www.iatrum.com

Consultation:
0049211-24790940
Kaiserswerther Str. 119
40474 Düsseldorf / Germany

Surgery for calf reduction

Calf reduction Surgery and Liposuction

 

Calf reduction has a subordinate role in plastic surgery, particularly in comparison with breast augmentation, breast reduction, abdominoplasty (tummy tuck), etc. However, there are many people (mostly women) who, due to their large calves, suffer psychological strain that is at least as intense as that of women who undergo breast augmentation because their breasts are too small, or women who decide on breast reduction surgery due to overly large breasts. This article should serve as information on the options available to you. In the end, whether you undergo calf reduction, and which method you decide on, depends on the subjective amount of psychological strain you are experiencing.

What are the indications for calf reduction?

 

 

The choice of calf reduction technique depends on what caused the calf to become too robust. Often bulky calves (also known as “radish calves" or "radish legs”) are caused by simple accumulation of fatty tissue; in this case, liposuction is the best method for calf reduction.

In many cases, however, the calf muscle is also excessively thick. Liposuction has no effect in these cases. Extreme growth of the calf area can be observed in patients with muscular dystrophy. Muscular dystrophy is a hereditary disease which takes many different forms. Aesthetic concerns are not the main issue for patients with muscular dystrophy, making surgical calf reduction pointless.

Internal factors that create 'fat calves', such as water retention (edema) or lymphostasis (lymphedema), also require treatment for the cause of the problem, not cosmetic surgery.

Calf reduction can be achieved by abstaining from exercise.

If the calves are perceived as too large due to intense physical activity, the enlargement can be reduced by avoiding certain exercises and types of training. Exercises which build up calf muscle should be avoided, in particular standing on your toes with and without weights, climbing stairs, hiking, and sprinting.

Can calf reduction be achieved with liposuction?

 

Calf reduction using Liposuction is an excellent treatment option in the event that the increase in size is caused by accumulation of fatty tissue. The amount of excess fatty tissue can be tested even by non-medical professionals, simply by pinching the tissue between two fingers. If what you pinch consists almost entirely of skin, then the calf is predominantly muscle. If this is the case, then calf reduction using liposuction is unlikely to be successful. Using liposuction for calf correction creates irregularities only very rarely. Ankles should be treated with restraint, as a radical course of action can cause swelling and changes in pigmentation. The post operational recovery phase depends on the amount of fat removed. It can take a few days, or a few weeks (in extreme cases). You should abstain from sport and wear a surgical stocking for 6 weeks after the operation.

Advantages:

  • Calf reduction using liposuction creates only a few small, barely visible scars (puncture points).

Disadvantages:

  • If the calf consists mainly of muscle, not fat, then liposuction has a minimal size reducing effect.

Calf reduction through muscle surgery.

 

 

calf muscle reductionImage: The picture shows calf hypertrophy, and includes the gastrocnemius muscle. Right: reduced calf. The white lines portray the incisions necessary for completing the calf reduction and the resulting position of the scars.

If overly robust musculature (calf hypertrophy) is causing the increase in calf size, then the only way to achieve significant calf reduction is to remove a part of the calf muscle. Patients who decide to undergo this operation generally suffer from intense psychological strain. Men do not wear short pants, women do not wear short skirts, and they generally avoid locations such as swimming pools or the beach. Sometimes sufferers find it impossible to find regular boots or ski boots that fit.

We explain in the next section how it is possible to remove part of the muscle without limiting it's function:

Calf Muscles

The actual calf muscle, located on the achilles tendon, is the triceps surae muscle (three headed calf muscle). This muscle is made up of the soleus muscle and the two headed gastrocnemius muscle. The former is essential for the function of the calf. The latter is an accessory muscle, whose loss does not lead to any change in function. The function of the muscle is simply assumed by other muscles (1,2). This is why the gastrocnemius muscle is frequently used in plastic surgery as a muscle flap to fix defects in the knee region.

History of Muscle Removal

 

Although surgically reducing the gastrocnemius muscle to achieve calf reduction is currently much more common in Asia than in Europe or on the American continent, the procedure originated in Germany. The first person to describe the technique was Prof. Gottfried Lemperle (5), who published a paper on the subject in 1998.

Patients who were supplied with a gastrocnemius muscle flap (both heads) to repair knee defects showed no long term mechanical damage to their calf function. In light of this information, 15 patients with muscular calf hypertrophy underwent calf reduction surgery involving complete removal of the gastrocnemius muscle. Two patients experienced temporary numbness at the outer edge of their foot due to a disturbance of a nerve serving this area (the sural nerve). This paresthesia disappeared completely, however. Every patient was satisfied with the results. None of the patients complained about loss of function. Every patient was able to participate in physical activities.

