Improving Calf Definition by Calf Implant Surgery or Fat Grafting

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In a woman the maximal circumference of an aesthetically pleasing leg should be less than one-fifth of her body height and the ideal aesthetic contour of the leg has been defined as relatively flat in the medial upper third of the calf, with a gradual tapering to the ankle. Calf asymmetry is defined as a difference in the maximal circumference greater than 2.0 cm between both calves when standing on tip toes. Asymmetry can be due to surgery, sports activities, nerve injury or obesity. Bodybuilders want larger more well defined calf muscles and most women want slender longer looking legs, especially if they are shorter in height.

The shape of the calf is determined by the development of gastrocnemius and soleus muscles, the length and orientation of the lower leg bones, and the subcutaneous fat distribution. Cosmetic surgery of the lower legs between the knees and ankles may be desired for a variety of reasons such as  lipedema or stove pipe legs, hypertrophied or large calf muscles, small calf muscles, right left calf asymmetry, insufficient calf definition etc.

The surgical approaches that have been employed include calf implant insertion, fat injection, selective nerve removal or neurectomy, liposuction, muscle resection, radiofrequency shrinkage of soft tissue and botulinum toxin injection into the muscle. In some cases a combination of procedures are employed such as implants and fat grafting for patients who get calf implants and have thin ankles.

The first implants used for calf augmentation in the 1980s were silicone gel filled and similar to breast implants. Harder implants began to be used in the 1990s. Now we have solid and semisoft silicone including cohesive material which more closely resembles calf muscle and can be bought off the shelf or custom made using a moulage. In order to get proper definition and calf muscle or muscular outline 2 calf implants are usually needed per leg using a larger implant over the outer gastrocnemius muscle. They are inserted via an incision in back of the knee and the implants are placed between the gastrocnemius muscles and their fascial coverings. It is important to keep an intact septum between the implants so that they do not run into or overlap each other. Due to compression by the implants and swelling the patient may have difficulty walking for a week and should limit ambulation during that time. All patients must avoid strenuous activities and wear compression garments for 3 months after calf implant surgery. The disadvantages of calf implants are possible future capsular contracture, seroma (pockets of fluid), infection, implant extrusion through the skin and erosion of the surface of any bone they sit on. If you develop circulation problems or diabetes with aging the implants will have to be removed.

It is crucial that an appropriate sized implant is inserted and activity restrictions are followed strictly after surgery because excessive swelling, too large an implant or infection can result in compartment syndrome and permanent muscle damage or worse. The bodybuilder girlfriend of one of my patients had her calf implants placed in Mexico. They subsequently became infected and she ended up requiring amputation below the knee on one side.

Fat injection or grafting to the calves involves liposuction on an area of the body containing unwanted fat. Then the fat is grafted onto the calves to make them larger. The main drawback of fat injection is that 2 to 4 sessions may be required with 2 to 3 month intervals between grafting sessions. Fat injection offers many advantages, including the use of autografts; small, less visible scars; no late complications; the opportunity to perform touch up injection; the ability to increase size with future procedures; lack of foreign body rejection; more precise size adjustment than implants alone; satisfactory long-lasting results; and no need to reverse the procedure if you develop diabetes or circulation problems when older. The best candidates for liposuction have pinch thickness of skin and fat greater than 1.5 cm at the central calf and 1.0 cm at the ankle. Liposuction patients also require compression garments for 2 to 3 months after surgery.

Neurectomy although a well reported procedure is best reserved for extreme cases because it permanently and irreversibly damages leg muscles.

The main problem with any surgical approach is a visible scar that no patient wants to see or be seen. Therefore most surgical incisions in the area are confined to the skin crease in back of the knee or behind either ankle bone. Although they fade over time they have a tendency to widen and be darker than the surrounding skin.

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