Aesthetic Improvement of Undeveloped Calves After Treatment of Congenital Clubfoot Deformity

Aesthetic Improvement of Undeveloped Calves After Treatment of Congenital Clubfoot Deformity Abstract Background Even when clubfoot deformity is treated in a timely manner, the consequences observed in adulthood include hypoplasia of the calf muscles, gait impairment, decreases in foot size, and it can also affect the tibial length. These consequences may have negative impacts on the patient’s subjective appraisal of long-term outcomes, and can influence the patient’s self-esteem in both male and female patients. Objectives We present our experience in the treatment of undeveloped calves after surgical treatment of congenital clubfoot. Methods In total, 72 patients underwent corrective surgery in order to improve undeveloped calves resulting from a congenital clubfoot deformity. We used calf silicone implants in combination with fat grafting in multistaged procedures, in order to decrease complication rates and improve aesthetic outcome. Results Amongst our patients there were 54 (75%) females and 18 (25%) males. All of the patients, except one, had unilateral calf hypoplasia. The procedures were divided into several groups: (1) medial calf augmentation with silicone implants; (2) medial calf augmentation with silicone implants and fat grafting; and (3) medial and lateral calf augmentation with silicone implants and fat grafting. We had one case of a hyperpigmented scar and one case of partial scar dehiscence. There were no cases of compartment syndrome. The average follow-up period was 9.8 months. Conclusions Calf enhancement surgery in patients with congenital clubfoot deformity is very gratifying. When combining calf implants with fat grafting in multistaged procedures, we can achieve excellent results with low complication rates. Level of Evidence: 4 Clubfoot (talipes equinovarus) is the most common congenital lower limb deformity, occurring in about one in every 1000 newborns. It affects bones, muscles, tendons, and blood vessels. Clubfoot can present in one or both feet and there is a 50% chance of both feet being affected. Its manifestation is the abnormal position of the feet in which the toes point downward or rotate inward.1 The main reason for this is that the ankle ligaments (posterior and medial) and tarsal joints are very thick and taut, therefore they severely restrain the foot in equinus and the navicular and calcaneus in adduction and inversion. In most cases the cause of clubfoot is idiopathic, although there may be a genetic link. In a small number of cases, clubfoot occurs as part of a more serious underlying condition, such as spina bifida.2,3 Since it was published, in 1963, the Ponseti method has been the gold standard for the treatment of clubfoot.4,5 The correction of clubfoot using this method is done by specific manipulation, serial casting, and bracing, if necessary performing tenotomy of the Achilles tendon and long-term follow up for recurrence. The calf circumference of limbs affected by clubfoot is significantly smaller in those patients receiving extensive surgery as compared with those treated with the Ponseti method alone.6 These patients also present more scars in the foot region caused by more extensive surgery. Calf wasting can be seen in utero. It becomes more pronounced with age and might sometimes slowly improve; however, the timing of surgical intervention does not influence this.7 All patients born with clubfoot deformity, and treated in early childhood, present a certain level of hypoplasia of the calf muscles, besides other findings. The more severe the deformity, the smaller the leg muscles. When clubfoot is most severe, the gastrocnemius and soleus muscles are small and in the top third of the calf. Usually, it is not a functional problem; frequently these patients are able to actively participate in sports. But, it can present a significant aesthetic problem and cause a lack of self-confidence especially during the summer period (they won’t wear shorts, avoid the beach, etc.). In this study we present a single surgeons (K.A.) experience in the treatment of undeveloped calves after surgical treatment of congenital clubfoot. METHODS We treated 72 patients with calf hypoplasia due to congenital clubfoot deformity between January 2004 and December 2016. They all underwent corrective surgery to treat the deformity in their early childhood. The study was done under approval number 29/XII-7 of the Institutional Review Board at the Faculty of Medicine, University of Belgrade. All patients signed a consent form prior to the surgical treatment and agreed with the surgical plan. In all patients the physical examination starts with an inspection of the calf muscles. The patient is asked to contract the calf muscles by lifting themselves on tip toe. Muscle mass is then compared with the opposite side (in unilateral cases). When the deformity is bilateral, the bodies of calf muscles are detected in the same manner. The mobility of the tissue present (muscle and overlying skin) is evaluated by a pinch test when the muscles are relaxed. During initial consultation, all limitations in terms of the final result are explained as well as the possibility of undergoing a multistage procedure in order to achieve the best possible symmetry in unilateral cases. We suggest the following surgical steps to the patients: • Medial calf augmentation with silicone implants. (We always start the reconstruction with medial calf augmentation.) • The second stage consists of fat grafting (in the area of Achilles tendon or over the medial calf implant) and/or lateral calf augmentation depending on patient’s request. If necessary, the second procedure is planned after a minimum of 1.5 to 2 months after the medial calf implant insertion. • If necessary, further surgery is planned to follow 2 months after the last procedure, and will be further refinements with fat grafting or lateral calf augmentation (if it wasn’t previously performed). Routine blood tests and other preoperative exams before surgery under general anesthesia were prerequisite, as well as ultrasonography exam of the calf muscles and Doppler ultrasonography of the leg vessels. Exclusion criteria were any abnormalities of the blood vessels and/or the total absence of muscle mass. For deep vein thrombosis prophylaxis we use in all our patients low molecular weight heparin (Fraxiparine, Glaxo Wellcome Production, Notre Dame de Bondeville, France) injections in daily doses of 0.3 mL before and for 7 days following the surgery. We advise patients not to use aspirin or anything similar prior to surgery. Calf Augmentation With Silicone Implants The procedure involves a medial or lateral subfascial calf implant augmentation.8 When planning medial or lateral calf augmentation in patients who have suffered from clubfoot, there are more things to consider in comparison to a purely aesthetic group of patients. With the patient standing, skin marking of the calf deformity is performed. Comparison with the opposite calf (in unilateral deformities) is discussed with the patient and points of maximal muscle projections medially or laterally (depending on the augmentation) are marked on the hypoplastic calf in the front and back. The position of the calf implant is limited inferiorly (caudally) with the scar from previous corrective surgery. Medially the limitation of the implant pocket is the junction of the medial and lateral gastrocnemius head. The cephalic limit of the implant pocket is located approximately 3 to 4 cm from the popliteal crease where the skin incision is situated (Figure 1). Figure 1. View largeDownload slide A 46-year-old man presenting hypoplasia of the left calf. Preoperative marking of the implant pocket for the medial calf augmentation. Figure 1. View largeDownload slide A 46-year-old man presenting hypoplasia of the left calf. Preoperative marking of the implant pocket for the medial calf augmentation. Due to different levels of hypoplasia of the calf muscles, the implant size should be selected with care. Pinching and stretching the muscle and overlying tissue in the medial and/or lateral calf region should give us an idea of the maximal implant projection that will fit. The implant length is determined caudally by the position of the scar from the corrective tendon surgery. The pocket dissection should not pass into the scar region because of the risk of extrusion. After performing all these skin markings and measurements of the available space it is possible to choose the best available implant and proceed with