoaspirate and 600 cc of muscular lipoaugmentation. The 24 percent minor complication rate comprised self-limiting seromas and infection, hypertrophic scarring, and umbilicus malposition. A non-standardized survey yielded a high index of satisfaction. Declaring all “successful,” the authors selected four case frontal views with volumes of liposuction noted and positive comments.
Since Illouz2 introduced liposuction with abdominoplasty, and Lockwood3 endorsed it, surgeons have had a love-hate relationship with it. A fully undermined abdominoplasty epigastric flap, stretched across the entire abdomen, probably does not retain enough vascularity to tolerate high-definition liposuction, whereas limited abdominoplasty with preservation of the umbilicus and aggressive liposuction of the epigastrium rarely provide enough tissue excision to adequately tighten the abdomen. The best solution is minimal central undermining lipoabdominoplasty, advanced and recently modified by Saldanha et al.4,5 While a subtle complementary adjunct in female patients, abdominoplasty with high-definition liposculpture has been not been available for masculinizing male patients.
Before accepting TULUA, one needs to understand its origins. Hailing from Tulua, Columbia, co-author Villegas adopted his town name for the acronym.6 With reliance on liposuction of the upper abdomen as the sole means of under- mining, he wrote, “TULUA remedied epigastric skin redundancy associated with obesity or when supraumbilical undermining inappropriate.”6 In the absence of diastasis recti, Villegas speculated that wide transverse plication of the hypogastrium would not only flatten the rectus muscle but also ease closure. Uncertain of its longevity, Villegas performed magnetic resonance imaging on four patients at 52 to 312 weeks. Imaging showed persistent fascial and muscle thickening.
Before publication of his technique, Villegas presented his novel approach for 3 years. With no reported adoption, Villegas continued to publish in isolation, culminating in his definitive analysis of 164 cases in the Aesthetic Surgery Journal.7 Uncertain as to its indications, he speculated that his operation is suited for men. In “TULUA Male High-Definition Abdominoplasty,” we applaud the 24 percent transient minor complication rate and the high index of satisfaction in high-expectation, body-conscious men.
The four photographically documented patients are typical of this hard-to-treat deformity. Along with moderate gynecomastia, they had superficial adiposity, mild skin laxity, and limited muscular visibility. Not appropriate for abdominoplasty, each case had sufficient superficial epigastric adiposity to realize enough skin laxity after liposuction and wide plication of the hypogastrium for secure suprapubic closure. The poses and backgrounds were consistent. Studio-grade lighting allowed for close examination of typography and nevi position. The four cases show no loose skin, flat abdomens, low and even scars, a well-positioned umbilicus with muscularity throughout the anterior torso, and correction of gynecomastia. Liposculpture of the chest greatly enhanced the upper torso appearance after non- excision correction of moderately ptotic gynecomastia. Their artistry is incredible.
We are disappointed not to see the results of a demonstrative case. The time interval to the post-operative photographs should have been noted. Unfortunately, the four frontal views are inadequate to assess abdominoplasty, let alone after 360-degree liposculpture.
Despite these amazing transformations, and a selective Journal process, few readers will implement TULUA male high-definition abdominoplasty. Prior experience with high-definition VASER liposuction is essential. Without knowledge of Villegas’ studies, the reader lacks background. Then there is the stressful uncertainty of this disruptive technique. The surgeon must replace customary abdominoplasty principles in favor of high-definition liposuction, no epigastric flap undermining, and wide transverse imbrication from a Therapeutic level IV publication.
Nevertheless, we have successfully adopted this technique. Intangibles make the difference. Having confronted this clinical challenge, we understand why our outcomes are lacking. The surgeons are trustworthy, innovative artists. There is no creative bias, as they are expanding the efforts of another. The senior discussant (D.J.H.) has had a rewarding career in adapting cutting-edge surgery. Find your comfort zone and follow the evolution of this breakthrough achievement.
1. Babaitis R, Villegas FJ, Hoyos AE, Perez M, Mogollon IR.
TULUA male high-definition abdominoplasty. Plast Reconstr
2. Illouz YG. A new safe and aesthetic approach to suction
abdominoplasty. Aesthetic Plast Surg. 1992;16:237–245.
3. Lockwood T. High-lateral-tension abdominoplasty with
superficial fascial system suspension. Plast Reconstr Surg.
4. Saldanha OR, De Souza Pinto EB, Mattos WN Jr, et al.
Lipoabdominoplasty with selective and safe undermining.
Aesthetic Plast Surg. 2003;27:322–327.
5. Saldanha O, Ordenes AI, Goyeneche C, et al.
Lipoabdominoplasty with anatomical definition. Plast
Reconstr Surg. 2020;146:766–777.
6. 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.
7. Villegas F. TULUA lipoabdominoplasty: No supraumbilical
elevation combined with transverse infraumbilical plication,
video description, and experience with 164 patients. Aesthetic
Surg J. 2021;41:577–594.
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