The next step was to create a submuscular pocket. After fascial release, the tendon of the semitendinosus muscle was seen and dissection proceeded medial to the tendon. By blunt dissection, the medial edge of the medial head of the gastrocnemius was exposed. An entry plane was created between the medial gastrocnemius and soleus. The dissection was further continued using a blunt dissector until the cavity was capacious enough to fit the selected implant. Because the dissection plane was relatively avascular, the dissection time was reduced and complications were avoided. After the dissection was completed, a sizer was placed to confirm optimal implant selection. The implants chosen were silicone gel-filled symmetrical and asymmetrical calf implant models sized from 120 to 220 cm3 (Euro Silicone, France).
After temporary implant insertion, the area for liposuction and fat grafting was meticulously addressed. After that, the implant was explanted to prevent further surgical procedures from causing harm to the implant. Suction-assisted lipectomy with 20 cm3 syringe of the premarked areas was performed, yielding pure fat while preserving the fat tissue for grafting.
Harvested fat tissues were centrifuged at 3000 rpm for 3 minutes. Centrifuged fat grafts were applied to the marked area. The structural fat grafting technique of Coleman10 was used. After liposuction and structural fat grafting, the submuscular pocket for implant insertion was checked for bleeding. The placement of the implant in the pocket was made based on the preoperative markings.
Finally, the incisions were closed. First the fascia was closed by 3/0 polydioxanone. This was followed by deep dermal reapproximation using 3/0 monocryl. Final skin closure was completed using 4/0 nylon.
Hypafix was applied for contour shaping followed by elastic bandage wrapping from toes to several centimeters above the knee, and following this, medium thrombo embolic deterrent hose thigh-high were applied carefully to each leg for gentle compression.
Patients were counseled about excessive walking and sitting for the day after surgery.
Overall satisfaction 1 year after calf contouring was rated on a scale of 1 (poor), 2 (fair), 3(good), 4 (very good), and 5(excellent).
Patients were followed up on a regular basis with a mean follow-up of 31 months.
The procedure was well tolerated with minimal discomfort in the postoperative course.
There were no major complications. No hematoma, infection, or skin sloughs were observed throughout early follow-up. Postoperative swelling and edema were limited, and edema nearly completely subsided by 3 weeks following surgery. There were no major motor or sensory disturbances in the lower legs. No permanent paresthesia was seen in any of the cases.
Late complications were limited. There was a wound dehiscence in one case (5%) and implant displacement in another (5%). The case involving implant displacement involved use of a short implant (13.9 cm length with 150 cm3 volume). The implant was subsequently replaced with a longer one. Rupture, leaking, or palpability of implants were not observed. No capsular contracture or compartment syndrome occurred.
Change in diameter of proximal and distal lower legs was measured at least 6 months after surgery. Mean diameter change of the proximal lower legs was 2.16 cm and 1.77 cm in the distal lower legs.
Overall satisfaction rate was highly satisfactory. Eighty-one percent of the patients rated their results. The results were as follows: 82% rated as “excellent” to “good”; 18% rated as good (Figs. 4A, B and 5A, B). The result of endoscopic fasciotomy was clearly noticeable at the end of the surgery. No functional impairment was seen postoperatively. Comparing the convexity at the inner lower leg, a filling effect of the muscle was seen when the patient was on a raised heel position (Figs. 5A, B and Table 1).
The muscles around the tibia and fibula largely comprise the anatomic silhouette of the lower leg. Besides the bone, the gastrocnemius and soleus muscles and the fat tissue primarily determine the contour of the lower leg. In particular, the inner leg bulge is caused by the medial belly of the gastrocnemius muscle lying posteriorly on top of the soleus muscle.9 The ratio of leg thickness is mostly dependent on calf muscles. Although the soleus is the more important postural muscle at the ankle, the gastrocnemius muscle, being more superficial and proximal, contributes more to the surface contour of the calf.
It is well known that the aesthetics of the attractive leg was based on the ratios of leg length, thickness, and shape.6,11,12 Interest in calf contouring has caused the development of different techniques dependent on 3 ratios of leg aesthetic where every case needs to be evaluated on an individual basis. First, procedures based on length have led to the use of distraction osteogenesis that has many risks and disadvantages and is not feasible if done only for aesthetic purposes. Second, the procedures based on thickness has led to the development of various techniques including circumferential liposuction,7 ultrasound-assisted lipoplasty,6 autologous fat grafting,13–16 selective neurectomy,8 and partial resection of gastrocnemius muscle.11 Although the reason for thickness of the leg is considerably accumulated amount of fat tissue, naturally the success seems to be related with liposuction or ultrasound-assisted lipectomy.5,6 If the thickness indicates muscular hypertrophy, it seems reasonable to indicate calf reduction procedures.8,11
As stated above, every case needs to be handled individually based on these 3 ratios of length, thickness, and shape. From our standpoint, shape, carrying the characteristics of former two, is the most determinant ratio in selecting which technique is best. In evaluating the shape, if thickness is the main contributing factor of leg aesthetics, then lipoplasty or calf reducing procedures will be the option. Our question was the case in which legs are slender and lack muscular definition but still have noticeable indentations and/or bulges.
In these cases, we suggest a combination of liposuction, structural fat grafting, and calf implant insertion combined with a novel procedure: endoscopic fasciotomy. The ideal candidate has both indentation and bulges in the lower leg. The indentations are mostly due to the lack of gastrocnemius bulge in that area while there is fat accumulation attached to the convexity of the lateral aspect of the lower leg. Here, fasciotomy ensured the correction of medial indentation accentuated with implant and structural fat grafting. Therefore, combining fasciotomy, calf implant, and structural grafting-based augmentation and lipoplasty revealed a satisfactory appearance (Figs. 6A–D, 7A, B, and 8A, B).