How does calf reduction by removing the gastrocnemius muscle work?

 

This is the most effective calf reduction method. The procedure can take place with the patient under general anesthetic or using an epidural.

If skin quality is good, then we only need to make a 5cm incision across the hollow of the knee and an additional incision, approx. 5cm long, running vertical from the original incision in the middle of the lower leg (see image). The gastrocnemius muscle can be mobilized without a problem using these two openings. It's neurovascular bundle is located in the hollow of the knee; the surgeon cuts through it. The bundle is detached and removed at it's origin and base. The knee hollow's vessel and nerve structures sit deeper in the body and are not affected. Once a drain has been inserted (this is not always necessary) the wound is sutured in several layers. Effect: depending on the preoperative diagnosis, this type of calf reduction can reduce the circumference of the calf by somewhere between 5 and 7cm.

Advantages:

  • The effectiveness of the calf reduction is maximized, because the hypertrophied muscle tissue is removed.

Disadvantages:

  • More scars
  • Increased short term loss of strength.
  • Healthy muscle tissue is removed.
  • The inner contour in the upper section of the calf can look a little unnatural, particularly for calves with very little fatty tissue.

Partial removal:

You can also have only part of the muscle described removed (6). For example, the surgeon can simply remove the inner muscle belly of the gastrocnemius muscle only. The technique is similar to that described above. This method does not prevent scars forming, as the muscle belly must be detached at the hollow of the knee and on the achilles tendon.

What has to be watched for in post-operative care?

 

 

  • The legs are bandaged after the operation, or a surgical stocking is worn – for three months!
  • Depending on the degree of immobilization, heparin may be administered as a thrombosis prophylaxis
  • Inpatient care is advisable for at least 24 hours after the operation
  • Crutches provide safety and security for the first 2-3 days after the operation
  • Physical reserve and elevation of the legs is recommended, particularly in the first two weeks after calf reduction
  • The patient should abstain from sport for approx. 6 weeks
  • Calves are fully functional after just a few weeks
  • It can take more than 6 months for the calf muscles to regain their full strength

What is an endoscopic partial removal of the muscle?

 

The most common calf reduction method in Asia, particularly in Korea, is endoscopic calf reduction. Using this method one (for one muscle head) or two (for both muscle heads) approx. 2cm incisions are made in the hollow of the knee to reduce the size of the gastrocnemius muscle. This means that only part of the muscle is removed. The muscle is thinned using an electrocautery pencil (a scalpel which cuts using electricity and heat). The natural shape of the calf is thus largely maintained.

Advantages:

  • Small incisions in the skin
  • It is possible to shape the calves individually.
  • Short term loss of strength is minimal.

Disadvantages:

  • Healthy muscle tissue is removed.
  • The calf's circumference is not reduced as much as with complete muscle removal.
  • If the surgeon is unable to shape the area cut out of the muscle smoothly then there could be visible irregular contours.

After care:

The after care for this type of calf reduction is similar to that listed in the previous section. However, in addition to those measures, the patient must perform intensive stretches multiple times a day for several months to prevent significant shrinking of the scar.

Additional Methods

 

Some studies, predominantly from Asia, have shown success in calf reduction by separating the gastrocnemius muscle's nerve branch (neurectomy) (3,7) and obliteration of the muscle using radio frequency (4). In addition, the calf muscle can also be paralyzed using Botox ®.

Calf reduction by denervation (nerve transection) is also described.

 

A neurectomy is the separation of the nerve trunk which innervates the gastrocnemius muscle.

After the neurectomy, the muscle atrophies, reducing the muscle's volume. This effect, however, cannot be compared with that of removing the gastrocnemius muscle. A neurectomy can achieve a reduction in volume between 1.5 and 3cm. This is due to the fact that a large amount of the calf muscle's volume remains despite attrition. In addition, the calf muscle may be innervated from individual nerve branches which do not originate from the typical bundle in the hollow of the knee. These branches could partially replace the lost nerve trunk and in doing so prevent the desired muscle attrition.

Generally only a selective neurectomy is employed for calf reduction. The surgeon only separates the nerve branch which connects to the inner head of the gastrocnemius muscle. The doctor does not separate the branch connecting the lateral muscle head, due to it's close proximity to the nerve branch of the soleus muscle. The patient will experience loss of function if a neurectomy is performed on the soleus muscle.

Advantages:

  • If the nerves are not atypically placed then the intrusion is minimal.
  • Post operative recovery is short.

