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Image 9.1 (a) Case I before surgical procedure. (b) Case I before surgical procedure, right lateral view
M. W. Payne and J. M. M. Nijboer
Case I
Our rst case is a 29-year-old woman, who presented after a
voluntary 56Kg weight loss, expressing the wish for “large
and balanced” breasts. Upon examination, we observed an
asymmetry in breast volume and shape. Combined with a
chest wall asymmetry due to a mild pectus excavatum; ribs
3–5 on the right side are concave shaped and a boney defect
lateral of the distal sternum/xyphoid process exists (Image
9.1a, b).
After simulation, we decided on round Motiva®
SilkSurface implants, right 400mL Full prole, left 265mL
Demi prole. The authors recommended round implants in
this case to help conceal the cranial boney defect. It was clear
that the volume asymmetry exceeded 135 mL, but we
decided 400mL to be the maximum implant size on the right
side because of the pectus excavatum and subsequent possibly abnormal origin of the pectoralis major and the dual
plane positioning of the implants. Meaning, we had to plan
for a left-sided volume reduction and uplift. Transfer of 100–
150mL fat was estimated to increase the natural look of the
right breast, and reduce both boney defects. The patient
signed an extensive informed consent, including remaining
asymmetry and possible indication for a repetition of fat
transfer.
1. Patient under general anesthesia, rst dose of antibiotics
(amoxicillin/clavulanic acid, 7days in total) at induction,
supine position with both arms out, prepped and draped.
2. Start on the smaller, right side. Approach through IMF
and submuscular positioning of the implant (round
Motiva® SilkSurface 400mL Full prole), dual plane.
For maximum sterility, use of MotivaImagine® Insertion
Sleeve and immediate wound closure in three layers, with
special attention to IMF.
3. On the left side positioning of round 265mL Demi sizer,
submuscular, dual plane. Temporary wound closure. With
the patient in upright position, adjustment of preoperative
marking.
4a. With sizer in situ, mastopexy with reduction of 80g of
breast tissue. After temporary wound closure and again
upright positioning, check for symmetry. Satised with
result, exchange of sizer for denitive implant (round
Motiva® SilkSurface 265mL Demi prole), wound closure in three layers, including repositioning the nipple.
4b. Inltration of marked area of lower abdomen with lipo-
suction solution.
5. Liposuction of 300mL from the abdomen, using bodyjet® and MicroAire PAL® machines. Patient is very slim
and after losing 56kg, the remaining fat tissue appeared
very resistant. Preparation of fat, using the MotivaImagine®
Puregraft 250 System. 120mL of pure fat is available for
9.1.1 The Operation
transfer.
6a. Marking the areas for fat transfer; 40mL in lateral breast,
Step
0. Preoperative photos and mark-up with patient standing.
50 mL in upper breast/boney defect, 30 mL around
Xyphoid.
9 Fat Transfer toImprove Results after Breast Surgery andinBreast Abnormalities
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used in the early stages of breast cancer (as part of a direct
reconstruction) [1–3].
Our patient is a 44-year-old woman, 7years after success-
ful unilateral cancer treatment with a right-sided breast ablation, chemotherapy and hormonal therapy. A direct
reconstruction with a submuscular silicone implant and nipple reconstruction was performed. Four years later, a reoperation followed to correct asymmetry in both volume and
shape, by means of a larger anatomical implant (480 mL
medium height, moderate prole) on the ablated side, and
second mastopexy on the healthy, left side. Currently, she
presented to us, requesting to improve the appearance of the
ablated breast and an improvement of the still present asymmetry (uctuating body weight being a factor). Upon examination, we observed an asymmetry based on volume and
shape, with extensive rippling and skin denting on the ablated
side (Image 9.3a, b). She practices boxing, and a well-
Image 9.2 Case I 1year after surgical procedure
6b. Injection of fat using the MotivaImagine® Bulb- Canula.
Theoretically, one can perforate the implant during fat
transfer! Without a Bulb-Canula, consider transfer of fat
with sizer in situ.