surgery. After standard patient preparation, with the patient in a prone position on the surgical bed, an infiltration of the whole previously marked area is done with 20 mL of solution of Marcaine 0.5% with Epinephrine diluted 1:200,000. The surgery proceeds with a 4 cm zigzag skin incision located medially or laterally (depending on the surgery) from the posterior calf midline, in the popliteal crease. At the very beginning we did a few cases with a horizontal straight incision. We noticed significant scar tissue contracture and deformation of the tip of the implant as a consequence of wound healing from the straight incision. That is why we changed it with zig-zag incision. Zig-zag incision creates a scar that is less conspicuous and more acceptable in comparison to the straight incision. Moreover, the zigzag incision affords a wider exposure than a long straight incision, thus greatly facilitating the operative procedure. The next step is to undermine the subcutaneous layer to the sural fascia level. The horizontal fascia incision is performed approximately 3 cm below the skin incision and a blunt dissector is introduced in order to create a subfascial pocket. It is important not to pass the midline fascial connection between the medial and lateral gastrocnemius head in order to preserve the small saphenous vein and the medial sural cutaneous nerves which are located there.9 When necessary, compressive hemostasis is always sufficient. After hemostasis, the implant is inserted and the pocket is sutured in layers; fascia level with Nylon 4.0, Vycril 4.0 for the subcutaneous layer and Monocryl 3.0 for the skin subcuticular. Immediately after surgery, mild compressive stockings are put on in order to prevent postoperative edema and to maintain the pocket as tightly as possible. Early ambulation is highly recommended. In addition, 2-inch high-heeled shoes (or clogs with additional heel cushions) are advised to aid ambulation in the first weeks after the procedure. Male patients are advised to use clogs with additional heel cushion. Patients were discharged 24 hours postoperatively and are seen once a week. They are recommended to go back to their daily activities after 10 days and to exercise regularly after 2 months. Fat Grafting Second stage surgery in patients who were treated for congenital clubfoot deformity as children is planned 6 weeks after the first surgery in order to further improve the appearance of the calf/calves. After initial medial calf augmentation, there are 3 regions, noted by patients, which may need further improvement (cited in order of importance): • Inferior third of the calf – Achilles tendon region (scar region). • Lateral gastrocnemius contour. • Further improvement of medial gastrocnemius curve (over the calf implant). We always recommend fat grafting in order to perform these improvements both because of its filling and regenerative properties. All our patients question the concavity in the Achilles tendon region that becomes even more pronounced after the medial calf augmentation is complete. This is the region where the vertical scar is usually present. Careful planning and preoperative marking of the areas to be grafted and further improved are done before the surgery (Figure 2). Figure 2. View largeDownload slide A 47-year-old man 18 months after medial calf augmentation surgery, in preoperative planning for the second surgery (fat grafting medially in the scar region and over the previously augmented area with 140 mL silicone implant, marking of the lateral implant pocket). Figure 2. View largeDownload slide A 47-year-old man 18 months after medial calf augmentation surgery, in preoperative planning for the second surgery (fat grafting medially in the scar region and over the previously augmented area with 140 mL silicone implant, marking of the lateral implant pocket). It is preferable to harvest fat from the abdominal or lateral thigh region. After routine preoperative preparation, we infiltrate the donor region with solution with Epinephrine 1:500,000. For fat harvesting we use Tulip 3.0 cannulas (Tulip Medical Products, San Diego, CA) and we process the fat using the Puregraft system (Bimini Technologies LLC, San Diego, CA). The purified fat graft is then transferred into 1 mL luer lock syringes and infiltration is performed utilizing Tulip 0.9 and 1.0 injectors. Fat grafting is done slowly in the subcutaneous layer, in a retrograde manner withdrawing 0.1 mL of fat per passage and in a fan fashion. The same procedure is done in all three above-mentioned calf areas. Additionally, caution will be necessary when performing fat grafting in the medial gastrocnemius curve where it should be done between the implant capsule and the skin in several layers. At the end of the procedure hypoallergenic surgical tape is applied to all grafted areas, thus avoiding excessive pressure. After both procedures, patients are placed in bed with the treated leg elevated above the heart level to decrease the postoperative edema. Patients are urged to walk to the bathroom or in the infirmary and are examined once every hour for the presence of signs and symptoms of acute compartment syndrome: (1) pain out of proportion to the clinical situation; (2) weakness and pain on passive stretch of the muscles of the compartment; (3) hypoesthesia in the distribution of the nerves running through the compartment; and (4) tenseness of the fascial boundaries of the compartment. Also, when discharged from the hospital, patients are advised to report immediately if they notice any of these signs.10,11 Deep vein thrombosis prophylaxis was implemented for all patients during the first and second procedure. Low molecular weight heparine (Fraxiparine) is administrated as a single daily dose of 0.3 mL, for 7 days. The first dose was given 2 to 4 hours preoperatively. Prophylactic antibiotic therapy was also administered before both surgeries, using Ceftriaxone 1 g IV single dose and discharged with a 7-day course of Cephalexin 500 mg 4 times daily. Ibuprofen 400 mg was prescribed as an anti-inflammatory and pain killer twice daily if necessary. RESULTS Among the 72 patients that we treated, there were 54 (75%) females and 18 (25%) males. Their ages ranged between 22 and 57 (average, 34.67 ± 11.71 years). All but one patient had unilateral calf hypoplasia as a result of congenital clubfoot deformity that was corrected in early childhood. One patient had bilateral hypoplasia. In 36 cases (51%) the right calf was involved and 35 (49%) presented hypoplasia of the left calf. All patients were primary cases, as they hadn’t had any treatment for aesthetic improvements to the underdeveloped calf previously. The distribution of patients according to the type and number of surgeries performed is given in Figure 3. Figure 3. View largeDownload slide The distribution of calf procedures performed. Figure 3. View largeDownload slide The distribution of calf procedures performed. There are common findings in all patients with congenital clubfoot (even when correction is performed successfully and in early childhood).12,13 These findings were also confirmed in all our patients and are the following: • Gastrocnemius and soleus muscles atrophy/underdeveloped calf muscles (the size of the leg muscles correlates inversely with the severity of the deformity). • A decrease in foot size (the affected foot may be up to 1.5 shoe sizes smaller than the unaffected foot). • Mobility may be slightly limited (gait impairment). • Decreased tibial length (the average shortening was 2.60 cm ± 0.23; range, 1.3-4.1 cm). • A scar following tendon Achilles tenotomy (the average length of the scar was 10.2 cm [range, 9.6-11.5 cm] and it was located at the skin overlying the Achilles tendon in the medial part). We performed medial calf augmentation on all 72 patients, and on 3 of them we performed lateral calf augmentation as well. We used only asymmetric or anatomical silicone calf implants with sizes varying from 85 mL to 180 mL. In the majority of the 47 cases (65%), we used a 140 mL implant. There was one case of hyperpigmented scar and one case of partial scar dehiscence that were resolved conservatively (topical creams and dressings respectively). There were no cases of compartment syndrome. After a minimum period of 6 weeks, fat grafting was performed following initial augmentation surgery in 48 patients. The grafted areas and amount of fat used in each calf area are presented in Table 1. One patient requested additional fat grafting, due to undercorrection. There were no other complications related to the procedure. Table 1. Fat Grafted