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Background: Augmentation of the lower legs can be done by either fat injections or implants. Each has their advantages and disadvantages which is consistent with the same choice for any other body muscle augmentation. Fat injections are an autologous procedure that has few complications and is a natural material but its volume retention is unpredictable and its aesthetic effect is more of a ballooning r swollen appearance of the augmented area. Implants are foreign bodies and, as a reult, can have more potential complications but is volumetrically stable and usually creates a more defined muscular appearance.

When considering calf implant augmentation an important aesthetic decision is whether one or both calf muscles should be augmented. The inner or medial gastrocnemius muscle is larger and longer in length than the outer muscle. It is also the most visible from the front view and thus is more aesthetically valuable. Patients usually augment the outer gastrocnemius muscle also when their goal is an overall larger lower leg appearance or they value how the lower leg looks from behind in which the enhancement of both muscles is important.

Beyond the aesthetic differences augmenting one vs two muscles per leg has other significant implications. The obvious one is the recovery. Traumatizing all four muscles of the lower leg does make the recovery more difficult and harder to walk early on after the surgery. But it also affects the choice of implant size. With twi implant placements per leg one has to be vigilant about the rare risk of compartment syndrome. Large implants in both muscles, combined with the swelling that will ensue, could potentially impede the blood flow to the foot by compression of the perineal artery. As a result of this risk, rare though it may be, it is prudent to choose smaller implant sizes in the 4 implant calf augmentation patient.

Case Study: This male desired to have both calf muscles of the lower leg augmented. Preoperative measurements were taken in the toe standing position to accurately determine the length and width of the calf muscles.

Under general anesthesia and in the prone position on the operative table, each implant has its own 3cm incision marked superiorly in the skin crease of the popliteal fossa. A preoperative midline mark had been made between the two muscle bellies as a guide to not cross it during pocket creation to protect the sensory sural nerve which runs between them.  

Once the incisions were made a stair step approach was down to the gastrconemius muscle fascia to stay below the hamstring insertions onto the fibula which can easily be confused as the gastrocnemius muscles. The muscle fascia is then horizontally incised through which subfascia pockets are developed with long blunt-ended instruments. The larger implants are placed in the inner pocket which the slightly small implants are placed in the lateral pocket. After the implant is placed the leg is bent at 90 degrees at the knee to ensure that the implant is pushed up towards or under the incision. (adequate lower end of the pocket has been developed. The muscle fascia is left open to help limit postoperative calf tightness. Only the skin is closed in two layers.

Calf implants provide a very effective and permanent method of calf augmentation. But the overlying fascia of the gastrocnemius muscles is naturally tight in which an implant interface between them will create some tight calf muscles and difficulty with walking early after the surgery. This is magnified when four implants are placed and this is going to definitely affect recovery. It is more ideal to have the inner and outer calf implants done separately as this will help with recovery. But the inefficiency of two surgeries is not very appealing to most patients.

Case Highlights:

1) Calf implants are most commonly placed in the subfascial pocket on top of the muscle through incisions placed in the popliteal fossa behind the knee.

2) An important preoperative decision is whether one or both gastrocnemius muscles of the lower leg are to be augmented.

3) Understanding and being prepared for the recovery from calf implants is an important preoperative education/preparation.

Dr. Barry Eppley

World Renowned Plastic Surgeon

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