Abstract: Increasing the size and definition of the calf with soft centered implants of Glitzenstein (and advocated by Felicio), the large single solid silicone implant of Carlsen, the hard multiple torpedo shaped implants of Novack and Bircoll and the lenticular implants of Aiache has been done successfully over the last thirty years. However, the problem of the poorly filled out leg below the calf has had little attention. Presented herein is a new one piece flexible silicone implant to address this condition. Ten patients have undergone correction with this device in the last four years. All have expressed great satisfaction. There has been one late complication.

Presented at the Rocky Mountain Association of Plastic Surgeons
Annual Meeting February 15, 2003 Park City, Utah

The under developed lower leg can be a source of embarrassment. This is even more true when it is associated with asymmetry, congenital deformity (tibial torsion, pes planus, genu valgus) trauma or disease (polio). In some people calf development fails to respond even to a strict exercise regimen. Augmentation of the calves with subfascial silicone has been practiced for over 25 years (Glitzenstein, Carlson, Bircoll, Aiache, Novak, Felicio) and is a reliable procedure, particularly with the Aiache lenticular implant. Technique and accurate selection of size bear heavily on the outcome. The implants are placed through a transverse popliteal incision in a plane dissected between the gastrocnemius fascia (“fascia cruris superficialis”) and muscle. A larger size is usually used over the medial head. The septum between the gastrocnemius heads with its neurovascular bundle is preserved. With significant tibial torsion it may be advisable to augment only the medial head to provide balance. It should be noted that all the cases of tibial torsion in this series have been associated with significant pes planas. The lack of longitudinal arch support may predispose to the torsion.

When the lower portion of the legs are thin, augmentation of the calves alone may exaggerate the deformity. Methods to address this situation were needed. I have used several techniques to fashion more pleasing contours. Liposuction of the knees, and at times, of the lateral distal leg may be combined with fat autografting to the lower medial knee and medial ankle. Subcutaneous augmentation of these areas, as well as the medial tibial area with Alloderm, and Fascian has been successful but of limited duration. Therefore a new combined medial calf, medial leg subfascial silicone implant has been developed. Thus far this implant has met with complete patient approval. Dissociative or even local anesthesia with instilled Marcaine (.5% bupivacaine HCL with epinephrine 1:200,000) is adequate for all calf/leg procedures.

(Figure 1)

Ten cases of calf/leg implantation have been performed over the last three years. There has been one late exposure in an actor who wore cowboy boots while on location 24 hours a day for ten days. All patients, even this young man, have expressed extreme satisfaction with the procedure. The salient factor is complete subfascial placement.

Surgical Technique: At consultation the length of the medial and lateral heads of the gastrocnemius is measured, and the length between the inferior border of the medial gastrocnemus and the superior border of the medial malleolus is also recorded. With these measurements the appropriate implants can be selected. The implant (design patent pending) provided by Hanson Medical is solid silicone, durometer 4.5-5.0. In general, the calf portion corresponds to an Aiche 3, 4, or 5. The extension varies from 12 to 18 cm in length, is 2.5cm in width and has a 1.2 cm projection. According to patient preference, surgery may be performed under local, dissociative, or general anesthesia. With patient in prone position, the ankles slightly elevated, the popliteal crease is marked for a 4 cm incision, 3 cm is medial to the midline of the leg and 1 cm lateral to that point. ½% Xylocaine with epinephrine is injected in this line and then continued as a field block for the calf and medial leg. The popliteal incision is deepened through subcutaneous tissue and superficial fascia to the thin fascial covering adherent to the gastrocnemius muscle. Grasping this layer, the subfascial pocket is made. If both heads of the muscle are to be augmented a bridge is allowed to remain over the lesser saphenous – sural nerve bundle.

In cases of tibial torsion it may be advisable to augment only the medial head especially in women. Dissection in this plane with blunt scissors, the middle finger, and a flat cannula (which also instills Marcaine (bupivacaine)) and finally the long paddle, spade or Hagar dissector, elevates the calf compartments. The long dissectors delineate the inferior border of the gastrocnemius fascia. A long straight ribbon retractor with a hole drilled near each end is passed into the medial compartment and pushed through the inferior aspect of the “sock” of the fascial compartment to enter the subfascial plane of the soleus. An umbilical tape is passed through the proximal hole in the instrument. The tape is tied over the implant so that the implant tip is on the metal “sled.” The ribbon retractor “sled” is advanced to just above the medial malleolus. Palpation delineates the instrument and a vertical incision 1 ½ cm is made over it. With lateral retraction on the incision the implant is exposed. The tibialis posterior tendon should be posterior to this area and the greater saphenous vein anterior to the exit point. The hole in the distal end of the “sled” is helpful in retrieving it with a curved hemostat. The ribbon retractor sled is pulled through, the implant extension follows and the calf portion of the implant is seated. The umbilical tape is removed, a slight distal extension of the subfascial pocket is made and the end of the implant is positioned so that the end is 2 cm distal to the skin incision.

(Figure 2)

The distal incision is repaired with fascial suture of 4 Nylon, subcutaneous suture of 4-O Vicryl and skin with subcuticular 4-O Prolene. If the lateral gastrocnemius compartment is to be augmented an appropriate sized Aiache lenticular sold silicone implant, 4.5 durometer, is positioned in the lateral subfascial pocket. The popliteal incision is repaired with 4-O Nylon, 3-O or 4-O Vicryl, and 4-O subcuticular Prolene. If patient will not be available for suture removal in 10-14 days due to geographic consideration, 4-O PDS is used. Xeroform gauze, 4x4 gauze, paper tape, and 6” ace wraps are used for dressing. Legs should be elevated as much as possible for the first two days with limited ambulation. Ace wraps are continued for another week. Use of an elevated heel is helpful in the early post-operative period. Lower body exercise may commence in four weeks.

(Figures 3-8)

Summary: A new silicone prosthesis that enhances the entire medial lower leg is presented. Ten cases have been done. Follow up ranges from nine months to four years. There was one late erosion in a non- compliant patient. This may have healed since he has expressed satisfaction with the procedure but he has not yet kept a direct follow up appointment. All patients have expressed great pleasure in their augmented contours. There has been no limitation of motion or athletic restriction.

References:

• Glitzenstein, I.: Correction of the amyotrophies of the limbs with silicone prosthesis inclusions Rev. Bras Cir: 69:117, 1979

• Carlsen, L. N.: Calf Augmentation – a preliminary report Annals of Plastic Surgery: 2; 508, 1979

• Bircoll, M.: Silicone gel subfascial calf augmentation:6; Am J. Cosmetic Surgery 235, 1989

• Aiache, A.: Calf implantation: Plastic and Reconstructive Surgery
  83: 488, 1989

• Novack, B. H.: Alloplastic Implants for Men Clinicis in Plastic Surgery:
  18; 829, Oct. 1991

• Felicio, Yhelda: Calfplasty. Aesthetic Plastic Surgery: 24 141, 2000
  Tureck, Samuel L.: Orthopedics T.B. Lippincott Co, 1959 pp154-156