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Ultrasound-Guided Selective Nerve Block

The best muscle-reduction method for creating slender calf lines

Recently, the trend in the cosmetic surgery field has been

actively reflecting patients’ needs and continually demanding

minimally invasive methods,

defined results,

and a guarantee of procedural safety.

At our clinic,

along with non-incisional ultrasound selective nerve block equipment,

we use an ultrasound diagnostic device

to perform procedures with fewer side effects

and a significantly lower recurrence rate.

This is not an incision-based procedure,

and it is not a muscle recession surgery using medium/high-frequency muscle cauterization,

which can cause significant swelling and pain.

It is a new concept in calf reduction surgery:

non-incisional ultrasound-guided selective nerve block.

The best muscle-reduction method

for creating slender calf lines

Basic equipment set for calf nerve block

The basic equipment for nerve block uses an integrated device that combines nerve detection and nerve block into one,

allowing both to be performed at once.

When the nerve touches the nerve detector and the muscle moves in response,

the mode is switched so the nerve can be blocked immediately.

The nerve detector, which is the basic equipment for nerve block,

has the drawback that finding invisible nerves is very difficult

and takes a lot of time.

Also, if the nerve deviates from its normal course,

finding it becomes very difficult,

and in many cases the procedure is not performed properly.

If the nerve cannot be found correctly,

the procedure effect decreases,

side effects may occur,

and there may be other problems such as a high recurrence rate.

To make nerve detection faster and more accurate,

an ultrasound imaging device equipped with a high-frequency probe is used.

By quickly and accurately locating the nerve while confirming it with ultrasound,

a large number of nerve branches can be effectively blocked in a short time.

The procedure that improves treatment effect,

has fewer side effects,

and significantly lowers the recurrence rate

is non-incisional ultrasound-guided selective nerve block.

Equipment for ultrasound-guided selective nerve block

In addition to the basic equipment for nerve block,

an ultrasound diagnostic device, which is a visual inspection tool,

is used to quickly and accurately find the nerve branches.

Basic equipment alone has limitations in finding nerves,

and when there are many nerve branches or nerves running along unexpected paths,

they are very difficult to locate.

The success or failure of the procedure depends on finding the nerve branches accurately within a short time.

For this, the ultrasound device helps improve precision and shorten the procedure time.

Advantages of ultrasound-guided selective nerve block

It can quickly and accurately find nerve branches, resulting in a very high treatment effect.
It significantly shortens the procedure time compared with using basic equipment alone.
By accurately finding the nerve branches, it does not damage tissues in other areas, so side effects are fewer.
Because the procedure time is shortened, there is less pain after the procedure and recovery is faster.
With accurate nerve detection, the recurrence rate is significantly reduced.

Causes of thick calves

The causes of thick calves or clearly bulging calf muscles

are muscle and fat, but in most cases the main cause is muscle.

Anatomy of bulging calves

The cause of bulging calves is the gastrocnemius, the outermost muscle of the calf.

The gastrocnemius is divided into medial and lateral portions,

and the medial side is usually more developed.

Beneath the gastrocnemius is the soleus,

and beneath the soleus there are multiple other muscle layers.

The thickness of the gastrocnemius is usually 2 cm when relaxed and

becomes 3 to 4 cm thick when contracted, creating bulging calves.

Selective nerve block is intended to reduce the volume of the outermost gastrocnemius,

which causes bulging calves.

The movement of the legs involves other muscle layers, including the soleus, in the movement of the calves and feet,

and the outer gastrocnemius has no special function,

so even without the gastrocnemius, leg function is not affected at all.

Selective nerve block works by blocking the gastrocnemius nerve, which branches from the tibial nerve to the gastrocnemius,

making the gastrocnemius lose its mobility.

When a muscle’s nerve is blocked, it cannot contract or relax,

so it loses mobility and the muscle inevitably atrophies over time.

This method blocks the nerves by using the principle that unused muscles atrophy.

Conventional methods for reducing calf muscles

1. Muscle resection through incisionThis method inserts instruments through an incision behind the knee and pulls out the gastrocnemius (gastrocnemius muscle) by tearing it away. This method leaves a large scar behind the knee and tears out the muscle unevenly, so the shape is not uniform. It is far from what is required aesthetically today.
2. Neurectomy through incisionThis method finds and cuts the nerve going to the gastrocnemius through an incision behind the knee. It can only be performed on the medial side, so it can easily create bow legs, and because it is an incision-based method, it leaves a large scar behind the knee, making it far removed from aesthetic purposes.
3. Muscle recession using medium/high frequencyThis method electrically coagulates the gastrocnemius using medium/high frequency to make the muscle recede. It burns away the muscle, and due to scar tissue developing from the burn inside the muscle, the effect of calf muscle recession is reduced. It is also not commonly performed because swelling is severe and walking after the procedure is difficult.
4. Neurolysis using drugs on the motor nerve of the gastrocnemiusThis method injects medication around the nerve going to the gastrocnemius (gastrocnemius muscle). It is difficult to inject precisely along the nerve path, and the effect of drug-induced nerve block is insufficient. The treatment effect is somewhat reduced or the recurrence rate is high. In addition, side effects may occur as the drug spreads to unwanted areas.

