INTRODUCTION

Recently, legs have become very important secondary gender characteristics in women, as well men. Female patients and young male athletes with unilateral muscle atrophy may be unhappy with slim, lean or asymmetric calves (so-called “skinny legs”) may cause body image problems. Increasingly, patients are seeking help from plastic surgeons to correct these leg deformities. Patients understand that there will be no restoration of impaired function but they would like to wear skirts or be inconspicuous at the swimming pool. Causes of unilateral or bilateral calf deformities include a) congenital hypoplasia /and aplasia or reduction of subcutaneous cellular-adipose tissue, muscular hypotrophy or atrophy; b) sequale of clubfoot, cerebral palsy, and spina bifida; c) poliomyelitis and osteomyelitis; and d) trauma following fractures of the femur and contractures resulting from burns. In our region, up until 1985 we would see obine deformities due to Rickets and consequently, demands for its correction.

Correction of these deformities is usually accomplished through the insertion of silicone calf prosthesis or liquid silicone injection. However, the utilization of autologous fat or tissue cocktail injections has always been our first choice for the treatment of these deformities. This is the first report in English literature of this technique.

Since 1985, Erol in our facility has had extensive experience with fat injections and, in 1989, developed the “tissue cocktail injection” . Since then, several modifications and improvements have made using this technique more practical and effective. This paper reports on Erol’s approach and experience of calf augmentation with fat and tissue cocktail injections in a series of 77 patients.

 

MATERIAL AND METHODS

Harvesting and preparation of micro fat grafting

calf augmentation tissue injection
This technique, designed and popularized by Erol, has evolved over time. In the first group of patients, treated between 1985 and 1992 (not included in this article) a vacuum machine was used to collect fat in a sterile interconnected bottle. The fat graft was then injected without pretreatment. An 18- to 16-gauge needle was used, and all patients were overcorrected to compensate for anticipated resorption. From 1992 to 1996, fat tissue was collected using a syringe and 4-mm cannula, treated by washing with Ringer’s lactate solution, and 1 g of first-generation cephalosporin was added per 50 cc of specimen. Overcorrection was not done because it was found that the revascularization of a small graft is much better than of a large graft.

In patients who were seen after 1996, fat tissue was again harvested under general anesthesia utilizing a syringe and a 4 mm cannula. Local anesthetic was not used in order to prevent damage to fat cells. The abdominal and flank regions are preferred for harvesting; occasionally the trochanteric regions or buttocks may be used. Harvested fat was centrifuged for 3 minutes at 3000 rpm, the extracellular lipids and blood were discarded and 1 g of first-generation cephalosporin was added per 100 cc of specimen, and the fat was ready for injection and/or cryopreservation.

Harvesting and preparation of tissue cocktail

Mini-micro grafts of dermis-fascia-fat are prepared from excised scar tissue, or tissue excised during abdominoplasty and or reduction mammoplasty. Tissue (dermis, fascia, fat) is cut into very small pieces measuring 0.5mm, so it can pass through 16 gauge needles, and antibiotic was added before injection.

Cryopreservation

Remaining tissue cocktail and fat were cryopreserved. Specimens are put in 50 cc sterile tubes, labeled and immersed in a liquid nitrogen tank, frozen at -196° C, and then transferred to a refrigerator (Electrolux UF 601medical refrigerator.) and stored at -80° C.

Pre-operative planning

First, standard photographs of the legs are taken. The thin and asymmetric parts of the legs to be augmented are marked while the patient is standing. The depressed area is observed at the antero-medial part of the tibia from the knee to the ankle. Photographs were taken to show marking areas, to assist in evaluation during surgery.

Surgery

A local anesthetic mixture composed of 20 cc 0.5% bupivacaine, 0.25 mg adrenaline, 20 cc physiologic serum, and 20 mg triamcinolone acetonide is injected into recipient sites. Infusion of this solution aims to decrease postoperative edema and echymoses and to create vasoconstriction of vessels to prevent or diminish the risk embolism.

A total of 75 to 200 cc of fat or tissue cocktail is injected into each leg. Small amounts of micro-mini grafts are injected into different layers, using a long cannula of 15 or 26 cm in length and 3 mm in diameter. No over correction was done to insure maximum revascularization. Injections are repeated two to four times at three-month intervals as necessary.

 

RESULTS

Between 1992 and 2003, 144 calf augmentations were performed in 77 patients, with an average age of 25 years (range 20-35 years). All the patients received autologous tissue injection (12 patients were treated with tissue cocktail injections and the rest with fat injections). A total of 75 to 200 cc (mean 132 cc) of fat or tissue cocktail was injected into each leg. Repeat injections at three-month intervals were performed twice in 17 patients, 3 times in 37, and 4 times in 23 patients. Follow-up ranged from one to eight years (mean 3.5 years).

The outcome was satisfactory in the majority of our patients, with the planned shape achieved in all patients after one to four injections. Small irregularities or asymmetries were observed in 12 patients after the first injection, but these were corrected with a second injection. No infection was seen in any of the cases.