7. Application of dressings, support-bra, support-body. End
of the procedure. Duration 3h.
No complications occurred during or after surgery. The
patient was t and comfortably discharged the next day. One
year after surgery, she is happy with the result; she no longer
nds her breasts awkward, feels more feminine and her selfesteem has increased (Image 9.2).
The boney defects are no longer visible, and the asym-
metry in volume and shape between both breasts have
improved signicantly, without an “implanty” look of the
previously smaller side.
9.2 Correction ofBreast Augmentation
Complications/Imperfections
Case II
This case describes the use of fat transfer to increase the soft
tissue covering of an implant after unilateral skin sparing
mastectomy because of breast cancer. Cosmetically, this is a
tricky situation, as per denition only skin and muscle is left
to cover the implant.
The concept of using autologous fat grafting after breast
cancer treatment has received a lukewarm response for fears
of oncological safety and complicating radiological follow up. Although understandable, to date, there is no clinical evidence conrming these fears. Currently, fat grafting is even
developed pectoralis major probably does not improve her
breast’s appearance.
After simulation, we opted for a right-sided volume
increase to a 625 mL Motiva® Ergonomix implant with
Demi prole + fat transfer, combined with another mastopexy and reduction of the left side. Besides signing an extensive informed consent, including remaining asymmetry and
skin denting, we informed the patient of the possible need for
a repeat fat transfer 3–6months postoperatively.
9.2.1 The Operation
The procedure started on the ablated, right side. For our
approach, we chose the new “IMF” as we wanted to avoid
reopening the scar through the reconstructed nipple. After
removal of implant, we found the pectoralis major to be relatively thick, 2.5cm, and the covering tissue, mainly skin, to
be very thin, 3–5mm (Image 9.4). After expansion of the
implant pocket caudally, a sizer was positioned, followed by
temporary closure.
On the left side, we performed a mastopexy with 133g
reduction. Liposuction was performed on the lower abdomen. With the sizer in situ, 100mL of fat graft was used to
thicken the soft tissue covering the pectoralis major, using
the MotivaImagine® Bulb-Cannula, followed by exchanging
sizer for denitive Implant (Motiva® Ergonomix 625 mL
Demi prole) with submuscular position and closure of incision. The operation took 2.5h and the patient was discharged
the next day. No complications occurred.
One year after surgery, the result is good, as expected a mild
asymmetry still exists (Image 9.5). The patient is delighted
with her cleavage and the feminine shape of the right breast.
She does not nd the remaining asymmetry bothersome.
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Image 9.3 (a) Case II before surgical procedure. (b) Case II before surgical procedure, right pectoralis major activated
M. W. Payne and J. M. M. Nijboer
9.3 As Part ofCorrection ofBreast
Abnormalities
Case III This case describes the use of fat transfer in addition to mastopexy, to improve shape and symmetry in tubular
breast deformity [4].
Our patient is a 27-year-old woman presenting with the
wish for a better breast shape, after two pregnancies and
breast feeding. Upon examination, a right-sided hypoplasia
of the lower medial and lateral quadrant but with sufcient
skin in the subareolar region was observed. Her left breast
showed a larger volume, mainly of the upper quadrants,
Image 9.4 Case II during surgery, notice thinness of soft tissue covering after removal of implant
combined with a mild hypoplasia of the lower quadrants
(Image 9.6). Implants were not desired.
9.3.1 The Operation
We corrected the shape of her right breast by a periareolar
mastopexy, of her left side with a vertical mastopexy. The
right-sided lack of volume of the lower quadrants was corrected by lipolling using 100mL of fat graft, another 80mL
was used to increase volume of the upper quadrants. The left
breast received 100mL fat graft, mainly in the lower quadrants (Video 9.1). The operation took 2h and the patient was
discharged later that day.
No postoperative complications occurred and 1year after
surgery both parties are satised with the result (Image 9.7).
Both breasts have a good, feminine shape with only a minor
asymmetry in size.