Disadvantages of conventional surgical methods

Neurectomy or muscle resection leaves an unattractive scar behind the knee after surgery, which is far from the patient’s needs.
Muscle resection can create a lumpy contour due to irregular removal of muscle, and may cause varicose veins in the legs.
Neurectomy leaves a large scar behind the knee and may cause bow legs as a sequela.
Neurolysis has inconsistent effects and may cause side effects due to drug spread to unwanted areas.
In medium/high-frequency cauterization, scar tissue remains inside, the effect is limited, and swelling and pain are severe.

Non-incisional selective nerve block

Using a nerve blocker,

after identifying the path of the motor nerves that supply the calf gastrocnemius,

this method selectively blocks only the gastrocnemius motor nerves

while minimizing damage to other tissues.

Non-incisional selective nerve block - procedure

Non-incisional selective nerve block uses local anesthesia

and a special medical device (with functions to find, identify, and block nerve branches)

to selectively block only the branches of the motor nerve.

Step 1 - The nerve location is confirmed with ultrasound and marked on the skin.
Step 2 - While lying face down, local anesthesia is lightly administered at the spot where the needle will be inserted.
Step 3 - While checking with ultrasound, the nerve location is identified and the needle is inserted toward the nerve.
Step 4 - A nerve detector is used to confirm that the gastrocnemius nerve is touching the needle.
Step 5 - The mode is switched to nerve block mode, and electrical heat that blocks nerve transmission is generated from the tip of the needle to block the nerve. If both the medial and lateral sides of the gastrocnemius are blocked, a total of four nerve sites are blocked on both sides combined.
Step 6 - After the procedure, the patient goes home immediately.

The nerve pathway is identified through ultrasound examination in the examination room.

Because the nerve pathway and depth differ from person to person,

identifying the exact nerve path

is a necessary step for a successful procedure.

After locating the nerve, the position to be blocked is marked.

The nerve pathway is drawn with design ink on the marked area.

The nerve is divided into medial and right-side nerves,

and it extends with many branches like tree limbs.

Even these small branches are searched for and marked with ink.

In most cases, the nerves in both legs do not run in exactly the same way.

Even in the same person, the left and right nerve paths differ,

and the number of branches is often different as well.

Accurate nerve detection can increase the success rate of the procedure

and reduce the recurrence rate to a minimum.

In the operating room, after sedation and local anesthesia are administered,

the nerve-block needle (search needle) is prepared in nerve-search mode.

The nerve-block needle is inserted into the locally anesthetized area.

After confirming that it has passed through the fascia, under ultrasound guidance

the needle tip is brought close to the location of the gastrocnemius motor nerve.

The nerve branches are quickly searched for with ultrasound and blocked.

To improve the treatment effect,

the nerve branches must be found accurately within a short time

and coagulated firmly so that recurrence due to nerve regeneration does not occur.

In addition, by preventing damage to important tissues other than the nerves to be blocked,

the procedure can be performed without side effects.

Finding blood vessels on ultrasound is not that difficult,

but nerves can only be located with considerable experience.

Since the diameter of a nerve is only about 1 to 2 mm,

detection is difficult, and finding nerves on ordinary ultrasound is almost impossible.

Detection is possible with a high-frequency ultrasound of 7.5 MHz or higher,

and accurate detection is needed from the nerve root to the branches.

When the tip of the needle touches the gastrocnemius motor nerve, the gastrocnemius begins to contract repeatedly.

After confirming muscle contraction,

the nerve-search mode is switched to nerve-block mode and electrical coagulation is performed.

After the electrical coagulation is finished,

the mode is switched back to nerve-search mode to confirm that the muscle does not contract.

If the muscle does not contract, the nerve has been blocked.

Because the blocking effect must be permanent,

the proximal part of the nerve is checked again and treated once more.

Usually, 7 to 8 sites are blocked in one muscle,

and blocking multiple nerve branches is more effective.

If all four muscles on both the medial and lateral sides of the calves are treated,

about 30 nerve branches in total must be blocked to prevent recurrence

and achieve a definite treatment effect.

Usually, when both the medial and lateral sides are treated on both legs, the procedure takes about 30 minutes to 1 hour.

