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Posts Tagged ‘calf augmentation’

Calf Implants Surgical Technique

Tuesday, January 26th, 2016


Calf augmentation can be done by two surgical methods. The most historic and reliable is the use of synthetic calf implants. A more recent but far more unpredictable technique is that of fat injections. Each calf augmentation method has its advantages and disadvantages but, like breast augmentation, fat injections are a good volume addition technique in only a very few carefully selected patients.

While calf implants are well known, the surgical method to place them is done by very few plastic surgeons. With good surgical technique, calf augmentation can be done with a good aesthetic outcome and very successful long-term results.

Calf Implant Incisions Dr Barry Eppley IndianapolisThe placement of calf implants is done from incisions behind the knees. A separate incision is need for either medial or lateral implants placed over the gastrocnemius muscles. Each incision does not need to be longer than about 3.5 cms. It should be placed directed in the visible skin crease in the popliteal fossa which is seen  even in young patients.

Calf Implant fascial incision Dr Barry Eppley IndianapolisOnce the skin incision is made, dissection is carried down through the subcutaneous fat to the the dense fascia layer over the muscle. One may encounter cutaneous sensory nerve branches at the end of the incisions and they should be preserved and pushed aside. Once the fascia is encountered it is incised at the same horizontal length as the skin incision.

Calf Implant Insertion Technique Dr Barry Eppley IndianapolisCalf Implant insertion Technique 2 Dr Barry Eppley IndianapolisA subfascial pocket is developed with special instruments that can create the dimensions needed without tearing the overlying fascial lining. It is important the the pocket not be developed too long so that the fascia is not violated at the bottom of the pocket where it gets adherent to the soleus region. Also the pocket should not be developed across the midline union of the gastrocnemius muscles to prevent implant drift. The calf implants are inserted by squeezing them through the skin and fascial incisions. The special double layer design of the calf implants (Implantech body contouring implants) allows them to be compressed and pushed through small incisions without tearing of his soft gel shape.

Calf Implant Incision Closure 2 Dr Barry Eppley IndianapolisOnce positioned into the pocket, the implant should like well below the fascial incision line. In closing the incision, the underlying fascia should not be attempted to be closed. (which often is impossible anyway) Closing the gastrocnemius fascia makes the calf area very tight and increases after surgery pain. A flap of fat should be used to cover the fascial opening. The skin is then closed in two layers with dissolvable sutures. The incision is covered by tapes and the calfs ace wrapped.

While calf implants are more invasive and involve a longer recovery than fat injections, well placed subfascial implants provide a permanent method of calf augmentation. The subfascial placement of the implants will require several weeks of recovery until one can resume full physical activities.

Dr. Barry Eppley

Indianapolis, Indiana

Calf Implants – Effectiveness and Complication Rates

Sunday, September 1st, 2013


Body implants, primarily for muscle augmentation, can be done for a variety of anatomic sites including the chest, shoulders, arms, buttock and calfs. While some of these implanted areas are new, the calfs represent one of the original types of body implants. Calf implants have been around now for several decades using a variety of silicone implant shapes.

The calfs acquire their shape by several factors including the size of the gastrocnemius and soleus muscles, the length and orientation of the crural bones, and the amount of fat between the skin and the underlying muscles. Some people have naturally thin or underdeveloped calf muscles that remain small no matter how much exercise they do. Calf implants can be used aesthetically to make the inner or outer heads of the gastrocnemius muscles appear larger by placing an implant on top of the muscle but below its investing fascia.

Calf implant surgery is fairly straightforward. The superficial anatomy of the calfs is not confounded by neurovascular structures nor being deeply embedded beneath a lot of tissues. The incision(s) are behind the knees, the entrance through the fascia of the gastrocnemius muscles is fairly easy to find, the subfascial plane is developed with long instruments, the chosen implant is slid into place and the incision is closed in multiple layers. Within an hour the calfs of both legs can be augmented.

With the relatively long history of calf augmentation, even though it is not commonly done, the success of the procedure and the incidence of complications should be well known. Two recently published articles chronicled significant calf augmentation experiences.