Image 9.5 Case II 1year after surgical procedure
9 Fat Transfer toImprove Results after Breast Surgery andinBreast Abnormalities
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References
1. Krastev T, van Turnhout A, Vriens E, et al. Long-term follow-up
of autologous fat transfer vs. conventional breast reconstruction
and association with cancer relapse in patients with breast cancer.
JAMA Surg. 2019;154(1):56–63.
2. Groen J, Negenborn V, Twisk D, etal. Autologous fat grafting in
onco-plastic breast reconstruction: a systematic review on onco-
logical and radiological safety, complications, volume retention
and patient/surgeon satisfaction. J Plast Reconstr Aesthet Surg.
2016;69(6):742–64.
3. Stumpf C, Zucatto A, Cavalheiro J, etal. Oncologic safety of imme-
diate autologous fat grafting for reconstruction in breast-conserving
surgery. Breast Cancer Res Treat. 2020;180(2):301–9.
4. Walters J, Bourn L, Tessler O, etal. Single staged mastopexy with
autologous fat grafting; an alternative to augmentation mastopexy
with implants. Aesthet Surg J. 2020;40(4):152–8.
Image 9.6 Case III before surgical procedure
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Image 9.7 Case III 1year after surgical procedure
N.I.L.—Nutational Infrasonic
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Liposculpture. Lipo andLipofilling
ÂngeloRebelo
Contents
10.1 Materials and Methods 89
References 100
10
Safety, Precision, Much Less Complications, Much Less
Morbidity, Quicker Recovery, Less Pain, No Mortality, Less
Revisions. This is the author’s experience from 23years with
vibroliposuction/N.I.L.
What’s new?
• Device up date
• Vibro local tumescent anesthesia
• Lipolling with fat harvested with N.I.L.
The N.I.L.®—Nutational Infrasonic Liposculpture—is
one of the “recent” techniques of liposuction/liposculpture
[1–4], an evolution of the liposculpture with compressed air,
after the name vibroliposuction and now N.I.L.®. It was
invented by Malak, a Belgium medical doctor, and presented
for the rst time in October of 1997in Belgium by Dr. Ângelo
Rebelo. He and the producer invited the author to make that
presentation and to collaborate in the further developments
needed to transform the prototype in a much better machine.
From the rst device Lipomatic, we are nowadays with the
fth prototype—the EVAmatic®5.
After 23years and more than 26.000 cases, the author
presents the technique and results of N.I.L.®—Nutational
Infrasonic Liposculpture and the new lipolling with fat harvested with this device and the innovate vibro local tumescent anesthesia.
®
®
10.1 Materials andMethods
From December of 1997, he has performed over 26,000
vibroliposuctions/N.I.L.® (Table 10.1) with this technique.
The LIPOMATIC®/EVAmatic®5 (Fig. 10.1) system was
used; it is a small machine that works with compressed air, is
easy to handle, weighing less than 700g, easy to clean and
wash, and may be sterilized in autoclave or other systems.
Specic cannulas (Fig.10.2) of different lengths and diameters (3–5mm) can be connected. The passage of air induces
movements of “come and go” with a frequency of 10Hz and
a course of 6mm. The cannulas vibrate and have a rotation
and translation, which causes a unique movement called
Nutation. Ten hertz corresponds to 600 times of back-andforth movement in each minute. The goal is to break down
the fat so that it is emulsied and aspirated at the same time.
It is of the utmost importance that the frequency stays closer
of that value. With higher frequency, the course becomes
shorter, inuencing the safety and increasing the operating
time. The option for the N.I.L.® Nutational Infrasonic
Liposculpture technique is due to the fact that in the technical characteristics of LIPOMATIC we nd a low frequency
and a long course.