All implants were placed in a submuscular plane in this technique. Although subfascial placement technique is more popular13–16 than submuscular plane,17 we preferred submuscular plane, as it is safe and simple. In subfascial technique, it is crucial to dissect with extreme care to avoid harm to the lesser saphenous vein and the lateral cutaneous sural nerves. In the technique of submuscular placement, the dissection can be made far away from the union of the gastrocnemius muscles where there are no vessels or nerves that could be damaged. Staying above the soleus muscle gives an extra space to avoid the aforementioned vital structures. Submuscular placement resulted in a more natural calf shape as ample muscle tissues cover the implant and prevent the palpability of the implant itself. Besides, continuous movement of muscles ensures a massage effect on implant that might play a role on capsule formation as capsular contracture was not seen in this series.
Calf augmentation with fat transplantation, as an alternative to implants, has been reported in recent literature.13,18–20 Regenerative cell-based strategies such as those encompassing the use of stem cells hold tremendous promise for augmentation of the soft tissue space. From this perspective, stem cell-rich fat grafting for lower leg contouring is an effective and promising technique. Combining the Coleman10 technique with fat grafting is believed to yield satisfactory results by means of fat viability. Increased fat tissue viability is the key for volume durability. It is difficult to estimate a percentage for fat graft survival in this series, but our satisfaction ratio of almost 82% rated as “excellent” to “good” may be an indirect evaluation of volume durability.
Endoscopic release of crural fascia provides many advantages. Selective release of precisely planned areas allows the muscle to gently enhance the medial contour that was deficient and the fascia to better encompass the inserted silicone implant. Under endoscopic vision, an injury to nerves and vessels and other anatomic structures are avoided. Under direct vision, superficial cutaneous branches of sural nerves and lesser saphaneous vein are seen. Therefore, any sensorial or motor disturbances and hematoma are avoided. Selective release of fascia enables to avoid extensive dissection and therefore provides less postoperative edema and discomfort.
As a conclusion, the contour of the lower leg has been a subject of cosmetic surgery for years. Although the demand for this surgery is increasing, the number of surgeons performing this procedure is conspicuously small. In this article, personal experience is presented. We have shown that lower leg contouring augmentation combined with endoscopic fasciotomy, structural fat grafting, and liposuction to the lower leg is a very powerful aesthetic tool in the appropriate candidate. Endoscopic fasciotomy technique with calf implant and structural fat grafting for improved lower leg aesthetics is a simple, effective, reliable, and predictable approach for calf recontouring.
1. Carlsen LN. Calf augmentation—a preliminary report. Ann Plast Surg. 1979;2:508–510
2. Illouz YG. Surgical remodeling of the silhouette by aspiration lipolysis or selective lipectomy. Aesthetic Plast Surg. 1985;9:7–21
3. Illouz YG, De Villar YT Body Sculpturing by Lipoplasty. 1989 New York Churchill-Livingstone:270–280
4. Reed LS. Lipoplasty of the calves and ankles. Clin Plast Surg. 1989;16:365–368
5. Mladick RA. Lipoplasty of the calves and ankles. Plast Reconstr Surg. 1990;86:84–93 discussion 94
6. Madick RA. Advances in liposuction contouring of calves and ankles. Plast Reconstr Surg. 1999;104:823–831
7. Ersek RA, Salisbury AV. Circumferential liposuction of knees, calves, and ankles. Plast Reconstr Surg. 1996;98:880–883
8. Kim GI, Hwong SH, Lew JM, et al. Endoscope-assisted calf reduction in Orientals. Plast Reconstr Surg. 2000;106:713–718
9. Aiache A. Leg contouring with calf implants. Clin Plast Surg. 1996;23:737–749
10. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118(3 Suppl):108S–120S
11. Lemperle G, Exner K. The resection of gastrocnemius muscles in aesthetically disturbing calf hypertrophy. Plast Reconstr Surg. 1998;102:2230–2236
12. von Szalay L. Calf augmentation: a new calf prosthesis. Plast Reconstr Surg. 1985;75:83–87
13. Guerrerosantos J. Autologous fat grafting for body contouring. Clin Plast Surg. 1996;23:619–631
14. de la Pen˜a-Salcedo JA, Soto-Miranda MA, Lopez-Salguero JF. Calf implants: a 25-year experience and an anatomical review. Aesthetic Plast Surg. 2012;36:261–270
15. Dini M, Innocenti A, Lorenzetti P. Aesthetic calf augmentation with silicone implants. Aesthetic Plast Surg. 2002;26:490–492
16. Pereira LH, Nicaretta B, Sterodimas A. Bilateral calf augmentation for aesthetic purposes. Aesthetic Plast Surg. 2012;36:295–302
17. Kalixto MA, Vergara R. Submuscular calf implants. Aesthetic Plast Surg. 2003;27:135–138
18. Stampos M, Xepoulias P. Fat transplantation for soft tissue augmentation in the lower limbs. Aesthetic Plast Surg. 2001;25:256–261
19. Pereira LH, Sterodimas A. Composite body contouring. Aesthetic Plast Surg. 2009;33:616–624
© 2013 American Society of Plastic Surgeons
20. Veber M Jr, Mojallal A. Calf augmentation with autologous tissue injection. Plast Reconstr Surg. 2010;125:423–424 author reply 424