In the April 2012 issue of Aesthetic Plastic Surgery, an article entitled ‘ Bilateral Calf Augmentation for Aesthetic Purposes’ was published. Calf implants were placed in 53 patients (40 women and 13 men, 106 implants) over a three year period and followed for an at least one year. Smooth silicone elastomer implants were used. The implant sizes were 125cc in 37 bilateral cases, 70cc implants in 10 cases and 175cc in 6 cases. No infections or hematomas occurred. Three seromas developed. (3%) Four cases of hypertrophic scars (4%) were seen. One patient (1%) wanted the implants were removed. No case of compartment syndrome or deep vein thrombosis was seen.  Implant displacement or rotation did not occur. From an aesthetic standpoint, 73% of the patients were completely satisfied and 19% were mainly satisfied. Only 8% of the patients felt that the appearance was not what they wanted.

In the June 2013 issue of the American Journal of Cosmetic Surgery, a published paper entitled ‘Calf Augmentation: A Single Institution Review of Over 200 Cases’ appeared. Over a five year period, a total of 202 calf augmentations were performed using semirigid silicone elastomer implants. They reported a satisfaction rate of 92% (186/202) Dissatisfactions were related to the amount of augmentation achieved or by hypertrophy of the knee scars.

Of all the locations for body augmentation, the calfs represent the ‘simplest’ location for the placement of implants based on the anatomy of the area. These two clinical studies demonstrate that the overall satisfaction rate is high and the complication rate fairly low. To put this in perspective, compare calf implant complication rates to that of breast implants and it is actually far less. The recovery is actually more difficult as it affects walking, as breast implants obviously do not, but the risk of potential complications appears to be much lower.

Dissatisfaction with calf implants largely resolves around the amount of augmentation obtained. Any patient’s interpretation of calf size is obviously subjective but there are limits to the size of calf implants that can be safely placed. The range of calf implant volumes is always less than 200cc, usually being between 70cc and 170cc with 125cc being the most common size calf implant placed in my practice. Larger implants, particularly if both muscle heads are implanted in each leg, raises concerns about the potential for a compartment syndrome or deep vein thrombosis (DVT) after implantation due to the compression of the deeper vessels. At the least over sizing implants in the calfs makes for a more uncomfortable and prolonged walking recovery.

Now that fat injections are becoming a standard option in plastic surgery for soft tissue augmentation, how well a synthetic implant performs by comparison is important to know. Implants offer an effective and low risk option for calf augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Postoperative Instructions for Calf Implants

Saturday, August 17th, 2013


Implants for calf augmentation are surgically placed by incisions behind the knee. Very soft solid silicone implants are inserted under the fascia and on top of the gastrocnemius muscle. Either the inner half of the muscle (two implants) or both halfs of the paired gastrocnemius muscle (four implants) can be augmented.

The following are the typical instructions for calf implant augmentation:

1. On discharge from the surgery center, go home directly to bed for the night. Get up only to go to the bathroom and keep the legs elevated as much as possible.

2. Calf implants are associated with a moderate amount of pain in the first few days after surgery.  Narcotic pain medications are almost always needed and you should them as prescribed. In a few days or by a week after surgery, you may switch to Ibuprofen completely or alternate between doses with the narcotic medication.

3.  There will be ace wraps placed around the calfs after surgery. This is in place for comfort only and does not play a role in maintaining the position of the implants. You may take these off the next day and they do not need to be put back on unless they feel better if they are worn.

4.  The incisions behind the knees are covered with glued on tapes. This may be allowed to get wet while showering. They will be removed during your first postoperative visit. The sutures in the incisions are under the skin and do not need to be removed.

5. Swelling and tightness of the calfs is common and peaks by two to three days after surgery. Conversely, bruising is uncommon although possible.

6. You can’t walk around a lot nor walk up stairs at first when you have this type of implant. You MUST limit your walking or risk infection. You should also elevate your legs as much as possible for the first week and wear a type of support hose for 3 weeks. Normally, you may return to exercise and other activities after 6 weeks.