Calf Areas and Corresponding Volumes of Implanted Fat   Inferior third of the calf – Achilles tendon region (scar region)  Further improvements of medial gastrocnemius curve (over the calf implant)  Lateral gastrocnemius contour  No. of patients (total no. of patients = 48)  48  48  15  Volume of grafted fat (mL)  13.4 ± 2.0  30.8 ± 5.3  41.5 ± 6.2    Inferior third of the calf – Achilles tendon region (scar region)  Further improvements of medial gastrocnemius curve (over the calf implant)  Lateral gastrocnemius contour  No. of patients (total no. of patients = 48)  48  48  15  Volume of grafted fat (mL)  13.4 ± 2.0  30.8 ± 5.3  41.5 ± 6.2  View Large Table 1. Fat Grafted Calf Areas and Corresponding Volumes of Implanted Fat   Inferior third of the calf – Achilles tendon region (scar region)  Further improvements of medial gastrocnemius curve (over the calf implant)  Lateral gastrocnemius contour  No. of patients (total no. of patients = 48)  48  48  15  Volume of grafted fat (mL)  13.4 ± 2.0  30.8 ± 5.3  41.5 ± 6.2    Inferior third of the calf – Achilles tendon region (scar region)  Further improvements of medial gastrocnemius curve (over the calf implant)  Lateral gastrocnemius contour  No. of patients (total no. of patients = 48)  48  48  15  Volume of grafted fat (mL)  13.4 ± 2.0  30.8 ± 5.3  41.5 ± 6.2  View Large Generally, patients are able to return to their usual daily activities and walk in flat shoes without any pain after 10 to 14 days. Overall, patient follow up ranged from 6 months to 1.5 years (average, 9.8 months). DISCUSSION Decreased calf size may have a negative impact on a patient’s subjective appraisal of long-term outcomes and influence patient self-esteem, both in male and female patients. Therefore, it is important to assess these patients after they are discharged by their orthopedic surgeon, and to try to properly address their calf condition. The right diagnosis of calf condition is of the utmost importance for proper surgical planning and a successful outcome. Since these patients are usually discharged by their orthopedic surgeon, they are not aware of the possibility of further improvement. Previously, there was no systematic approach to the treatment of this deformity; they were treated in the same manner as patients seeking purely aesthetic calf enhancement. In our opinion, there are some important differences between these two groups that must be recognized before treatment. These findings contribute to a better understanding of this condition, and increases the knowledge base when it comes to the treatment of patients with calf hypoplasia after clubfoot deformity. The quality and elasticity of the calf tissue differs from normal calves because of the pathophysiology of clubfoot. During the child’s first years, the synthesis of collagen is excessive in muscles, ligaments, and tendon, hence the tarsal joints and posterior and medial aspect of the ankle are overly thick and taut. Collagen rich connective tissue increases at the distal end of the gastrocnemius and soleus muscles, which often spreads to the Achillis tendon and deep fasciae.14 The vast majority of patients with congenital clubfoot deformity end up with a scar that is derived from surgery aiming to further stretch the tendon region. Considering the increased risk of implant extrusion, the implant pocket should never enter the scar region. Due to the limitations in elasticity of calf tissue, the size of the implant should be selected carefully, and surgery should be performed in several stages when considering medial and lateral calf enhancement. Keeping all this in mind should significantly reduce the risk of complications, especially the incidence of compartment syndrome. The affected calf bones are always shorter than unaffected ones. The muscles are smaller in size and shorter than in a normal foot. The level of difficulty in achieving symmetry in unilateral cases depends both on the level of hypoplasia of the affected muscle and the patient’s constitution. Sometimes, even severe hypoplasia can be easy to symmetrize and satisfactory result can be gained with a single stage procedure (Figure 4). More procedures are always necessary when the opposite muscles are well defined/hypertrophic. These patients are mostly active sportsmen that have developed muscles through exercise (Figures 5 and 6). Figure 4. View largeDownload slide Satisfactory result in the single stage procedure. This 24-year-old man underwent medial calf augmentation with asymmetric 180 mL silicone implants. (A) Preoperative and (B) 18-month postoperative photographs. Figure 4. View largeDownload slide Satisfactory result in the single stage procedure. This 24-year-old man underwent medial calf augmentation with asymmetric 180 mL silicone implants. (A) Preoperative and (B) 18-month postoperative photographs. Figure 5. View largeDownload slide This 39-year-old woman (age at the first surgery) presented with well-developed contralateral calf muscles. A two-staged procedure was performed. (A, D) Preoperative views, (B, E) 14 months after the medial calf augmentation with 140 mL asymmetric calf implant, and (C, F) the final result 6 months after additional fat grafting (total amount of 45 mL) over the previously augmented region (according to Figure 2). Figure 5. View largeDownload slide This 39-year-old woman (age at the first surgery) presented with well-developed contralateral calf muscles. A two-staged procedure was performed. (A, D) Preoperative views, (B, E) 14 months after the medial calf augmentation with 140 mL asymmetric calf implant, and (C, F) the final result 6 months after additional fat grafting (total amount of 45 mL) over the previously augmented region (according to Figure 2). Figure 6. View largeDownload slide This 46-year-old man (age at the first surgery) presented with hypertrophic calf muscles on the contralateral leg. A two-staged procedure was performed. (A, D) Preoperative views, (B, E) 18 months after the medial calf augmentation with 140 mL asymmetric calf implant, and (C, F) the final result 2 months after lateral calf augmentation with asymmetric 150 mL silicone calf implant and fat grafting in the scar region (15 mL) and over the medial calf implant (32 mL) (according to Figure 3). Figure 6. View largeDownload slide This 46-year-old man (age at the first surgery) presented with hypertrophic calf muscles on the contralateral leg. A two-staged procedure was performed. (A, D) Preoperative views, (B, E) 18 months after the medial calf augmentation with 140 mL asymmetric calf implant, and (C, F) the final result 2 months after lateral calf augmentation with asymmetric 150 mL silicone calf implant and fat grafting in the scar region (15 mL) and over the medial calf implant (32 mL) (according to Figure 3). In the case of bilateral clubfoot, the surgical plan depends mostly on the patient’s constitution. Although we don’t have much experience with these patients (we treated only one), it is our opinion that it would be much easier to achieve symmetry in comparison with unilateral cases. Also, the patient’s expectations were low, so a satisfactory result was achieved with medial calf augmentation only. In all cases it was possible to avoid placement of tissue expander, which is a very unpopular method amongst patients. We consider skin expansion to be a hazardous procedure, especially in lower limbs, with a high rate of complication especially below the knee, which range from 20% to 80%.15 Instead of placing tissue expander, we use a lower volume implant and improve the result afterwards with fat grafting. By combining these two procedures, patient downtime, the number of postoperative consultations, as well as morbidity rates decreased significantly. We acknowledge that some complication may occur later (our maximum follow-up period was 18 months), but in this patient group we didn’t have complications such as implant extrusion, or infections, which are the most frequent complications after tissue expansion in lower extremities.16 Although we haven’t used expanders in any of our cases, we don’t exclude their necessity in cases of severe deformity, or when sufficient small calf implants are unavailable, or in very skinny patients when there is not enough fat tissue, or when patients refuse liposuction or fat grafting methods. In these cases, additional precautions should be taken, because the outcomes are dependent on thorough preoperative planning, patient compliance, and meticulous surgical techniques.17 We recognize that the absence of these patients and a lack of experience in treating such severe deformities