 

DISCUSSION

Aesthetics is the study of beauty, and beauty is obvious for everyone to see but very difficult to describe and define. The perception of beauty is subconscious, not in the cognitive part of the brain (neo-cortex), but is assumed to be located in the primitive portion of the brain – the limbic system  Ricketts analyzed structure, harmony, balance, and proportions of the human body, applying mathematical and geometric calculations. The aesthetically ideal, golden proportions were known to the ancient Egyptians and were applied in the art and architecture in ancient Greece. In 1202, Filius Bonacci, an Italian mathematician determined the mathematical base of the length proportions called golden section as the 1:1.618, which the sixteenth century German scientist Johannes Kepler called the divine proportion.

The ideal length proportions of the calves were described by Howard, who used drawings by Leonardo da Vinci as the basis of his analysis. The golden ratio of calf aesthetics was defined as the distance between the ankle and the lower border of the gastrocnemius muscle being equal to the distance between the knee and the most prominent point on the medial curvature of the gastrocnemius muscle. The entire length of the gastrocnemius muscle is 1.6 times the former value. Von Szalay determined an attractive range for the female calf circumference to be between 33 and 36 cm and a much thinner or thicker calf was considered aesthetically unacceptable.

Calf augmentation is indicated for cosmetic reasons or to reconstruct lower leg deformities due to trauma, disease or congenital underdevelopment. Today an increasing number of patients are seeking calf correction in order to improve their overall appearance.

The shape of the calf is determined by the development of gastrocnemius and soleus muscles, the length and orientation of the crural bones, and the subcutaneous fat distribution. It is difficult, and in most cases unrealistic, to alter the bones for purely aesthetic reasons. However, unfavorable fat distribution can be corrected by liposuction, and the hypotrophic muscles can be supplemented with implants. Soft-tissue fillers cannot replace implants as a method for calf augmentation but they can be used for equalization of lesser calf surface irregularities, as an alternative to custom-made implants.

The principle of improving or restoring volume and shape with the insertion of silicone implants is well known, and has been proven over the past five decades in breast surgery. Calf implants are made of solid, semi-soft silicone /gel, which can be customized by carving, or of a thick shell of solid silicone containing cohesive silicone. Calf enlargement can be achieved by the introduction of one or more implants into the medial and the lateral sides of the leg. In 1979, Carlsen and Glicenstein were the first to address the problem of calf augmentation, and subsequently, different studies have been reported). In all of these reports silicone-gel filled implants and silicone rubber implants were used, inserted below the deep fascia of the calf. Problems associated with silicone gel implants included visible capsular contracture, infection, and extrusion. With soft rubber implants, although patients were satisfied with the shape of their calves, the edges of the implants were palpable and the area over the implants was harder than the contiguous muscle. Calf prosthesis are unable to correct deformity at the ankle region, and other disadvantages include displacement, capsular contracture and extrusion.

To decrease or avoid the drawbacks of solid implants, new techniques were developed and prosthesis were inserted submuscularly , supraperiosteally with fasciatomy , with a microsurgical of transverse rectus abdominis myocutaneous (TRAM) flap transfer and more recently, the newly designed combined calf-tibial implant . This prosthesis is designed to augment or correct both the calf and the region between the calf and ankle. However, this implant, as any other prosthesis, is a foreign material, not autologous tissue. After 35 years of follow-up the drawbacks of prosthesis are well-known, and include capsular contracture, infection, visualization, palpation, mobilization, abnormal consistency of the leg, rupture of the prosthesis, and erosion of the bone surface.

The use of autologous tissue injections was developed to overcome the drawbacks of silicone injections and implants. A review of the literature found that the use of TRAM free flap, autologous tissue cocktail  and fat injections for correction of calf contour deformities demonstrated excellent results. Muscle mass can be changed with sports and physical activity, but the only area that can be changed easily, is subcutaneous fat. Our experience in volumetric facial rejuvenation with fat and tissue cocktail in layers, was applied to this area. The technique described in this article offers the advantage of being able to add tissue where you choose, and to see the result when immediately after injection. Some resorption will occur because this is graft, not flap, but in three months the result are visible and more tissue can be added with additional injections if necessary.

Our experience demonstrates that fat injection is very effective, easy to perform, long lasting and is associated with a short postoperative recovery time. The only disadvantage of fat injection is the requirement of repeat injections, touch-ups. A tissue cocktail, a mixture of mini-micro grafts of dermis-fascia-fat, because it has a majority content of micro particles of dermis, has a greater survival rate comparing to micro fat graft and one or two injections is sufficient to obtain suitable and permanent results. However, the harvesting of tissue cocktail is more complicated than the harvesting of fat, and the main disadvantage of this technique is the availability of injectable tissue.

CONCLUSION

Calf augmentations were performed in 77 patients with calf deformities using autologous tissue injection, with no major complications during 1 to 8 years of follow-up. Tissue injection offers many advantages including the use of auto grafts, a small, unnoticeable scar, no late complications, the opportunity to perform touch up injections and satisfactory long lasting results. We recommend the utilization of this technique for calf augmentation on select patients.