Calf-contouring surgery of gastrocnemius hypertrophy: selective neurectomy of the sural nerve

Endoscopic Concurrent Gastrocnemius Muscle Resection and Soleus Muscle Neurectomy for Severe Muscular Calf Hypertrophy

BACKGROUND

Selective neurectomy or muscle resection techniques for calf reduction conventionally focus on the gastrocnemius muscle. However, the underlying soleus muscle plays an important role in muscular calf hypertrophy. In the authors' experience, the results of calf reduction have been suboptimal in patients with severe muscular calf hypertrophy who underwent gastrocnemius muscle resection only. This article describes a new calf reduction method that uses concurrent gastrocnemius muscle resection and soleus muscle neurectomy using an endoscope-assisted single-incision approach in patients with severe muscular calf hypertrophy.

METHODS

A total of 139 patients who underwent simultaneous gastrocnemius muscle resection and soleus muscle neurectomy for severe calf hypertrophy from March of 2017 to June of 2020 were retrospectively analyzed.

RESULTS

After combined gastrocnemius resection (mean weight per calf, 349 g) and soleus neurectomy, about 3.8 to 8.2 cm (mean, 6.4 cm) or 12.8% to 24.3% (mean, 16.6%) of the calf was reduced. Complications included cellulitis, hematoma, seroma, and mild depression ( n = 1 each). Two patients had traction injury to the sural nerve. One patient developed Achilles tendon rupture at 2 months postoperatively. No patient complained of functional impairment with respect to easy fatigability, stability, gait, or sport activities at 6 months postoperatively.

CONCLUSION

This study is the first to combine gastrocnemius muscle resection with selective soleus muscle neurectomy to achieve the most efficient calf reduction for severe muscular calf hypertrophy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The Effect of Calf Subcutaneous Fat Thickness on Patient Satisfaction after Calf Contouring with Botulinum Toxin A

BACKGROUND

As a minimally invasive therapy, botulinum toxin A (BTXA) treatment effectively reduces the hypertrophy of the gastrocnemius muscle (GM). Patient satisfaction is, however, reported to be low after treatment, with a possible correlation between high satisfaction and thinner subcutaneous fat. The goal of this study was to classify the subcutaneous fat of calves to understand the relation between fat thickness and patient satisfaction after BTXA treatment.

METHODS

The maximal leg circumference was measured, and B-mode ultrasound was used to measure the thickness of the medial head of the GM and of the subcutaneous fat. Patients were followed up at 1 and 6 months after BTXA treatment.

RESULTS

A total of 50 cases were classified into the following levels of fat thickness: slim (<0.55 cm), moderate (0.55 to 0.85 cm), and bulge (>0.85 cm). All patients were treated with 300 units of BTXA. Patients in the slim and bulge groups reported higher satisfaction rate than patients in the moderate group, with patients in the slim and bulge groups reporting complete satisfaction (100%) with calf contour at the 6-month follow-up. The satisfaction rate with the improvement in total leg circumference was low in all 3 groups. No severe complications were encountered in this study.

CONCLUSIONS

This study identified a U-shaped correlation between calf subcutaneous fat thickness and patient satisfaction rate after treatment. The authors' results provide a theoretical basis for BTXA treatment and suggest the importance of preprocedure conversations in GM hypertrophy treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Classification of gastrocnemius muscle hypertrophy for personalized botulinum toxin type A treatment

BACKGROUND

Owing to its safety and convenience, botulinum toxin type A (BoNtA) has become a first-choice treatment for contouring calf muscle asymmetries or deformities. Different injection methods and dosages have been discussed in the literature, but a standardized BoNtA treatment remains unclear.

AIMS

This study aimed to classify gastrocnemius muscle hypertrophy (GMH) through multiple measurements to provide a personalized BoNtA treatment protocol.