7. It may be helpful to wear hoes with 1 – 2” heels after surgery and for several weeks thereafter. This will cause the calf muscles to not be under too much stretch and the discomfort will be less.

8. Do not expose the calf or scars to the sun or tanning bed for at least 2 -3 weeks after the surgery as severe burns can occur from minimal exposure. Scars must be covered when exposed to sun or the tanning bed (so as not to hyperpigment) until all redness is gone which takes 3 to 6 months. You may use tanning creams.

9. The incision behind the knee will heal in about 10 days. However, it will remain red for up to 6 months until its color eventually fades and blends in better with the surrounding skin. A small fine-line scar will remain. The area surrounding the implants, however, will take about 6 weeks to fully heal. Therefore, you need to be careful with activities to avoid potential problems. Most complications occur in men who do not follow instructions well and insist on returning to work or the gym too early. This can result in hematoma (bleeding), excess swelling, or other problems.

10.  If any redness, tenderness, or drainage develops on the chest or from the armpit incisions after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Consent for Plastic Surgery – Calf Implants

Saturday, August 17th, 2013


These explanations are intended to improve your understanding of the calf implant procedure. Please read them carefully and understand that this list includes many, but not all of the different outcomes from surgery. Please feel free to ask Dr. Eppley any further questions regarding your surgery.


The alternative to implants for calf augmentation are strenuous exercise/weight training (non-surgical) and fat injections. (surgical)Fat injections are the most commonly used alternative augmentation technique.


The goal of calf implants is to increase the size and shape of the gastrocnemius muscle by creating the appearance of increased muscle mass by placing an implant on top of the muscle under the fascia. This could be done for either the inner half of the calf muscle (medial belly of the gastrocnemius muscle), the outer half of the calf muscle (lateral head of the gastrocnemius muscle) or both.


The limitations to calf augmentation is the tightness of the surrounding skin of the calfs and how much the skin can stretch. This ultimately determines the size of implants that can be placed and whether one or two implants are placed per leg.


Expected outcomes include the following: temporary swelling and possible bruising of the calfs, a temporary firmness/hardness of the calfs, mild to moderate discomfort of the calfs and temporary redness of the behind the knee incision line/scar. It will take four to six weeks before the final shape and appearance of the calfs can be completely appreciated.


Complications may include bleeding, infection, dehiscence of the incisional closure (partial or complete separation), prominent or noticeable knee scars, calf implant asymmetry, and too big or too small of a calf size increase result.


How the implanted site heals and the occurrence of complications can influence the final shape and appearance of the calfs. Should complications or the desire to enhance the result further by additional surgery be needed, this will generate additional costs.

Case Study: Calf Implants in Bilateral Clubfeet

Saturday, August 3rd, 2013


Background: Calf augmentation using either a synthetic implant or fat injections is a well known surgical procedure to increase the prominence of the calf muscle. While many people think of the typical calf augmentation patient as a body builder or an athlete, aesthetic enhancement of normal calf muscles is only one reason to have the procedure. The other reason calf implants are done is for congenital deformities or obvious developmental asymmetries. Such deformities can include club foot, spina bifida and even polio.

Clubfoot is a well recognized lower leg deformity which is reported to be the most common birth defect. Medically known as congenital talipes equinovarus, the involved foot looks like it has been turned inward at the ankle. It occurs half the time in both feet at birth and more frequently in males. The calf (gastrocnemius) muscle is always smaller on the affected foot. Besides the issue of less functional use, studies have shown that the smaller size of the gastrocnemius muscle is due to wasting of the calf muscle from a reduction in the number of muscle fibers rather than their size.

When occurring on one side, clubfeet patients have a much smaller muscle than on the normal leg. When occurring in both feet, the calfs (as well as the entire leg) can be extremely thin. The calf muscle is so atrophic that there is a straight line from the inner knee straight down to the ankle without the usual calf muscle bulge seen in the frontal view. This is a source of embarrassment for many patients and will often prevent them from wearing shorts or otherwise exposing their calfs in public.