In terms of technologies, there is an important difference
between nutational infrasonic liposculpture (“N.I.L.®”) and
ultrasonic-assisted liposuction (“UAL”):
Â. Rebelo (*)
Plastic, Reconstructive and Aesthetic Surgery, Clínica Milénio,
Lisboa, Portugal
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. Di Giuseppe et al. (eds.), Fat Transfer in Plastic Surgery, https://doi.org/10.1007/978-3-031-10881-5_10
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Table 10.1 Difference between
ultrasonic-assisted liposuction
(“UAL”) and nutational
infrasonic liposculpture
(“N.I.L.®”)
Â. Rebelo
Fig. 10.1 LIPOMATIC®/EVAmatic®5
10.1.1 Technique
The N.I.L.® Nutational Infrasonic Liposculpture is performed with patients monitored under vibro local tumescent
anesthesia and IV sedation with Propofol and Midazolam.
Inltration with EVAsp®6: it’s the most recent technique
to perform the tumescent anesthesia with a better and easier
diffusion of the liquid, especially in difcult and/or brotic
areas. The EVAsp® is composed of a control box (with an
entirely digitalized display) regulating the compressed air
supply to the Lipomatic/EVAmatic® which allows the
Nutational Infrasonic Liposculpture, a high-speed aspirator
and a quantitative inltration system. The EVA sp®6 is a
complete system. The quantitative inltration system allows
to control precisely the inltrated quantity in different predened zones. The system of pistons ensures a homogeneous
inltration at a constant pressure, whatever the type of fat,
even brous and allows a faster inltration with a better and
easier diffusion of the liquid, especially in difcult and/or
brotic areas.
The tumescent solution is based in the Klein [5–10] formula. In general and epidural anesthesia, the patient bleeds
much more than with local tumescent anesthesia. In the latter, we achieve a very good vasoconstriction resulting in an
almost null loss of blood. The control is more effective cutting the risks down and patient can leave the clinic some
hours after the surgery.
The association of more than one anatomical region
depends on the total amount of tumescence and Lidocaine to
be used. According to Klein, the amount of Lidocaine we
have been using is far below their limits. We have conrmed
that it is safer and more comfortable for the patient to perform the N.I.L.® Nutational Infrasonic Liposculpture in
more than one session when indicated and necessary. Apart
from the recovery being quicker, they are less limited in their
everyday life. Thanks to N.I.L.® Nutational Infrasonic
Liposculpture, it is rare to spend more than two hours on a
surgery even in bigger or associated ones. The mean time
between administrating the anesthesia and completing the
N.I.L.® Nutational Infrasonic Liposculpture is between
45min and 2h.
Oral medication is administered 60min before the surgery with Lysine Clonixinate—250mg+Hydroxyzine—50
mg and all surgeries are performed with patients monitored.
Every patient follows a protocol with photos, measurements, and weight before and after surgery.
10 N.I.L.—Nutational Infrasonic Liposculpture. Lipo andLipolling
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Fig. 10.2 Specic cannulas of different lengths and diameters (3–5mm)
91
Fig. 10.3 The EVAsp®6 Inltrator from Euromi
10.1.2 The Vibro Local Tumescent Anesthesia
To each 1.000 cc of 9% saline solution ambient temperature
add:
1. 1 or 2 ampoule of adrenaline 1mg/mL
2. 30 cc of Lidocaine 2% WITHOUT adrenaline
For the tumescence, we use the EVAsp®6 Inltrator
from Euromi (Fig.10.3) with special cannulas of 2.5mm in
diameter (Fig. 10.4). It’s not common to use more than
3.000 cc per surgery. For a very good vasoconstriction, one
should wait at least 30 min, especially in the abdominal
area. In our experience, with this technique, there is no
relationship between the inltrated volume and the fat
removed.
Fig. 10.4 Special cannulas of 2.5mm in diameter
10.1.3 The N.I.L.®: Nutational Infrasonic
Liposculpture
To perform the N.I.L.®—Nutational Infrasonic Liposculpture,
different types of cannulas may be used. A short or long cannula, with a small or large diameter and specic holes, can be
chosen, depending on the local, the area to be treated and the
volume to be aspirated.
The 3.5-mm cannula, with different models, are more fre-
quently used.