METHODS

The measurements combining of gastrocnemius muscle (GM) contour, max leg circumference and GM thickness was applied to classify different type of GMH in a normal population. Based on these findings, a personalized BoNtA treatment protocol was determined and evaluated regarding max leg circumference, GM thickness, the position of max leg circumference, patient and doctor satisfaction rate, and complications.

RESULTS

A total of 100 GMH were classified into two bulging types (bilateral-bulging type and unilateral-bulging type) and two categories (moderate GMH and severe GMH). 40 cases were treated with personalized BoNtA injection methods ("Even" or "Intense"method) and dosages (300 or 400 units). Follow-up examinations at 1, 3, and 6 months after treatment. Max leg circumference and GM thickness decreased significantly and the position of max leg circumference rose prominently during treatment (2.56± 1.93; p< 0.05). The overall patient satisfaction rate was 70%-100%. No serious complications occurred.

CONCLUSIONS

We identify four groups of GMH through several measurements and outline a personalized BoNtA treatment for each type. This recommended protocol may improve the therapeutic outcomes and patient satisfaction after treatment.

Techniques and Applications of Lower Extremity Feminization and Masculinization

Background

Significant differences exist between feminine and masculine lower extremities, and this region contributes to gender dysphoria in transgender and nonbinary individuals.

Methods

A systematic review was conducted for primary literature on lower extremity (LE) gender affirmation techniques as well as anthropometric differences between male and female lower extremities, which could guide surgical planning. Multiple databases were searched for articles before June 2, 2021 using Medical Subject Headings. Data on techniques, outcomes, complications, and anthropometrics were collected.

Results

A total of 852 unique articles were identified: 17 met criteria for male and female anthropometrics and 1 met criteria for LE surgical techniques potentially applicable to gender affirmation. None met criteria for LE gender affirmation techniques specifically. Therefore, this review was expanded to discuss surgical techniques for the LE, targeting masculine and feminine anthropometric ideals. LE masculinization can target feminine qualities, such as mid-lateral gluteal fullness and excess subcutaneous fat in the thigh and hips. Feminization can target masculine qualities like a low waist-to-hip ratio, mid-lateral gluteal concavity, calf hypertrophy, and body hair. Cultural differences and patient body habitus, which influence what is considered "ideal" for both sexes, should be discussed. Applicable techniques include hormone therapy, lipo-contouring, fat grafting, implant placement, and botulinum toxin injection, among others.

Conclusions

Due to lack of existing outcomes-based literature, gender affirmation of the lower extremities will rely on application of an array of existing plastic surgery techniques. However, quality outcomes data for these procedures is required to determine best practices.

Simultaneous calf reduction and contouring with customized differential subtotal gastrocnemius resection and muscle transposition: Analysis of 200 cases

BACKGROUND

Oversized muscular calves can cause severe emotional distress. Total, partial, and subtotal resections of the gastrocnemius muscle for calf reduction have been described. However, the amount of muscle resected may be inappropriate, and the resultant leg contour may not be straight or esthetically pleasing enough.

OBJECTIVES

This study aimed to describe a technique of customized differential subtotal gastrocnemius resection and muscle transposition.

METHODS

A total of 200 patients who underwent customized differential subtotal gastrocnemius resection and muscle transposition for hypertrophic muscular calves from July 2013 to June 2016 were included in the study.

RESULTS

A total of 148 patients underwent subtotal resection of both heads, and calf reduction ranged from 3.2 to 7.2 cm (mean 14.8%). Forty-two patients underwent subtotal resection of the medial head alone, and calf reduction ranged from 2.8 to 5.5 cm (mean 9.2%). Ten patients underwent subtotal resection of the lateral head alone, and calf reduction ranged from 1.2 to 2.1 cm (mean 4.6%). The medial gastrocnemius muscle was subtotally resected in 190 (95%) patients. In 130 (65%) patients, the preserved medial gastrocnemius muscle was transposed superomedially to achieve a straighter medial contour. None of the patients complained that their legs were too thin because of over-reduction. Cybex test showed that near-total muscle strength recovery was achieved within 6 months.

