**4. Surgical technique**

## **4.1 Medical history**

Patients were screened for history of previous operations, diabetes mellitus, hypertension, use of blood thinners, pregnancies, smoking, and cardiovascular diseases.

## **4.2 Examination**

Body shape, buttock shape, fat distribution, skin laxity, adhesion lines, intraabdominal fat, abdominal muscle weakness, hernias, cellulite condition, stretch marks, scars and umbilicus were all examined. Patient waists were measured at the smallest (maximal indentation) point and patient hips were measured at the widest part. The measurements were divided to obtain waist-to-hip ratio.

### **4.3 Photography**

Patients were photographed from shoulders to knees at a distance of 2 meters and from different angles: anteriorly at 45 degrees to the right and left, laterally on both sides, and posteriorly at 45 degrees to the right and left. Cellulite condition of the buttock area was photographed in both a state of relaxation and during muscle clenching.

## **4.4 Marking**

Permanent markers were used to mark areas for deep and superficial liposuction, adhesion lines, areas for lipoinjection, and areas of cellulite.

And dynamic muscle lines definition.

## **4.5 Anesthesia**

Both general and epidural anesthesia were used.

## **4.6 Patient positioning**

Patients were placed prone then supine.

## **4.7 Liposuction: Video 1, https://bit.ly/3QHTY6c**

### *4.7.1 Tumescent infiltration*

Tranexamic acid (50 mg for 500 cc of Ringer's solution with maximum dose of 200 mg).

*4.7.2 Suction-assisted liposuction (SAL)/traditional liposuction*

No. 5 Mercedes cannula and no. 4 Basket cannula used for deep liposuction. No. 4 Mercedes cannula used for superficial liposuction and dynamic lines.

*4.7.3 Power-assisted liposuction (PAL)*

No. 4 and no. 5 Mercedes cannulae.

*4.7.4 Ultrasound-assisted liposuction (UAL)/VASER liposuction*

VASER and LipoSound devices. Used before liposuction.

*4.7.5 Laser-assisted liposuction (LAL)*

Fotona's Nd: YAG laser machine.

Used before liposuction.

In a few cases, we used the laser both before and after liposuction (sandwich technique).

#### *4.7.6 Syringe liposuction*

Toomey tip syringes mounted on toomey tip ready no. 4 Mercedes cannulae.

#### **4.8 Fat processing and preparation**

Fat was aspirated into sterile 2000-cc containers or into toomey tipped syringes. Decantation was performed only if fat was yellow in color. Wash of aspirated fat with Ringer's solution if bloody.

#### **4.9 Lipoinjection: Video 1, https://bit.ly/3QHTY6c**

No intramuscular injections were used in this series. Instead, only deep and superficial subcutaneous lipoinjections were used accordingly.

#### *4.9.1 Syringe lipoinjection*

Tommy tip syringes mounted on no. 4 Mercedes cannulae. Three Luer lock syringes on no. 3 and no. 2 single-hole cannulae.

#### *4.9.2 Expansion vibration Lipoinjection (EVL)*

There is no propeller machine available in our practice and thus we used Toomey tipped syringes connected to a sterile single-use tube attached to a no. 4 Mercedes cannula.

Lipo-injection using power machine while vibration is on, another step of redistribution of fat after completion of lipoinjection by moving the cannula confirming homogenous redistribution of fat.