that need expander insertion, could be one of the limitations of our study. Another limitation is the absence of objective patients’ satisfaction assessment. Although some authors have no faith in fat “take” in upper ankle region,18 in our hands it worked well and was our number one choice when considering contour improvements in the lower third of calves, and also when there is a necessity for further improvement after silicone calf implants. We agree with Hendy in this and we further share his opinion that silicone implants are more suitable for improving the upper part of the calf.19 Fat grafting alone wasn’t a very popular method amongst our patients for medial and upper augmentation. The main reason for this lack of popularity is the uncertainty of fat survival rates and the potential of a multistage procedure, in contrast to predictable and long-lasting implant augmentation. The calf region is highly vascularized and constantly moving so the absorption rate is higher than other places in the body. That is why, when fat grafting has been chosen over silicone augmentation, it is necessary to put in more fat than immediately necessary. Another very important fact is that postoperative edema after fat injections are more likely as well as the risk of bleeding. Both edema and bleeding can increase the chances of compartment syndrome in the postoperative period which is the worst complication for this kind of surgery. However, for contour improvements in further surgical procedures, fat has been both the patients’ and our favorite choice. We have not observed compartment syndrome in our practice. In our opinion, this is probably due to the preventive measures that we employ. We explain in detail, to our patients, the limitations in volume that can be achieved with a calf implant. We prefer to initially put in a smaller implant and prepare the patient for a second or third stage procedure. If an additional procedure is needed, we wait at least 1.5 months, especially if fat grafting is necessary in the region over the inserted implant. This waiting period is to allow the tissue to adapt and for most of the swelling to subside. To recap, minimally aggressive surgery, smaller implants, multistage procedures, control of edema, and frequent monitoring of the symptoms (5P) in the immediate postoperative period are the precautions that we think are crucial in preventing compartment syndrome.20,21 The literature related to calf implant augmentation contains few reports of infection following augmentation surgery, which our study confirms. Differing methods of prophylaxis exist. Some surgeons suggest using powderless gloves, injections of antibiotics into the fascial pocket, or OpSite barrier.22,23 As suggested by a recent systematic review, and even though a supposedly aseptic procedure, postsurgical infection is a leading cause of morbidity in implant-based procedures.24 We pay close attention to any comorbid conditions that present a high risk of heparin-induced bleeding,25 and we are particularly vigilant when it is known that the patient has undergone recent surgery or trauma. Using previously mentioned, current protocol for deep vein thrombosis prophylaxis, we have had no incidence of deep vein thrombosis or hematoma. CONCLUSIONS Undeveloped calf muscles as a consequence of clubfoot deformity can cause significant aesthetic problems and a lack of self-confidence. Successful results are possible in calf augmentation surgery when combining silicone calf implants and fat grafting in a multistage procedure. Careful patient preoperative evaluation and analysis of their expectations are paramount for the successful outcome of this procedure. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Fulton Z, Briggs D, Silva S, Szalay EA. Calf circumference discrepancies in patients with unilateral clubfoot: Ponseti versus surgical release. J Pediatr Orthop . 2015; 35( 4): 403- 406. Google Scholar CrossRef Search ADS PubMed  2. Tayton KJ, Weisl H. The spina bifida club foot. Z Kinderchir Grenzgeb . 1979; 28( 4): 401- 408. Google Scholar PubMed  3. Swaroop VT, Dias L. Orthopaedic management of spina bifida-part II: foot and ankle deformities. J Child Orthop . 2011; 5( 6): 403- 414. Google Scholar CrossRef Search ADS PubMed  4. Ponseti IV, Smoley EN. The classic: congenital club foot: the results of treatment. 1963. Clin Orthop Relat Res . 2009; 467( 5): 1133- 1145. Google Scholar CrossRef Search ADS PubMed  5. Radler C. The Ponseti method for the treatment of congenital club foot: review of the current literature and treatment recommendations. Int Orthop . 2013; 37( 9): 1747- 1753. Google Scholar CrossRef Search ADS PubMed  6. Fulton Z, Briggs D, Silva S, Szalay EA. Calf circumference discrepancies in patients with unilateral clubfoot: Ponseti versus surgical release. J Pediatr Orthop . 2015; 35( 4): 403- 406. Google Scholar CrossRef Search ADS PubMed  7. Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am . 1980; 62( 1): 23- 31. Google Scholar CrossRef Search ADS PubMed  8. Andjelkov K, Sforza M, Husein R, Atanasijevic TC, Popovic VM. Safety and efficacy of subfascial calf augmentation. Plast Reconstr Surg . 2017; 139( 3): 657e- 669e. Google Scholar CrossRef Search ADS PubMed  9. Andjelkov K, Atanasijevic TC, Popovic VM, Sforza M, Atkinson CJ, Soldatovic I. Anatomical aspects of the gastrocnemius muscles: a study in 47 fresh cadavers. J Plast Reconstr Aesthet Surg . 2016; 69( 8): 1102- 1108. Google Scholar CrossRef Search ADS PubMed  10. Matsen FA3rd, Winquist RA, Krugmire RBJr. Diagnosis and management of compartmental syndromes. J Bone Joint Surg Am . 1980; 62( 2): 286- 291. Google Scholar CrossRef Search ADS PubMed  11. Roberts CS, Gorczyca JT, Ring D, Pugh KJ. Diagnosis and treatment of less common compartment syndromes of the upper and lower extremities: current evidence and best practices. Instr Course Lect . 2011; 60: 43- 50. Google Scholar PubMed  12. Feldbrin Z, Gilai AN, Ezra E, Khermosh O, Kramer U, Wientroub S. Muscle imbalance in the aetiology of idiopathic club foot. An electromyographic study. J Bone Joint Surg Br . 1995; 77( 4): 596- 601. Google Scholar CrossRef Search ADS PubMed  13. Turco VJ. Resistant congenital club foot: one-stage posteromedial release with internal fixation: a follow-up report of a fifteen-year experience. J Bone Joint Surg Am . 1979; 61( 6A): 805- 814. Google Scholar CrossRef Search ADS PubMed  14. Akşahin E, Yüksel HY, Yavuzer G, Muratlı HH, Celebi L, Biçimlioğlu A. Quantitative gait characteristics of children who had successful unilateral clubfoot operation. Acta Orthop Traumatol Turc . 2010; 44( 5): 378- 384. Google Scholar CrossRef Search ADS PubMed  15. Meland NB, Loessin SJ, Thimsen D, Jackson IT. Tissue expansion in the extremities using external reservoirs. Ann Plast Surg . 1992; 29( 1): 36- 39; discussion 40. Google Scholar CrossRef Search ADS PubMed  16. Antonyshyn O, Gruss JS, Mackinnon SE, Zuker R. Complications of soft tissue expansion. Br J Plast Surg . 1988; 41( 3): 239- 250. Google Scholar CrossRef Search ADS PubMed  17. Neale HW, High RM, Billmire DA, Carey JP, Smith D, Warden G. Complications of controlled tissue expansion in the pediatric burn patient. Plast Reconstr Surg . 1988; 82( 5): 840- 848. Google Scholar CrossRef Search ADS PubMed  18. Mundinger GS, Vogel JE. Calf augmentation and reshaping with autologous fat grafting. Aesthet Surg J . 2016; 36( 2): 211- 220. Google Scholar CrossRef Search ADS PubMed  19. Hendy AM. Calf and leg augmentation: autologous fat or silicone implant. Egypt J Plast Reconstr Surg . 2010; 34( 2): 123– 126. 20. Harvey EJ, Sanders DW, Shuler MS et al.   What’s new in acute compartment syndrome? J Orthop Trauma . 2012; 26( 12): 699- 702. Google Scholar CrossRef Search ADS PubMed  21. Niechajev I. Calf augmentation and restoration. Plast Reconstr Surg . 2005; 116( 1): 295- 305; discussion 306–307. Google Scholar CrossRef Search ADS PubMed  22. Niechajev I, Krag C. Calf augmentation and restoration: long-term results and the review of the reported complications. Aesthetic Plast Surg . 2017; 41( 5): 1115- 1131. 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Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Aesthetic Improvement of Undeveloped Calves After Treatment of Congenital Clubfoot Deformity

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© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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Abstract