Case Study: This 23 year-old male was born with bilateral clubfeet and had been through many years of physical therapy, splints and achilles release surgery. He had thin upper thighs and very thin calfs that tapered inward from below the knee to the ankle. His skin was very tight around his calfs. While he ideally could have aesthetically benefited by both medial and lateral calf implants for both legs, the tightness of his tissues made that consideration too risky for fear of a compartment syndrome after surgery.

Under general anesthesia in the prone position, 3.5 cms long incisions were made in skin creases behind the knees at the inner half. Dissection was carried down to the muscle fascia where, in a stairstep fashion, fascial incisions were made well below the level of the skin incisions. An instrument dissected out a subfascial plane over the medial gastrocnemius muscle where solid soft silicone elastomer calf implants (15cm long x 5 cm wide, 135cc volume) were placed. the fascia and skin were closed in separate layers. He was dressed with tapes for his incisions and ace wraps for his calfs. The procedure was completed in one hour.

He rested his legs for the first few days, keeping his legs elevated. His recovery occurred over the next 3 weeks during which the calf muscles became used to having an implant sitting on top of it and the overlying skin stretched a bit. Returning to normal walking gradually occurred although a bit slower in the club foot patient who already had comfortable walking issues beforehand. His results showed a visible enlargement in his inner calf size that was proportionate to his thighs.

Calf implants in the clubfoot patient provide an immediate improvement in calf size. Fat injections are often not an option if they do not have any significant amount of fat to harvest in thinner patients. It is tempting to use larger sizes of calf implant or even two implants per leg but the tightness of the surrounding skin makes this a more risky approach in the patient with an atrophic overall calf. A larger size or an additional implant can be placed at a later date if desired.

Case Highlights:

1) For the clubfoot patient, calf augmentation with implants can provide a immediate and visible change in atrophic calf size.

2) Calf implants are placed on top of the muscle under the fascia in the inner calf muscle to get the most visible effect.

3) Calf implant augmentation is a very straightforward procedure that is accompanied by a longer recovery than the simplicity of the operation would suggest due to lower extremity dependency and function.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Implant Augmentation in Calf Asymmetry in Clubfoot

Saturday, June 22nd, 2013


Background:  Augmentation of deficient calf muscles is done for a variety of reasons. These include naturally small calfs, in bodybuilders who want their calfs to match the muscular look of the rest of their body and for congenital leg defects in which calf muscle development is small and ill-defined either on one leg or both legs.

One of the most common congenital lower leg defects that affects the calf muscles is that of clubfoot. Clubfoot is a well known birth defect, also called talipes equinovarus, as it occurs in about one in every 1,000 births. In about half of those so affected, it will occur on both sides. It is a birth defect that is far more common in males than females. The appearance of the foot so affected is unmistakeable with the foot turned inward on its side. The involved foot, calf and overall leg length is smaller and shorter.  If clubfoot is limited to one side, the calf asymmetry compared to that of the normal side is very apparent. Circumferential calf measurements are often 2 to 5 cms smaller than that of the unaffected leg.

Calf augmentation is most commonly done by synthetic implants. Commercially available calf implants offer immediate and permanent changes in calf size and are made of a very soft durometer solid (spongy) silicone material.  They are shaped like long fat cigars in various lengths, widths and volumes. These implants are placed in a subfascial location on top of the calf muscles. Complications can include infection and inadequate positioning whose risks are very low. The biggest issue with calf implants is the recovery, particularly if both calfs are treated.

Case Study: This 16 year-old female was born with a right clubfoot deformity. Her leg leg and foot were unaffected. She had been treated by serial casting as an infant and had a fairly normal gait. She was bothered by the difference in her calf sizes which was very visible in shorts. The difference in circumferential calf size measurement was 3.7 cms at the mid-calf area.

Under general anesthesia and in the prone position, a 3 cm incision above the medial gastocnemius muscle head was made in the popliteal skin crease of the right leg. Dissection was carried down to the gastrocnemius fascia which was horizontally incised. An instrument was used to develop the subfascial pocket over the muscle. A small silicone calf implant, measuring 16cms in length by 5.5cms in width (70cc volume) was inserted. The fascia and skin was closed with dissolveable sutures and taped. No other dressing was used.

