Background: Calf implants are largely done for aesthetic augmentation of small sized lower legs regardless of gender. In less commonly performed cases the motivation for calf implants is reconstructive in nature. One such congenital reason is clubfoot, one of the most common birth defects. It is seen clinically as a foot or feet that are turned inward which is caused by a shortened achilles tendon. While early treatment can be effective at straightening the foot position there are some lingering long term effects such as calf muscle underdevelopment and a thinner leg from the knee to the ankle.
The clubfoot calf deformity comes in a wide variety of expressions reflective of how small the calf muscles are and how tight the overlying skin envelope is. When considering calf implants in such a patient this is a very different than the typical aesthetic patient. When significant under development of the gastrocnemius and soleus muscles exists there often is not much room to put an implant in the typical subfascial location on top of the muscle. In some severely affected patients the muscle is so small that there is no merit at all to even do so. The limiting effect of the small muscle with tight fascia is compounded by the often tighter enveloping skin around the lower leg in general.
Because of the soft tissue limitations in the more severely affected club foot patient the consideration of a subcutaneous placed calf implant is a more effective option with a lower risk of potential complications. It is going to be far more successful to stretch out the overlying tight skin than it is that of the fascia of the underdeveloped calf muscles. While this does increase the risk of postoperative fluid collections and even implant show a small subfascial implant which has very limited augmentation effect or potential compression of the underlying arterial flow to the foot are worthy trade-offs.
The other consideration of calf implants in the clubfoot patient is the asymmetry whether one or both legs are affected and whether any of the standard calf implant options available would fit the dimensions of the augmentation needed. Therefore in some patients the use of a custom calf implant design may be indicated.
Case Study: This young male was born with and underwent an early surgical correction. As an adult he had significant calf muscle and lower leg under development with the right leg being the most severely affected. This resulted in some very visible asymmetry between the two legs. The right leg was very thin and tight with very little calf muscle. The left leg was better but was still significantly under developed. He had no range of motion of either ankle. Because of the asymmetry between the two lower legs custom calf implants were designed based on external measurements of Length and widths. The amount the the projection of the implants was estimated based on trying not to have too much implant volume given that the overlying skin was very tight. The surgical plan was also to place the implants in a subcutaneous location.
Under general anesthesia and in the prone position medial small skin incisions were made in the popliteal skin increase. Subcutaneous dissection was then done to create the pockets based on the external in implant markings.The custom calf implants were prepared for placement by initially cutting 6 mm perfusion holes through the implant with a dermal punch. This was done to allow for tissue ingrowth as well as to potentially decrease the risk of postoperative fluid collections.
In the larger right calf implants its upper portion was a bit too full and this was then manually reduced but the footprint remain the same. The implant was then inserted with the orientation is far anterior as possible over the tibia for maximum visible aesthetic effect.
On the opposite left leg the much smaller calf implant was similarly prepared and inserted.
No drains were used in the popliteal incisions were then closed into layers with resorbable sutures. The immediate intraoperative effect of the implants as seen in the prone position was a visible improvement but some asymmetry persisted due to the smaller right lower leg which could not be made symmetric to the left even with a custom implant that had four times the volume is that of the left.
Key Points:
1) The clubfoot patient poses challenges for calf augmentation with muscle underdevelopment and a tighter skin sleeve.
2) Subcutaneous implant placement in the clubfoot patient allows for a larger implant size than a subfascial location.
3) Custom designed calf implants offer the ability to address different sized lower legs due to the congenital clubfoot and prior surgical effects.
Dr. Barry Eppley
World-Renowned Plastic Surgeon