Abstract Background Even when clubfoot deformity is treated in a timely manner, the consequences observed in adulthood include hypoplasia of the calf muscles, gait impairment, decreases in foot size, and it can also affect the tibial length. These consequences may have negative impacts on the patient’s subjective appraisal of long-term outcomes, and can influence the patient’s self-esteem in both male and female patients. Objectives We present our experience in the treatment of undeveloped calves after surgical treatment of congenital clubfoot. Methods In total, 72 patients underwent corrective surgery in order to improve undeveloped calves resulting from a congenital clubfoot deformity. We used calf silicone implants in combination with fat grafting in multistaged procedures, in order to decrease complication rates and improve aesthetic outcome. Results Amongst our patients there were 54 (75%) females and 18 (25%) males. All of the patients, except one, had unilateral calf hypoplasia. The procedures were divided into several groups: (1) medial calf augmentation with silicone implants; (2) medial calf augmentation with silicone implants and fat grafting; and (3) medial and lateral calf augmentation with silicone implants and fat grafting. We had one case of a hyperpigmented scar and one case of partial scar dehiscence. There were no cases of compartment syndrome. The average follow-up period was 9.8 months. Conclusions Calf enhancement surgery in patients with congenital clubfoot deformity is very gratifying. When combining calf implants with fat grafting in multistaged procedures, we can achieve excellent results with low complication rates. Level of Evidence: 4 Clubfoot (talipes equinovarus) is the most common congenital lower limb deformity, occurring in about one in every 1000 newborns. It affects bones, muscles, tendons, and blood vessels. Clubfoot can present in one or both feet and there is a 50% chance of both feet being affected. Its manifestation is the abnormal position of the feet in which the toes point downward or rotate inward.1 The main reason for this is that the ankle ligaments (posterior and medial) and tarsal joints are very thick and taut, therefore they severely restrain the foot in equinus and the navicular and calcaneus in adduction and inversion. In most cases the cause of clubfoot is idiopathic, although there may be a genetic link. In a small number of cases, clubfoot occurs as part of a more serious underlying condition, such as spina bifida.2,3 Since it was published, in 1963, the Ponseti method has been the gold standard for the treatment of clubfoot.4,5 The correction of clubfoot using this method is done by specific manipulation, serial casting, and bracing, if necessary performing tenotomy of the Achilles tendon and long-term follow up for recurrence. The calf circumference of limbs affected by clubfoot is significantly smaller in those patients receiving extensive surgery as compared with those treated with the Ponseti method alone.6 These patients also present more scars in the foot region caused by more extensive surgery. Calf wasting can be seen in utero. It becomes more pronounced with age and might sometimes slowly improve; however, the timing of surgical intervention does not influence this.7 All patients born with clubfoot deformity, and treated in early childhood, present a certain level of hypoplasia of the calf muscles, besides other findings. The more severe the deformity, the smaller the leg muscles. When clubfoot is most severe, the gastrocnemius and soleus muscles are small and in the top third of the calf. Usually, it is not a functional problem; frequently these patients are able to actively participate in sports. But, it can present a significant aesthetic problem and cause a lack of self-confidence especially during the summer period (they won’t wear shorts, avoid the beach, etc.). In this study we present a single surgeons (K.A.) experience in the treatment of undeveloped calves after surgical treatment of congenital clubfoot. METHODS We treated 72 patients with calf hypoplasia due to congenital clubfoot deformity between January 2004 and December 2016. They all underwent corrective surgery to treat the deformity in their early childhood. The study was done under approval number 29/XII-7 of the Institutional Review Board at the Faculty of Medicine, University of Belgrade. All patients signed a consent form prior to the surgical treatment and agreed with the surgical plan. In all patients the physical examination starts with an inspection of the calf muscles. The patient is asked to contract the calf muscles by lifting themselves on tip toe. Muscle mass is then compared with the opposite side (in unilateral cases). When the deformity is bilateral, the bodies of calf muscles are detected in the same manner. The mobility of the tissue present (muscle and overlying skin) is evaluated by a pinch test when the muscles are relaxed. During initial consultation, all limitations in terms of the final result are explained as well as the possibility of undergoing a multistage procedure in order to achieve the best possible symmetry in unilateral cases. We suggest the following surgical steps to the patients: • Medial calf augmentation with silicone implants. (We always start the reconstruction with medial calf augmentation.) • The second stage consists of fat grafting (in the area of Achilles tendon or over the medial calf implant) and/or lateral calf augmentation depending on patient’s request. If necessary, the second procedure is planned after a minimum of 1.5 to 2 months after the medial calf implant insertion. • If necessary, further surgery is planned to follow 2 months after the last procedure, and will be further refinements with fat grafting or lateral calf augmentation (if it wasn’t previously performed). Routine blood tests and other preoperative exams before surgery under general anesthesia were prerequisite, as well as ultrasonography exam of the calf muscles and Doppler ultrasonography of the leg vessels. Exclusion criteria were any abnormalities of the blood vessels and/or the total absence of muscle mass. For deep vein thrombosis prophylaxis we use in all our patients low molecular weight heparin (Fraxiparine, Glaxo Wellcome Production, Notre Dame de Bondeville, France) injections in daily doses of 0.3 mL before and for 7 days following the surgery. We advise patients not to use aspirin or anything similar prior to surgery. Calf Augmentation With Silicone Implants The procedure involves a medial or lateral subfascial calf implant augmentation.8 When planning medial or lateral calf augmentation in patients who have suffered from clubfoot, there are more things to consider in comparison to a purely aesthetic group of patients. With the patient standing, skin marking of the calf deformity is performed. Comparison with the opposite calf (in unilateral deformities) is discussed with the patient and points of maximal muscle projections medially or laterally (depending on the augmentation) are marked on the hypoplastic calf in the front and back. The position of the calf implant is limited inferiorly (caudally) with the scar from previous corrective surgery. Medially the limitation of the implant pocket is the junction of the medial and lateral gastrocnemius head. The cephalic limit of the implant pocket is located approximately 3 to 4 cm from the popliteal crease where the skin incision is situated (Figure 1). Figure 1. View largeDownload slide A 46-year-old man presenting hypoplasia of the left calf. Preoperative marking of the implant pocket for the medial calf augmentation. Figure 1. View largeDownload slide A 46-year-old man presenting hypoplasia of the left calf. Preoperative marking of the implant pocket for the medial calf augmentation. Due to different levels of hypoplasia of the calf muscles, the implant size should be selected with care. Pinching and stretching the muscle and overlying tissue in the medial and/or lateral calf region should give us an idea of the maximal implant projection that will fit. The implant length is determined caudally by the position of the scar from the corrective tendon surgery. The pocket dissection should not pass into the scar region because of the risk of extrusion. After performing all these skin markings and measurements of the available space it is possible to choose the best available implant and proceed with surgery. After standard patient preparation, with the patient in a prone position on the surgical bed, an infiltration of the whole previously marked area is done with 20 mL of solution of Marcaine 0.5% with Epinephrine diluted 1:200,000. The surgery proceeds with a 4 cm zigzag skin incision located medially or laterally (depending on the