Her recovery included some calf pain, swelling and inability to comfortably fully flex the ankle for a few weeks. By six weeks after surgery she had returned to all normal activities. Her calf asymmetry was improved, although not perfect, with a change to only a 1.5 cm difference in circumferential mid-calf measurement from that of the left normal side.

Gastrocnemius muscle augmentation using implants can provide an effective improvement in calf asymmetry due to clubfoot. The congenital shortness of tissue around the calf makes for tight skin. This limits the size of the calf implant that can be placed and dual muscle augmentation (medial and lateral heads) is not usually advised.

Case Highlights:

1) Calf augmentation by synthetic implants is the most reliable method of permanent volume enhancement

2) Congenital clubfoot deformity is associated with other lower leg issues of which small calf muscle development also occurs.

3) Calf augmentation (reconstruction) in club foot with synthetic implants must take into consideration the tightness and shortage of circumferential skin when selecting implant size.

Dr. Barry Eppley

Indianapolis, Indiana

Calf Augmentation with Fat Injections

Friday, June 21st, 2013


The shape of the lower third of the leg is highlighted by the appearance of the calfs. Whether they are big, small or somewhere in between, they are the dominant shape between the knee and ankle. The shape of the calfs is largely controlled by the size of the paired medial and lateral heads of the gastrocnemius muscle. Usually the inner or medial head of the gastrocnemius is bigger than the outer or lateral head although the medial head is most commonly seen and used to judge the muscular characteristics of the calfs.

Unlike many other body parts, the calfs have not been as easy to augment or increase in size. It can be one of the toughest muscles in the body to build up by exercise. While silicone calf implants are the quickest and most assured method of calf augmentation, it does require some significant recovery like the placement of any body implant. With the rise and popularity of fat injections, the calfs have not been left out as a place to be treated with this natural method of aesthetic enhancement.

In the July 2013 issue of the Journal of Plastic, Reconstructive and Aesthetic Surgery, an article was published entitled ‘Calf Lipo-Reshaping’. In this paper, the authors looked at five (5) patients over two years who had been treated by fat injections for calf augmentation.  An average of around 120cc as injected into each calf. Their follow-up was between six and eighteen months after the procedure and included circumferential measurements and magnetic resonance imaging (MRI) in two patients at the end of their follow-up. Their results showed that an average increase of just over 2.5 cms in circumferential enlargement occurred. Viable fat could be localized by MRI.

This is not the first article that has been published on the success of fat injections for modest to moderate amounts of calf augmentation. While lipoaugmentation is a viable alternative to the use of solid silicone implants, it is not a technique that is useful for many patients who seek a noticeable increase in the size of their calfs. One has to have enough fat to harvest for an adequate amount of fat to be injected and some patients with small legs/skinny calfs do not have enough donor material. There is also the question of how much fat will survive. This and other published studies to date, however, show that the calfs exhibit good fat retention and are not a more difficult place for its survival than most other body areas.

Should one have synthetic implants or fat injections for calf augmentation? This question is not that one is better than the other. Numerous factors come into play as to which one is best in any patient. But fat injection grafting has a legitimate role for calf enlargement, particularly those who are having other body contouring procedures and willing to accept a modest increase in calf size.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Injections for Calf Augmentation