Disadvantages:

  • On occasion, the nerves are placed atypically; the results are therefore hard to predict.
  • If the nerves are placed atypically this could cause injury to other calf muscle's nerve branches, resulting in a weakening of calf function.
  • Significantly less calf reduction.
  • A neurectomy is performed on a healthy muscle.

The Radio-Frequency Method

 

Radio frequency calf reduction refers to obliteration of the muscle through several small skin punctures using electricity and heat. The procedure can be performed to varying degrees of intensity, but usually requires general anesthetic. Essentially, the musculature is burned, causing partial necrosis (death of the tissue). Enough tissue remains, however, for this calf reduction method to be less effective than removal of the gastrocnemius muscle. On the other hand, the patient comes away from the operation with fewer and smaller scars. It is important not to misjudge the effect of inner scarring on the gastrocnemius muscle, however. The patient will need to exercise and train their calf over a period of weeks to prevent shrinkage of the muscle. In addition, the patient can expect significantly more swelling due to the increased trauma caused by radio frequency calf reduction. This swelling can last for weeks or even months.

Advantages:

  • Small, inconspicuous outer scars.
  • Less short term loss of strength in the muscle.

Disadvantages:

  • Inner muscle scarring.
  • Longer period of swelling after the calf reduction.
  • Less effective, as the gastrocnemius muscle remains.
  • Healthy muscle tissue is destroyed.

Can calf reduction be achieved with Botox®?

Botox Calf reduction without OperationWe should also mention the Botox® (Botulinum toxin A) calf reduction method (8). Botox is a neurotoxin which causes myoparesis (slight muscular paralysis). Botox is currently a standard treatment for mimetic wrinkles. Botox also has other uses, however – including calf reduction. Botox ® is injected into the muscle using numerous small punctures (10 to 15 per side). The procedure does not require anesthetic.

Advantages:

  • Barely invasive, does not cause scars.
  • The treatment is simple to carry out and requires no surgical skill.
  • There is no recovery period required.
  • If you do not like the results, the muscle returns to normal within 3-6 months.

Disadvantages:

  • Minimal reduction of calf sizeafter repeated treatment.
  • Lasts only 3-6 months.
  • A costly method, long term. The procedure has to be repeated once every 3 to 6 months, and the required dose is high due to the size of the muscle.

 

Updated on 25.09.2012

Bibliography:

Pubmed:

  1. The Gastrocnemius muscle as a free-flap donor site. - Potparic, Colen, Sucur, Carwell, Carraway - Plast. Reconstr. Surg. 95:1245 (1995)
  2. Subtotal resection of Gastrocnemius muscles for hypertrophic muscular calves in Asians. - Lee JT, Wang CH, Cheng LF, Lin CM, Huang CC, Chien SH. - Plast Reconstr Surg. 2006 Nov;118(6):1472-83.
  3. The anatomic study and clinical observation of the neurectomy of the nerve to the medial Gastrocnemius muscle for calf reduction - Liu DL, Li XI, Shan L, Li Q, Yuan JL, Yuan Q. - Zhonghua Zheng Xing Wai Ke Za Zhi. 2007 Mar;23(2):125-7. Chinese.
  4. Radiofrequency volume reduction of Gastrocnemius muscle hypertrophy for cosmetic purposes. - Park YJ, Jo YW, Bang SI, Kim HJ, Lim SY, Mun GH, Hyon WS, Oh KS. - Aesthetic Plast Surg. 2007 Jan-Feb;31(1):53-61.
  5. The resection of gastrocnemius muscles in aesthetically disturbing calf hypertrophy. -  Lemperle G, Exner K. - Plast Reconstr Surg. 1998 Nov;102(6):2230-6.
  6. Leg re-contouring by using a new technique of partially removing Gastrocnemius - Qin RS, Wang X, Chen YZ, Xie HB, Zhu L, Li B, Ma YG, You WT, Li D, Li JN. - Zhonghua Zheng Xing Wai Ke Za Zhi. 2003 Mar;19(2):85-7. Chinese.
  7. Selective neurectomy of the Gastrocnemius and soleus muscles for calf hypertrophy: an anatomical study and 700 clinical cases. - Tsai FC, Mardini S, Fong TH, Kang JH, Chou CM. - Plast Reconstr Surg. 2008 Jul;122(1):178-87.
  8. Botulinum toxin a for aesthetic contouring of enlarged medial gastrocnemius muscle. - Lee HJ, Lee DW, Park YH, Cha MK, Kim HS, Ha SJ. - Dermatol Surg. 2004 Jun;30(6):867-71; discussion 871.

 

 

 

Copyright© 2008-

Dr. Rene Schumann, Specialist in Plastic and Cosmetic Surgery in Germany (Düsseldorf)

The author reserves all rights.