surgery) from the posterior calf midline, in the popliteal crease. At the very beginning we did a few cases with a horizontal straight incision. We noticed significant scar tissue contracture and deformation of the tip of the implant as a consequence of wound healing from the straight incision. That is why we changed it with zig-zag incision. Zig-zag incision creates a scar that is less conspicuous and more acceptable in comparison to the straight incision. Moreover, the zigzag incision affords a wider exposure than a long straight incision, thus greatly facilitating the operative procedure. The next step is to undermine the subcutaneous layer to the sural fascia level. The horizontal fascia incision is performed approximately 3 cm below the skin incision and a blunt dissector is introduced in order to create a subfascial pocket. It is important not to pass the midline fascial connection between the medial and lateral gastrocnemius head in order to preserve the small saphenous vein and the medial sural cutaneous nerves which are located there.9 When necessary, compressive hemostasis is always sufficient. After hemostasis, the implant is inserted and the pocket is sutured in layers; fascia level with Nylon 4.0, Vycril 4.0 for the subcutaneous layer and Monocryl 3.0 for the skin subcuticular. Immediately after surgery, mild compressive stockings are put on in order to prevent postoperative edema and to maintain the pocket as tightly as possible. Early ambulation is highly recommended. In addition, 2-inch high-heeled shoes (or clogs with additional heel cushions) are advised to aid ambulation in the first weeks after the procedure. Male patients are advised to use clogs with additional heel cushion. Patients were discharged 24 hours postoperatively and are seen once a week. They are recommended to go back to their daily activities after 10 days and to exercise regularly after 2 months. Fat Grafting Second stage surgery in patients who were treated for congenital clubfoot deformity as children is planned 6 weeks after the first surgery in order to further improve the appearance of the calf/calves. After initial medial calf augmentation, there are 3 regions, noted by patients, which may need further improvement (cited in order of importance): • Inferior third of the calf – Achilles tendon region (scar region). • Lateral gastrocnemius contour. • Further improvement of medial gastrocnemius curve (over the calf implant). We always recommend fat grafting in order to perform these improvements both because of its filling and regenerative properties. All our patients question the concavity in the Achilles tendon region that becomes even more pronounced after the medial calf augmentation is complete. This is the region where the vertical scar is usually present. Careful planning and preoperative marking of the areas to be grafted and further improved are done before the surgery (Figure 2). Figure 2. View largeDownload slide A 47-year-old man 18 months after medial calf augmentation surgery, in preoperative planning for the second surgery (fat grafting medially in the scar region and over the previously augmented area with 140 mL silicone implant, marking of the lateral implant pocket). Figure 2. View largeDownload slide A 47-year-old man 18 months after medial calf augmentation surgery, in preoperative planning for the second surgery (fat grafting medially in the scar region and over the previously augmented area with 140 mL silicone implant, marking of the lateral implant pocket). It is preferable to harvest fat from the abdominal or lateral thigh region. After routine preoperative preparation, we infiltrate the donor region with solution with Epinephrine 1:500,000. For fat harvesting we use Tulip 3.0 cannulas (Tulip Medical Products, San Diego, CA) and we process the fat using the Puregraft system (Bimini Technologies LLC, San Diego, CA). The purified fat graft is then transferred into 1 mL luer lock syringes and infiltration is performed utilizing Tulip 0.9 and 1.0 injectors. Fat grafting is done slowly in the subcutaneous layer, in a retrograde manner withdrawing 0.1 mL of fat per passage and in a fan fashion. The same procedure is done in all three above-mentioned calf areas. Additionally, caution will be necessary when performing fat grafting in the medial gastrocnemius curve where it should be done between the implant capsule and the skin in several layers. At the end of the procedure hypoallergenic surgical tape is applied to all grafted areas, thus avoiding excessive pressure. After both procedures, patients are placed in bed with the treated leg elevated above the heart level to decrease the postoperative edema. Patients are urged to walk to the bathroom or in the infirmary and are examined once every hour for the presence of signs and symptoms of acute compartment syndrome: (1) pain out of proportion to the clinical situation; (2) weakness and pain on passive stretch of the muscles of the compartment; (3) hypoesthesia in the distribution of the nerves running through the compartment; and (4) tenseness of the fascial boundaries of the compartment. Also, when discharged from the hospital, patients are advised to report immediately if they notice any of these signs.10,11 Deep vein thrombosis prophylaxis was implemented for all patients during the first and second procedure. Low molecular weight heparine (Fraxiparine) is administrated as a single daily dose of 0.3 mL, for 7 days. The first dose was given 2 to 4 hours preoperatively. Prophylactic antibiotic therapy was also administered before both surgeries, using Ceftriaxone 1 g IV single dose and discharged with a 7-day course of Cephalexin 500 mg 4 times daily. Ibuprofen 400 mg was prescribed as an anti-inflammatory and pain killer twice daily if necessary. RESULTS Among the 72 patients that we treated, there were 54 (75%) females and 18 (25%) males. Their ages ranged between 22 and 57 (average, 34.67 ± 11.71 years). All but one patient had unilateral calf hypoplasia as a result of congenital clubfoot deformity that was corrected in early childhood. One patient had bilateral hypoplasia. In 36 cases (51%) the right calf was involved and 35 (49%) presented hypoplasia of the left calf. All patients were primary cases, as they hadn’t had any treatment for aesthetic improvements to the underdeveloped calf previously. The distribution of patients according to the type and number of surgeries performed is given in Figure 3. Figure 3. View largeDownload slide The distribution of calf procedures performed. Figure 3. View largeDownload slide The distribution of calf procedures performed. There are common findings in all patients with congenital clubfoot (even when correction is performed successfully and in early childhood).12,13 These findings were also confirmed in all our patients and are the following: • Gastrocnemius and soleus muscles atrophy/underdeveloped calf muscles (the size of the leg muscles correlates inversely with the severity of the deformity). • A decrease in foot size (the affected foot may be up to 1.5 shoe sizes smaller than the unaffected foot). • Mobility may be slightly limited (gait impairment). • Decreased tibial length (the average shortening was 2.60 cm ± 0.23; range, 1.3-4.1 cm). • A scar following tendon Achilles tenotomy (the average length of the scar was 10.2 cm [range, 9.6-11.5 cm] and it was located at the skin overlying the Achilles tendon in the medial part). We performed medial calf augmentation on all 72 patients, and on 3 of them we performed lateral calf augmentation as well. We used only asymmetric or anatomical silicone calf implants with sizes varying from 85 mL to 180 mL. In the majority of the 47 cases (65%), we used a 140 mL implant. There was one case of hyperpigmented scar and one case of partial scar dehiscence that were resolved conservatively (topical creams and dressings respectively). There were no cases of compartment syndrome. After a minimum period of 6 weeks, fat grafting was performed following initial augmentation surgery in 48 patients. The grafted areas and amount of fat used in each calf area are presented in Table 1. One patient requested additional fat grafting, due to undercorrection. There were no other complications related to the procedure. Table 1. Fat Grafted Calf Areas and Corresponding Volumes of Implanted Fat   Inferior third of the calf – Achilles tendon region (scar region)  Further improvements of medial gastrocnemius curve (over the calf implant)  Lateral gastrocnemius contour  No. of patients (total no. of patients = 48)  48  48  15  Volume of grafted fat (mL)  13.4 ± 2.0  30.8 ± 5.3  41.5 ± 6.2    Inferior third of the calf – Achilles tendon region (scar region)  Further improvements of medial gastrocnemius curve (over the calf implant)  Lateral gastrocnemius contour  No. of patients (total no. of patients = 48)  48  48  15  Volume of grafted fat (mL)  13.4 ± 2.0  30.8 ± 5.3  41.5 ± 6.2  View Large Table 1. Fat Grafted Calf Areas and Corresponding Volumes of Implanted Fat   Inferior third of the calf – Achilles tendon region (scar region)  Further improvements of medial gastrocnemius curve (over the calf implant)  Lateral gastrocnemius contour  No. of patients (total no. of patients = 48)  48  48  15  Volume of grafted fat (mL)  13.4 ± 2.0  30.8 ± 5.3  41.5 ± 6.2    Inferior third of the calf – Achilles tendon region (scar region)  Further improvements of medial gastrocnemius curve (over the calf implant)  Lateral gastrocnemius contour  No. of patients (total no. of patients = 48)  48  48  15  Volume of grafted fat (mL)  13.4 ± 2.0  30.8 ± 5.3  41.5 ± 6.2  View Large Generally, patients are able to return to their usual daily activities and walk in flat shoes without any pain after 10 to 14 days. Overall, patient follow up ranged from 6 months to 1.5 years (average, 9.8 months). DISCUSSION Decreased calf size may have a negative impact on a patient’s subjective appraisal of long-term outcomes and influence patient self-esteem, both in male and female patients. Therefore, it is important to assess these patients after they are discharged by their orthopedic surgeon, and to try to properly address their calf condition. The right diagnosis of calf condition is of the utmost importance for proper surgical planning and a successful outcome. Since these patients are usually discharged by their orthopedic surgeon, they are not aware of the possibility of further improvement. Previously, there was no systematic approach to the treatment of this deformity; they were treated in the same manner as patients seeking purely aesthetic calf enhancement. In our opinion, there are some important differences between these two groups that must be recognized before treatment. These findings contribute to a better understanding of this condition, and increases the knowledge base when it comes to the treatment of patients with calf hypoplasia after clubfoot deformity. The quality and elasticity of the calf tissue differs from normal calves because of the pathophysiology of clubfoot. During the child’s first years, the synthesis of collagen is excessive in muscles, ligaments, and tendon, hence the tarsal joints and posterior and medial aspect of the ankle are overly thick and taut. Collagen rich connective tissue increases at the distal end of the gastrocnemius and soleus muscles, which often spreads to the Achillis tendon and deep fasciae.14 The vast majority of patients with congenital clubfoot deformity end up with a scar that is derived from surgery aiming to further stretch the tendon region. Considering the increased risk of implant extrusion, the implant pocket should never enter the scar region. Due to the limitations in elasticity of calf tissue, the size of the implant should be selected carefully, and surgery should be performed in several stages when considering medial and lateral calf enhancement. Keeping all this in mind should significantly reduce the risk of complications, especially the incidence of compartment syndrome. The affected calf bones are always shorter than unaffected ones. The muscles are smaller in size and shorter than in a normal foot. The level of difficulty in achieving symmetry in unilateral cases depends both on the level of hypoplasia of the affected muscle and the patient’s constitution. Sometimes, even severe hypoplasia can be easy to symmetrize and satisfactory result can be gained with a single stage procedure (Figure 4). More procedures are always necessary when the opposite muscles are well defined/hypertrophic. These patients are mostly active sportsmen that have developed muscles through exercise (Figures 5 and 6). Figure 4. View largeDownload slide Satisfactory result in the single stage procedure. This 24-year-old man underwent medial calf augmentation with asymmetric 180 mL silicone implants. (A) Preoperative and (B) 18-month postoperative photographs. Figure 4. View largeDownload slide Satisfactory result in the single stage procedure. This 24-year-old man underwent medial calf augmentation with asymmetric 180 mL silicone implants. (A) Preoperative and (B) 18-month postoperative photographs. Figure 5. View largeDownload slide This 39-year-old woman (age at the first surgery) presented with well-developed contralateral calf muscles. A two-staged procedure was performed. (A, D) Preoperative views, (B, E) 14 months after the medial calf augmentation with 140 mL asymmetric calf implant, and (C, F) the final result 6 months after additional fat grafting (total amount of 45 mL) over the previously augmented region (according to Figure 2). Figure 5. View largeDownload slide This 39-year-old woman (age at the first surgery) presented with well-developed contralateral calf muscles. A two-staged procedure was performed. (A, D) Preoperative views, (B, E) 14 months after the medial calf augmentation with 140 mL asymmetric calf implant, and (C, F) the final result 6 months after additional fat grafting (total amount of 45 mL) over the previously augmented region (according to Figure 2). Figure 6. View largeDownload slide This 46-year-old man (age at the first surgery) presented with hypertrophic calf muscles on the contralateral leg. A two-staged procedure was performed. (A, D) Preoperative views, (B, E) 18 months after the medial calf augmentation with 140 mL asymmetric calf implant, and (C, F) the final result 2 months after lateral calf augmentation with asymmetric 150 mL silicone calf implant and fat grafting in the scar region (15 mL) and over the medial calf implant (32 mL) (according to Figure 3). Figure 6. View largeDownload slide This 46-year-old man (age at the first surgery) presented with hypertrophic calf muscles on the contralateral leg. A two-staged procedure was performed. (A, D) Preoperative views, (B, E) 18 months after the medial calf augmentation with 140 mL asymmetric calf implant, and (C, F) the final result 2 months after lateral calf augmentation with asymmetric 150 mL silicone calf implant and fat grafting in the scar region (15 mL) and over the medial calf implant (32 mL) (according to Figure 3). In the case of bilateral clubfoot, the surgical plan depends mostly on the patient’s constitution. Although we don’t have much experience with these patients (we treated only one), it is our opinion that it would be much easier to achieve symmetry in comparison with unilateral cases. Also, the patient’s expectations were low, so a satisfactory result was achieved with medial calf augmentation only. In all cases it was possible to avoid placement of tissue expander, which is a very unpopular method amongst patients. We consider skin expansion to be a hazardous procedure, especially in lower limbs, with a high rate of complication especially below the knee, which range from 20% to 80%.15 Instead of placing tissue expander, we use a lower volume implant and improve the result afterwards with fat grafting. By combining these two procedures, patient downtime, the number of postoperative consultations, as well as morbidity rates decreased significantly. We acknowledge that some complication may occur later (our maximum follow-up period was 18 months), but in this patient group we didn’t have complications such as implant extrusion, or infections, which are the most frequent complications after tissue expansion in lower extremities.16 Although we haven’t used expanders in any of our cases, we don’t exclude their necessity in cases of severe deformity, or when sufficient small calf implants are unavailable, or in very skinny patients when there is not enough fat tissue, or when patients refuse liposuction or fat grafting methods. In these cases, additional precautions should be taken, because the outcomes are dependent on thorough preoperative planning, patient compliance, and meticulous surgical techniques.17 We recognize that the absence of these patients and a lack of experience in treating such severe deformities that need expander insertion, could be one of the limitations of our study. Another limitation is the absence of objective patients’ satisfaction assessment. Although some authors have no faith in fat “take” in upper ankle region,18 in our hands it worked well and was our number one choice when considering contour improvements in