CONCLUSION

Customized differential subtotal gastrocnemius resection together with muscle transposition resulted in enhanced calf reduction with straighter leg contour, without any impairment of the leg function. This approach may be more appealing to both patients and surgeons.

Ultrasonographic analysis of the calves for efficient botulinum toxin type A injection

BACKGROUND

Large calves are considered unattractive. Botulinum toxin type A (BoNT-A), acting as a neurotoxin that reduces muscle contraction, is widely used in calf contouring. However, there lacks detailed anatomical data to guide clinical injection.

OBJECTIVES

This study aims to use ultrasonography to provide depth information of the calf muscles and determine the morphological types of the gastrocnemius muscle.

METHODS

Ultrasound scanning was performed at six sites on 40 Chinese adults. A real-time ultrasound scannerwas used to detect the depth of the gastrocnemius muscle and the soleus muscle.

RESULTS

The thickness of the gastrocnemius muscle and the soleus muscle was measured. The depth from the skin to the surface, the middle, and the bottom of the gastrocnemius muscle was measured. The morphology of gastrocnemius muscle was classified into four different types under ultrasound according to the muscle bulge pattern.

CONCLUSION

This study took ultrasonic measurements of Asian calves to guide accurate and effective BoNT-A injection in real clinical practice.

Single Incision Endoscope-Assisted Gastrocnemius Muscle Resection for Calf Hypertrophy: Analysis of 300 Cases

BACKGROUND

Muscular calf hypertrophy can cause severe psychological distress. Total or subtotal resection of the gastrocnemius muscle results in significant calf reduction. However, both techniques require a second incision of 5 and 2 cm, respectively, at the posterior mid-calf. The resultant mid-calf scar is more difficult to conceal when wearing short skirts or pants.

OBJECTIVES

The authors sought to describe the technique of endoscope-assisted gastrocnemius muscle resection to obviate the need for a mid-calf scar and to review the outcomes of patients who underwent this procedure.

METHODS

A retrospective study of 300 patients in a single center in Taiwan who underwent endoscope-assisted subtotal resection of the gastrocnemius muscle for hypertrophic muscular calves, between March 2015 to June 2019, were included in this study.

RESULTS

The combined weight of the resected gastrocnemius muscle ranged from 156 to 484 g per calf (mean = 276 g). The mean maximal calf circumference was 36.1 cm preoperatively and 30.9 cm postoperatively. The calf reduction achieved was 3.0 to 8.1 cm (mean = 5.2 cm), or 8.9% to 19.8% (mean = 14.4%). The complications were minor, and the rate was low (2%). As for the popliteal fossa scar, 6 patients underwent further treatment of their hyperpigmented or hypertrophic transverse scar. There were no complaints of impaired leg function regarding gait or sports activities 3 to 6 months postoperatively.

CONCLUSIONS

At present, gastrocnemius muscle resection remains unrivaled in its ability to achieve calf reduction. The surgery is now much more appealing to patients as a result of employing the endoscope-assisted technique to obviate the mid-calf scar.

LEVEL OF EVIDENCE: 4

Calf Reduction by Partial Resection of Gastrocnemius Using a Suction-Assisted Cartilage Shaver

BACKGROUND

Long-term aesthetic reduction of the legs in Asians is gaining increasing popularity among cosmetic patients. Current treatment options include botulinum toxin injection, radiofrequency, neurectomy, and total, subtotal, or partial muscle resection of the gastrocnemius. Partial resection using Kelly forceps was introduced in 2000. This article presents the use of a suction-assisted cartilage shaver to perform partial resection, describing the procedures and shaver modifications and evaluating its use.

METHODS

A retrospective review of 71 cases with a minimum 6-month follow-up (average, 36.5 months; range, 6 to 160 months) was performed. Twenty partial calf reductions were performed with a short shaver, 27 with a long shaver, and 24 with an endoscope-guided long shaver.