In the post-op period, patients can, from the day after, take a
daily shower and they use moderate compression during
2–4weeks. All patients have a manual lymphatic drainage program during one month, starting the day after the surgery. The
medication after surgery consists of an oral antibiotic, antiinammatory and analgesic (rarely used). We recommend
massage with an anti-inammatory cream and heparinoid
cream twice a day, until the bruising disappears. Sun block protection is recommended on the small scars and ecchymosis.
10.1.4 The Lipolling withFat Harvested
withN.I.L.
The authors describe a new approach to large-volume lipolling that combines liposculpting and fat harvesting that were
performed in the same session with Lipomatic/N.I.L.® system.
®
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Â. Rebelo
N.I.L.® transfer of autologous fat improves the ability of
the recipient site to receive the graft and allows for explantation and fat transplantation in a single session and the possibility of large-volume fat grafting. This surgical approach
minimizes operating time.
The Lipomatic/N.I.L.® system was employed to make the
vibro local anesthesia with the modied Klein’s solution and to
harvest and graft fat. Fat was harvested with a 3-mm multiplehole cannula attached to a hand-piece and set to 4,2 bars and
0.9atm. Lipoaspirate was collected into a closed sterile system,
after being washed and decanted with Dextrose 5% (Fig.10.5).
The remaining solution of adipose tissue was transferred into
sterile 20, 60 cc syringes and 100 cc bags to be frozen (Fig.10.6).
There are no relationships with the Revolve™ or similar
system.
The harvest fat is frozen to be utilized in lipolling of
some regions like buttocks, correction of lipo deformities
and all others indications for lipolling, and can also be used
to store stem cells.
Power-assisted lipolling with autologous fat is an efcient, safe, and reproducible procedure that produces an aesthetically pleasing result (Fig.10.7 and 10.8).
Fig. 10.5 Lipoaspirate collected into a closed sterile system, and after
washed and decanted
Fig. 10.6 Solution of adipose tissue transferred into sterile 20, 60 cc
syringes and 100 cc bags to frozen
Before After
10 N.I.L.—Nutational Infrasonic Liposculpture. Lipo andLipolling
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Fig. 10.7 Buttocks (55years old; ve sessions; 920 cc)
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Before After
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Â. Rebelo
Fig. 10.8 Buttocks (45years old; six sessions; 860 cc)
10.1.5 Complications andManagement
We can say that N.I.L.®—Nutational Infrasonic Liposculpture
is with no doubt a great and important development and it is
proven that it is safe and efcient and has no counter indications. No special maintenance is needed, with good results
and less problems and risks. It is very easy to execute especially where the other techniques fail (difcult areas, secondary lipos, etc.) with no technical problems. Much less tiring,
this allows the surgeon to perform several surgeries daily. It
is more convenient for the patient, with less swelling and
bruising, with faster and better recovery as a result.
10.1.6 Results
All regions (Fig.10.9, 10.10, 10.11, 10.12) can be treated by
N.I.L.®—Nutational Infrasonic Liposculpture, from small
to big areas, from one to several areas at once, but in author’s
opinions and experience, the best indicator is for localized
fat and localized lipo-dystrophies, which means there is a
genetic cause, besides that it works very well in difcult
areas with brotic fat and in secondary liposuctions. In a
specic program, it can give a very good help to treat
obesity.
The author’s experience to treat obese patients is by following an important protocol, a non-predominant of visceral
fat. During the consultation and according to a previous evaluation, decisions are made about how many sessions are
needed, 2 or 3, to remove fat of different body regions with
N.I.L.®. With this technique, we can obtain a good skin
retraction, and between 6 and 12 months the patients are
revaluated to remove more fat and/or skin.
All of us performing liposuction over several years know
very well that the physical effort expended by the surgeon
during this surgery is considerable and it reects on the number of patients operated in a working day. The surgery itself,
being long and tiring in the ultimate analysis, can jeopardize
the nal results.
We cannot ignore the fact that many surgeons and medical
doctors refuse to perform liposuction/liposculpture because
of the sheer physical effort involved, age and physical being
the disability factors involved. With the N.I.L.® —Nutational
Infrasonic Liposculpture, this don’t happen (Table10.2).
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