The authors report on a significant aspect of personal dissatisfaction among those seeking body contour surgery, namely underdeveloped calves.1 For this alone they are to be commended as individual perceptions and concern for calf size and shape have received little emphasis at aesthetic surgical meetings and in the literature. The surgical experience of the current authors is to employ fat grafting techniques as well as implants to correct calf deficiencies associated with club foot deformities. Our experience, which spans close to 15 years, is with fat grafting alone and in the vast majority of cases the indication is simply for cosmetic enhancement of normal but hypoplastic calf muscles. Nevertheless, the surgical approach of the authors and our own experience both address patients’ personal dissatisfaction with their calves and some relevant comments comparing our experience can be made. The reported series treats patients with two and possibly three surgeries. The authors first procedure is a medial gastrocnemius implant followed by fat grafting a few months later. A third procedure consisting of additional fat grafting often follows. In our series2 and in current practice all calf grafting procedures are single stage. Since the publication of our article approximately 2% of calf augment patients have requested a second procedure to further enhance calf volume. The authors state 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.” This potential complication appears to be the primary reason they prefer to stage their calf augmentation procedures. One can only assume that the laudable zero incidence of compartment syndrome in their series reinforces their multistage approach. However, in our series of single stage fat grafting to the calves we also report a zero incidence of compartment syndrome. Additionally, no patients in our practice since the original series publication have experienced compartment syndrome following a single stage calf augmentation procedure. Additionally, the authors of the current report question the survival and dependability of fat grafting and instead rely on the durability of calf implants. Yet their average follow up of 72 patients over a 12-year period was only 9.8 months. They openly agree that this is not sufficient time to assess long-term implant related complications. However, and more relevant to the concept of fat alone as a satisfactory method for calf enhancement, the authors state that the “calf region is highly vascularized and constantly moving so the absorption rate is higher than other places in the body.” Our experience does not support this claim. The published series with 13 patients followed over 5 years with a mean follow up of 19.6 months confirms fat as a reproducible and long-lasting grafting source in the calves (Figure 1). Figure 1. View largeDownload slide (A, C) Preoperative and (B, D) 3-year postoperative photographs of a 41-year-old woman who underwent single stage, 450 mL bilateral fat grafting to medial and lateral calves. Fat harvesting and liposuction of inner thigh, inner knee, hips, and waistline was performed. Lipo-contouring of the upper leg and inner knee in combination with augmentation of the calf is a fundamental principle achieving aesthetic proportions and balance in the lower extremity.2 Figure 1. View largeDownload slide (A, C) Preoperative and (B, D) 3-year postoperative photographs of a 41-year-old woman who underwent single stage, 450 mL bilateral fat grafting to medial and lateral calves. Fat harvesting and liposuction of inner thigh, inner knee, hips, and waistline was performed. Lipo-contouring of the upper leg and inner knee in combination with augmentation of the calf is a fundamental principle achieving aesthetic proportions and balance in the lower extremity.2 In spite of their cited comments regarding fat durability in the calves, the authors curiously state that “although some authors have no faith in fat ‘take’ in upper ankle region, in our hands it worked well and was our number one choice when considering contour improvements in the lower third of calves.” They have referenced our experience2 with calf augmentation and thus clarification of our approach bears mention. While we do not routinely inject fat grafts in the Achilles tendon area it is important to extend the fat distribution inferiorly as indicated in the preoperative markings seen in Figure 2. The primary reason not to extend the fat distribution too far inferiorly is to intentionally create a volume discrepancy between the Achilles tendon area and the gastrocnemius muscles to accentuate a shapely and aesthetic calf (Figure 1). Figure 2. View largeDownload slide (A) Preoperative fat grafting planning for a 36-year-old man who suffered polio in childhood with resulting hypoplasia of left lower leg muscles Note the peripheral inferior tapering of the primary area for planned fat grafting. In spite of inferior tapering, it is important to maintain a volume discrepancy between calf and Achilles area. (B) Result at 16 months postoperative following 235 mL fat grafting to medial and lateral left calf. Figure 2. View largeDownload slide (A) Preoperative fat grafting planning for a 36-year-old man who suffered polio in childhood with resulting hypoplasia of left lower leg muscles Note the peripheral inferior tapering of the primary area for planned fat grafting. In spite of inferior tapering, it is important to maintain a volume discrepancy between calf and Achilles area. (B) Result at 16 months postoperative following 235 mL fat grafting to medial and lateral left calf. Given the surgical hypothesis of the current authors it is not surprising that they report that fat grafting was not a popular method amongst their patients. Given the universal high success of fat grafting in our field (in general) over the last 2 decades and in our published series it is now well established that a single stage procedure for calf enhancement can be safely and reliably performed. Obviously, the experiences and approach to patients with personal dissatisfaction with hypoplastic calves differ with those of the current authors. Nevertheless, in their series and ours we both document the technical ability and options to address this under appreciated and but frequently sought-after body contouring procedure. Disclosures The author declares no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and/or publication of this article. REFERENCES 1. Andjelkov K, Llull R, Colic M, Atanasijevic TC, Popovic VM, Colic M. Aesthetic improvement of undeveloped calves after treatment of congenital clubfoot deformity. Aesthet Surg J . 2018. doi: 10.1093/asj/sjy046. 2. 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 © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: firstname.lastname@example.org 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)
Aesthetic Surgery Journal – Oxford University Press
Published: Apr 14, 2018
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