RESULTS

Mean reduction of calf circumference was 2 cm (range, -1 to 6 cm); the mean preoperative and postoperative calf circumferences were 35.8 cm and 33.8 cm, respectively. Mean tissue reduction per calf was 110 g (range, 25 to 300 g).Two patients developed larger calves after surgery, one because of weight gain and the other because of weight training. Complications included surface irregularity (n = 4, 5.6 percent), numbness over the lateral ankle or lateral foot (n = 9, 12.7 percent), hematoma clot requiring surgical evacuation (n = 11, 15.5 percent), prolonged seroma (n = 2, 2.8 percent), and left ankle plantar-flexion contracture due to tight, sustained postsurgery bandaging (n = 1, 1.5 percent). Scar-related complications were hyperpigmentation (n = 6, 8.5 percent), depressed scars (n = 5, 7 percent), and hypertrophic scars (n = 2, 2.8 percent).

CONCLUSIONS

Short, long, and endoscope-guided long suction-assisted cartilage shavers for partial resection of calf muscles can be used effectively to reduce the calf. Several mostly treatable complications were noted.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Validated Assessment Scales for the Female Asian Calf

BACKGROUND

Clinical photonumeric scales have been developed and validated to objectively measure the effectiveness of aesthetic treatments in specific anatomical areas; however, these are based on the typical features of Caucasian patients. No clinical scale for Asian calf appearance currently exists.

OBJECTIVE

To develop and validate a calf assessment scale for use in the female Asian patient population.

METHODS AND MATERIALS

During 2 validation sessions, 13 raters assessed calf images of female Asian subjects (N = 35) viewed from behind with feet flat on the floor (at rest) and on tiptoes (dynamic). Images were rated from 0 (very slim, linear profile) to 4 (very severe convex profile).

RESULTS

Inter-rater and intra-rater reliability were "substantial" (≥0.6, intraclass correlation coefficient [ICC] and weighted kappa) for the calf-at rest, calf-dynamic, and calf summary score. Reliability was "substantial" for calf-at rest and calf-dynamic (≥0.6, ICC and weighted kappa) and "almost perfect" (0.85) for the calf summary score. BMI and calf circumference were highly correlated with scale ratings, and calf circumference was a significant predictor.

CONCLUSION

This new photonumeric assessment scale has value for assessing the female Asian calf, providing a standardized measure of calf appearance in clinical practice and clinical research settings.

Treatment of Gastrocnemius Muscle Hypertrophy with Botulinum Toxin Injection Followed by Magnetic Resonance Imaging Assessment and 3-Dimensional Evaluation

BACKGROUND

Hypertrophy of the gastrocnemius muscle is considered to be a hindrance to lower leg beauty in the Asian aesthetic market. A noninvasive technique that has been gaining recognition involves botulinum toxin A injection; however, there are no proper guidelines or standardized protocols for the administration of botulinum toxin to correct gastrocnemius hypertrophy.

OBJECTIVES

This study sought to determine the most effective botulinum toxin injection method for correcting the contour of the lower leg calf, as well as to determine the dose that can produce the maximum effect in meeting the demands of the physician and patient.

METHODS

Eighteen female patients aged between 18 and 35 years were enrolled in this study from January 2015 to July 2015. Two injection methods were compared: (I) 48 injection points with a distance of 2 cm between every point; and (II) 10 injection points. Magnetic resonance imaging examinations were conducted at baseline prior to treatment and at one month and 6 months after treatment. A 3-dimensional study was performed to analyze the volumetric changes.

RESULTS

The most effective and significant treatment method for hypertrophic gastrocnemius muscle was the 48-point method (scattering injection). Following injection, this method exhibited a significant level of satisfaction with outcome.

CONCLUSIONS

Our study reveals that injection dosage and method have a strong relationship with achieving a better contouring result.

LEVEL OF EVIDENCE

3.