Monday, June 9th, 2008

Augmentation of the calfs is most consistently done with a synthetic implant. Most patients who seek calf augmentation are typically body builder types, those born with very thin calfs who have been unable to build them up, or sosmeone with significant calf asymmetry. Despite an implant’s predictable improvement in the size and shape of the calfs, calf implants are not without problems. Implant placement into and on top of the calf muscles makes recovery uncomfortable and having to stand and walk around early on afetr surgery makes it possible for the implant to shift, develop a fluid collections (seroma) or possibly even get infected.
Because of these implant concerns, the alternative treatment of fat injections or free fat grafting has emerged. A recent article in Plastic and Reconstructive Surgery presents a patient series using fat injections for calf augmentation. Their reported experience is encouraging. Fat grafting to the calfs has numerous potential advantages such as the elimination of the need for a synthetic implant, the use of a patient’s own body tissues, an easier recovery with few limitations, and a very low risk of bleeding or infection. Such advantages over an implant gives serious thought to its use.
All of these advantages of free fat fat grafting is counterbalanced by one significant disadvantage….an unpredictability of after surgery shape and size. How much fat survives and is retained is widely variable. No plastic surgeon can guarantee or predict with 100% accuracy how much fat will survive on a consistent basis. The article reports using 75 – 125cc per calf with good volume retention.The burning question through the past several decades is…how to make fat grafting work better. The injection technique is, of course, important but is only half of the answer. How the fat is prepared after harvest in the oeprating room is the other half. Everyone agrees that concentration is very important after harvest. This is the mechanical process of removing the liquids from the more solid fat components. Whether this is done by a centrifuge or passing the fat aspirate through a strainer or sieve are two methods of which one has not been proven to be better than the other. Additives to the fat are theoretically appealing but there is no universal magical additive. Currently, I add platelet-rich plasma (PRP) to the concentrated fat prior to injection. Whether this aids fat survival is not proven but since it is a product of the patient, there is no risk in so doing. PRP is a concentrate of a patient’s own blood done at the time of surgery. While there is no standardized amount of PRP to add to fat, I would envision adding 3cc of PRP per calf graft site.
Having done a few cases of calf augmentation with fat injections, the technical aspect of this approach is straightforward. Careful marking of the patient while standing beforehand is critical to get the proper areas augmented. Like all fat injection surgeries, the patient must accept that the amount of fat that will survive is unpredictable. It may require more than one injection session to obtain the best result. Most fat grafting methods will not achieve the degree of volume enhancement that a calf implant will. In reviewing the before and after photos from the above mentioned article, that observation seems to be true.
Dr. Barry Eppley

Indianapolis, Indiana

Calf Implants for Lower Leg Enhancement

Monday, December 24th, 2007

Calf Implants and Augmentation

The use of calf implants to give the lower leg more shape is not as uncommon as you think. There are many different reasons why someone wants calf implants; from the bodybuilder who can’t get the calfs big enough compared to the rest of the thighs, a birth defect or surgically-induced problem where one calf is much smaller than the other (asymmetry), or someone that just has extremely thin calfs since they were born. (stick legs) Calf muscles are some of the hardest muscles to build up by exercise and are extremely resistent to getting bigger without a herculean effort at weight-lifting.

Calf implant surgery is based on two important concepts; the placement of calf implants to simulate the two calf muscles on both sides of the calf (although not every patient requires two implants per calf) and the use of rubbery (semisolid, not liquid) silicone implants that come in a variety of sizes and shapes. The location and size of the implants should be determined in the office in advance of surgery by measurements.

Calf implants are placed through an incision in the back of the knee and pockets into which the implants are placed developed within the calf muscles. After which, the implants are slipped into place. The surgery does not take long but you need to be prepared for some recovery after surgery. While the procedure is done as an outpatient, calf implant surgery can be quite painful and full recovery is going to require some time. Be prepared to do the following after calf implant surgery; plan to take two weeks off work, rest your legs and elevate your ankles for several days after surgery and use crutches to get around, plan to walk in heeled shoes for a while (walking flat footed initially is very uncomfortable), walk with knees slightly bent, don’t work out for 4 to 6 weeks after surgery, and avoid running for two to three months after surgery. The biggest complication of calf implant surgery is the implants shifting from their place or a fluid collection occurring around them (seroma). Both of these problems are caused by too much calf activity after surgery! Also, expect stiff and sore calves for a month or so after surgery.

Calf implants can definitely give a better shape and a more muscular appearance to the lower legs but you have to be prepared for the recovery period. Calf implants take the longest to recover from any other body implant surgery in my experience. (pectoral, biceps, triceps, buttocks)

Dr Barry Eppley

Indianapolis, Indianapolis

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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