the lower third of calves, and also when there is a necessity for further improvement after silicone calf implants. We agree with Hendy in this and we further share his opinion that silicone implants are more suitable for improving the upper part of the calf.19 Fat grafting alone wasn’t a very popular method amongst our patients for medial and upper augmentation. The main reason for this lack of popularity is the uncertainty of fat survival rates and the potential of a multistage procedure, in contrast to predictable and long-lasting implant augmentation. The calf region is highly vascularized and constantly moving so the absorption rate is higher than other places in the body. That is why, when fat grafting has been chosen over silicone augmentation, it is necessary to put in more fat than immediately necessary. Another very important fact is that postoperative edema after fat injections are more likely as well as the risk of bleeding. Both edema and bleeding can increase the chances of compartment syndrome in the postoperative period which is the worst complication for this kind of surgery. However, for contour improvements in further surgical procedures, fat has been both the patients’ and our favorite choice. We have not observed compartment syndrome in our practice. In our opinion, this is probably due to the preventive measures that we employ. We explain in detail, to our patients, the limitations in volume that can be achieved with a calf implant. We prefer to initially put in a smaller implant and prepare the patient for a second or third stage procedure. If an additional procedure is needed, we wait at least 1.5 months, especially if fat grafting is necessary in the region over the inserted implant. This waiting period is to allow the tissue to adapt and for most of the swelling to subside. To recap, minimally aggressive surgery, smaller implants, multistage procedures, control of edema, and frequent monitoring of the symptoms (5P) in the immediate postoperative period are the precautions that we think are crucial in preventing compartment syndrome.20,21 The literature related to calf implant augmentation contains few reports of infection following augmentation surgery, which our study confirms. Differing methods of prophylaxis exist. Some surgeons suggest using powderless gloves, injections of antibiotics into the fascial pocket, or OpSite barrier.22,23 As suggested by a recent systematic review, and even though a supposedly aseptic procedure, postsurgical infection is a leading cause of morbidity in implant-based procedures.24 We pay close attention to any comorbid conditions that present a high risk of heparin-induced bleeding,25 and we are particularly vigilant when it is known that the patient has undergone recent surgery or trauma. Using previously mentioned, current protocol for deep vein thrombosis prophylaxis, we have had no incidence of deep vein thrombosis or hematoma. CONCLUSIONS Undeveloped calf muscles as a consequence of clubfoot deformity can cause significant aesthetic problems and a lack of self-confidence. Successful results are possible in calf augmentation surgery when combining silicone calf implants and fat grafting in a multistage procedure. Careful patient preoperative evaluation and analysis of their expectations are paramount for the successful outcome of this procedure. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Fulton Z, Briggs D, Silva S, Szalay EA. Calf circumference discrepancies in patients with unilateral clubfoot: Ponseti versus surgical release. J Pediatr Orthop . 2015; 35( 4): 403- 406. Google Scholar CrossRef Search ADS PubMed  2. Tayton KJ, Weisl H. The spina bifida club foot. Z Kinderchir Grenzgeb . 1979; 28( 4): 401- 408. Google Scholar PubMed  3. Swaroop VT, Dias L. Orthopaedic management of spina bifida-part II: foot and ankle deformities. J Child Orthop . 2011; 5( 6): 403- 414. Google Scholar CrossRef Search ADS PubMed  4. Ponseti IV, Smoley EN. The classic: congenital club foot: the results of treatment. 1963. Clin Orthop Relat Res . 2009; 467( 5): 1133- 1145. Google Scholar CrossRef Search ADS PubMed  5. Radler C. The Ponseti method for the treatment of congenital club foot: review of the current literature and treatment recommendations. Int Orthop . 2013; 37( 9): 1747- 1753. Google Scholar CrossRef Search ADS PubMed  6. Fulton Z, Briggs D, Silva S, Szalay EA. Calf circumference discrepancies in patients with unilateral clubfoot: Ponseti versus surgical release. J Pediatr Orthop . 2015; 35( 4): 403- 406. Google Scholar CrossRef Search ADS PubMed  7. Laaveg SJ, Ponseti IV. Long-term results of treatment of congenital club foot. J Bone Joint Surg Am . 1980; 62( 1): 23- 31. Google Scholar CrossRef Search ADS PubMed  8. Andjelkov K, Sforza M, Husein R, Atanasijevic TC, Popovic VM. Safety and efficacy of subfascial calf augmentation. Plast Reconstr Surg . 2017; 139( 3): 657e- 669e. Google Scholar CrossRef Search ADS PubMed  9. Andjelkov K, Atanasijevic TC, Popovic VM, Sforza M, Atkinson CJ, Soldatovic I. Anatomical aspects of the gastrocnemius muscles: a study in 47 fresh cadavers. J Plast Reconstr Aesthet Surg . 2016; 69( 8): 1102- 1108. Google Scholar CrossRef Search ADS PubMed  10. Matsen FA3rd, Winquist RA, Krugmire RBJr. Diagnosis and management of compartmental syndromes. J Bone Joint Surg Am . 1980; 62( 2): 286- 291. Google Scholar CrossRef Search ADS PubMed  11. Roberts CS, Gorczyca JT, Ring D, Pugh KJ. Diagnosis and treatment of less common compartment syndromes of the upper and lower extremities: current evidence and best practices. Instr Course Lect . 2011; 60: 43- 50. Google Scholar PubMed  12. Feldbrin Z, Gilai AN, Ezra E, Khermosh O, Kramer U, Wientroub S. Muscle imbalance in the aetiology of idiopathic club foot. An electromyographic study. J Bone Joint Surg Br . 1995; 77( 4): 596- 601. Google Scholar CrossRef Search ADS PubMed  13. Turco VJ. Resistant congenital club foot: one-stage posteromedial release with internal fixation: a follow-up report of a fifteen-year experience. J Bone Joint Surg Am . 1979; 61( 6A): 805- 814. Google Scholar CrossRef Search ADS PubMed  14. Akşahin E, Yüksel HY, Yavuzer G, Muratlı HH, Celebi L, Biçimlioğlu A. Quantitative gait characteristics of children who had successful unilateral clubfoot operation. Acta Orthop Traumatol Turc . 2010; 44( 5): 378- 384. Google Scholar CrossRef Search ADS PubMed  15. Meland NB, Loessin SJ, Thimsen D, Jackson IT. Tissue expansion in the extremities using external reservoirs. Ann Plast Surg . 1992; 29( 1): 36- 39; discussion 40. Google Scholar CrossRef Search ADS PubMed  16. Antonyshyn O, Gruss JS, Mackinnon SE, Zuker R. Complications of soft tissue expansion. Br J Plast Surg . 1988; 41( 3): 239- 250. Google Scholar CrossRef Search ADS PubMed  17. Neale HW, High RM, Billmire DA, Carey JP, Smith D, Warden G. Complications of controlled tissue expansion in the pediatric burn patient. Plast Reconstr Surg . 1988; 82( 5): 840- 848. Google Scholar CrossRef Search ADS PubMed  18. Mundinger GS, Vogel JE. Calf augmentation and reshaping with autologous fat grafting. Aesthet Surg J . 2016; 36( 2): 211- 220. Google Scholar CrossRef Search ADS PubMed  19. Hendy AM. Calf and leg augmentation: autologous fat or silicone implant. Egypt J Plast Reconstr Surg . 2010; 34( 2): 123– 126. 20. Harvey EJ, Sanders DW, Shuler MS et al.   What’s new in acute compartment syndrome? J Orthop Trauma . 2012; 26( 12): 699- 702. Google Scholar CrossRef Search ADS PubMed  21. Niechajev I. Calf augmentation and restoration. Plast Reconstr Surg . 2005; 116( 1): 295- 305; discussion 306–307. Google Scholar CrossRef Search ADS PubMed  22. Niechajev I, Krag C. Calf augmentation and restoration: long-term results and the review of the reported complications. Aesthetic Plast Surg . 2017; 41( 5): 1115- 1131. Google Scholar CrossRef Search ADS PubMed  23. von Szalay L. Calf augmentation: a new calf prosthesis. Plast Reconstr Surg . 1985; 75( 1): 83- 87. Google Scholar CrossRef Search ADS PubMed  24. Huang N, Liu M, Yu P, Wu J. Antibiotic prophylaxis in prosthesis-based mammoplasty: a systematic review. Int J Surg . 2015; 15: 31- 37. Google Scholar CrossRef Search ADS PubMed  25. Levine MN, Raskob G, Beyth RJ, Kearon C, Schulman S. Hemorrhagic complications of anticoagulant treatment: the seventh ACCP Conference on antithrombotic and thrombolytic therapy. Chest . 2004; 126(3): 287S- 310S. Google Scholar CrossRef Search ADS   © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Aesthetic Surgery JournalOxford University Press

Published: Feb 21, 2018

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