Ankle Plantar-Flexion Contracture Complication After Aesthetic Calf Volume Reduction Procedure

Minimally invasive, aesthetic calf volume reduction procedures are considered to be relatively safe. Published complications are mostly transient, with minimal functional loss. We hereby report debilitating ankle plantar-flexion contracture after aesthetic calf volume reduction procedure by selective neurectomy, with magnetic resonance imaging analysis and surgical treatment outcomes of this complication. From 2009 to 2010, 11 patients (17 lower legs) were surgically treated for this complication. The average preoperative ankle contracture angle of all involved lower legs was -22 degrees (range, -5 to -30 degrees). Magnetic resonance imaging performed in 14 lower legs showed lesions indicative of denervation atrophy, with fibrotic lesions causing longitudinal shortening of the gastrocnemius muscle. Of the 17 ankle contractures, 15 Silfverskiöld test-positive cases received miniopen gastrocnemius release, whereas 2 Silfverskiöld test-negative cases received Achilles tendon lengthening by percutaneous triple hemiresection. At last follow-up, the dorsiflexion angle of all ankles improved to an average of 25 degrees (range, 20-30 degrees) with full plantar flexion in all patients, whereas the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale scores improved from an average of 59.2 to 94.2. Surgeons and patients alike should be aware of debilitating ankle planter flexion contractures after aesthetic calf volume reduction procedures. Using minimally invasive gastrocnemius and Achilles tendon release, we were able to provide symptomatic and functional relief from this complication with minimal cosmetic sacrifice.

Anatomical study of the nerve regeneration after selective neurectomy in the rabbit: clinical application for esthetic calf reduction

The purposes of this study were therefore to characterize the degeneration and regeneration of nerves to the calf muscles after selective neurectomy, both macroscopically and microscopically, and to determine the incidence of such regeneration in a rabbit model. Seventy four New Zealand white rabbits were used. Selective neurectomy to the triceps surae muscles was performed, and the muscles were subsequently harvested and weighed 1-4 months postneurectomy. The gastrocnemius muscles were stained with Sihler's solution to enable the macroscopic observation of any nerve regeneration that may have occurred subsequent to neurectomy. The change in triceps surae muscle weight was measured along the time course of the experiment. After neurectomy, nerve degeneration was followed by regeneration in all cases. The weight of the triceps surae muscle decreased dramatically between completion of the neurectomy and 1 month postneurectomy, but increased thereafter. The nerve branches were weakly stained with Sihler's solution until 2 months postneurectomy, and then strongly stained after 3 months. The number of myelinated axons was decreased at 2 month after neurectomy compared to nonneurectomized controls, but then gradually increased thereafter. Although there are currently no reports on the incidence of recovery after calf reduction, it may be a very common occurrence in the clinical field based on our findings. The findings of this study provide fundamental anatomical and surgical information to aid planning and practice in calf-reduction surgery.

Bilateral idiopathic calf muscle hypertrophy: an exceptional cause of unsightly leg curvature

The authors present the management of a young female patient who presented with longstanding bilateral calf muscle hypertrophy, with no known cause. Taking into account the patient's wishes and the fact that the hypertrophy was mainly located in the posteromedial compartment, we chose to carry out a subtotal bilateral resection of medial gastrocnemius muscles. This procedure was performed with an harmonic scalpel, permitting a excellent cosmetic result while avoiding complications or functional impairment. After a reviewing of the commonly used techniques, the authors discuss the chosen surgical approach taking into account its clinical particularity.

Anatomic study of selective neurectomy of gastrocnemius muscle for calf reduction in Chinese

BACKGROUND

Selective neurectomy of the innervating nerves of the gastrocnemius muscle is a popular method employed for calf reduction. However, accidental injury to the untargeted adjacent nerves could happen. This study aims to provide detailed morphometry of the motor branches from the tibial nerve innervating the gastrocnemius muscle, the soleus and the medial sural cutaneous nerve in the popliteal fossa.

METHODS

23 lower legs from female cadavers were dissected to explore the origin, length of and the spatial relationship between the four branches given off from the tibial nerve in the popliteal fossa.

RESULTS

Our study showed there were seven origin patterns existing among the four nerve branches; the origin of the branches to the medial and lateral heads of the gastrocnemius muscle was located ranging from -16 mm to 22 mm away from the midpoint of the line between the lateral and medial condyles of the femur; In 95% of the specimens, the location of the origin of the nerve branch to the medial head was proximal to its lateral counterpart. The nerve to the medial head was often given off from the medial aspect or the posteromedial aspect of the tibial nerve, while the other three often from the lateral aspect.

CONCLUSIONS

A variety of origin patterns among the nerves to the lateral and medial gastrocnemius muscle, the nerve to the soleus muscle and the sural cutaneous nerve exist, necessitating the formulation of diversifying surgical strategies preoperatively and the meticulous and sequential dissection intra-operatively to ensure the lowest level of accidental injury.

Clinical and anatomical approach using Sihler's staining technique (whole mount nerve stain)

Sihler's staining allows visualization of the nerve distribution within soft tissues without extensive dissection and does not require slide preparation, unlike traditional approaches. This technique can be applied to the mucosa, muscle, and organs that contain myelinated nerve fibers. In particular, Sihler's technique may be considered the best tool for observing nerve distribution within skeletal muscles. The intramuscular distribution pattern of nerves is difficult to observe through manual manipulation due to the gradual tapering of nerves toward the terminal end of muscles, so it should be accompanied by histological studies to establish the finer branches therein. This method provides useful information not only for anatomists but also for physiologists and clinicians. Advanced knowledge of the nerve distribution patterns will be useful for developing guidelines for clinicians who perform operations such as muscle resection, tendon transplantation, and botulinum toxin injection. Furthermore, it is a useful technique to develop neurosurgical techniques and perform electrophysiological experiments. In this review, Sihler's staining technique is described in detail, covering its history, staining protocol, advantages, disadvantages, and possible applications. The application of this technique for determining the arterial distribution pattern is also described additionally in this study.

Correction of asymmetric calf hypertrophy with differential selective neurectomy

Contour asymmetry of the legs is a major aesthetic concern among Asian women. This study enrolled 60 patients with asymmetric calf hypertrophy, defined as a differential calf circumference exceeding 0.6 cm. Differential selective neurectomy techniques, which depend on the sizes of the small and large calves, were performed exactly via a 1-cm popliteal wound. The pre- and postoperative mean differences between the larger and smaller calf circumferences at the 1-year follow-up consultation were 1.38 +/- 0.65 and 0.42 +/- 0.38 cm, respectively (p < 0.01). The reduction was significantly greater in the leg that was initially larger. The procedure was effective in reducing circumference discrepancies so that leg contours were more balanced. All the patients were able to ambulate normally within 5 months after the procedure without disability. The authors posit that differential neurectomy is a safe and reliable technique for the correction of asymmetric calf hypertrophy, with minimal morbidities.

Extra- and intramuscular nerves distributions of the triceps surae muscle as a basis for muscle resection and botulinum toxin injections

PURPOSE

To compare the distribution of extramuscular nerve branches with their intramuscular ramifications in the triceps surae muscle, thus providing anatomical substantiation for the topography of muscle resection and botulinum toxin injections.

METHODS

Dissection and modified Sihler's staining of 18 whole-mount human cadaveric specimens.

RESULTS

The distance between the areas with the highest extramuscular branch density and the area of densest intramuscular arborization in gastrocnemius and soleus muscles is approximately 10% of the calf length. This finding should be taken into consideration during nerve blocking and botulinum toxin injections for the treatment of spasticity. Intramuscular nerve arborization patterns make it possible to outline neuromuscular segments in the gastrocnemius and soleus muscles.

CONCLUSIONS

Surgical or therapeutic interventions in areas of high extramuscular and intramuscular nerve density can increase the efficacy and safety of botulinum toxin injections and neurotomy. Intramuscular nerve branching patterns should be taken into consideration during triceps surae resection.