If only the medial side is treated, the procedure takes about 30 minutes.

You can go home immediately after the procedure, and before leaving, you lift your heels

to confirm that the calf bulges do not reappear, and then leave.

When leaving, you can wear a compression band.

The usefulness of ultrasound diagnostic devices in nerve block procedures

The device used as an auxiliary tool in addition to the basic equipment for nerve block is the ultrasound imaging device.

An ultrasound diagnostic device equipped with a 7.5 MHz high-frequency probe

is useful for locating structures such as blood vessels and nerves.

The key to success in nerve block procedures is

how accurately and effectively the nerve branches can be found.

The nerves to be located are the main trunk and branches of the nerve going to the gastrocnemius.

Usually, the number of nerve branches blocked within one gastrocnemius is about 7 to 8.

The more nerves are blocked, the better the treatment effect becomes.

To find the nerve branches effectively,

rather than the conventional method of randomly poking around with the search needle,

it is better to accurately identify the nerve path while looking at the ultrasound screen,

and move the search needle directly toward the nerve to improve the accuracy and effect of the procedure.

Without an ultrasound device, there are even cases where the procedure is almost impossible,

especially when the nerve does not respond well to the search needle.

Only when the nerve responds can electrical coagulation be performed,

so if the needle touches the nerve but there is no response, the procedure becomes impossible.

In such cases, if ultrasound confirms that the search needle is touching the nerve,

it is useful because electrical coagulation can still be performed even if the nerve does not necessarily respond.

The immediate effect after non-incisional selective nerve block

After the procedure, if you lift your heels,

you can visually confirm that the bulging muscle does not tense up immediately.

This surgery can achieve satisfactory results with a single procedure,

and because there are no scars or uncomfortable post-surgical issues, it is a highly welcomed treatment.

The recovery process after non-incisional selective nerve block

If only the medial side of the calf is treated, the procedure ends in about 30 minutes. After the procedure, simply wear the compression band provided by the hospital.
Immediately after the procedure, you can lift your heels and confirm right away that the calf does not bulge.
After the procedure, there may be a slight pulling pain, but it does not interfere with daily life.
There is almost no swelling or bruising.
Due to gradual muscle atrophy, a slight pulling and tight feeling in the calf for about a month is a normal part of the recovery process.
A visible sense that the calf has become slimmer can be noticed after about 15 days to one month.
The maximum effect appears after 3 to 6 months, and if there is no recurrence, the treatment effect is permanent.

Post-procedure precautions for non-incisional selective nerve block

1. Due to gradual muscle atrophy, a slight pulling and tight feeling in the calf for about a month is a normal part of the recovery process. There may be some mild discomfort while walking, but as you walk and naturally stretch the muscle, the pulling sensation will gradually go away. The time for the pulling sensation to disappear can be as short as 2 weeks or as long as more than a month.
2. It is better not to wear very high heels for about a month. As the muscle atrophies and becomes smaller, a pulling sensation may occur. To address this, stretching the muscle will help. Wearing low-heeled shoes or sneakers and doing light exercise such as walking little by little can improve the treatment effect and quickly relieve the pulling and tight feeling in the muscle.
3. If you wear high heels continuously from immediately after the procedure, the muscle length may shorten and cause a side effect of tiptoe walking, where the heels do not touch the ground, so caution is needed. However, this problem will absolutely not occur if you wear low shoes or sneakers for about a month.
4. Some clinics with insufficient experience in calf procedures may even tell patients to continue wearing high heels after the procedure. This should absolutely not be done. Wearing high heels keeps the muscle contracted, so if that condition continues, it is natural for the muscle to become shorter. If the muscle becomes shorter, the heels will not touch the ground. This is advice given without understanding the principle of muscle atrophy, and it can result in side effects that should not occur, so please keep this in mind.

Before-and-after photos of non-incisional selective nerve block

The four principles of calf recession surgery

There must be no recurrence. It is most important to perform the procedure properly so that it does not recur.
The effect must be definite. The result of muscle recession should be close to 100%.
There must be no side effects. There should be no damage to other tissues, and side effects should not occur.
You must be able to return to daily life immediately. Bruising, swelling, and pain should be minimized so that normal life is possible right after the procedure.

Important key points for successful nerve block procedures

The key to successful treatment in nerve block procedures is

how accurately and quickly the nerve branches can be found.

Because the procedure is done without an incision,

it is necessary to quickly find the invisible nerve branches and block as many branches as possible

in order to achieve satisfactory muscle recession.

The biggest weakness of nerve block procedures is

that the search needle of the basic detection equipment cannot find the nerve quickly.

Depending on the individual, the nerve may not respond properly to the search needle,

and some nerves do not follow the normal path.

In such cases, the nerve branches can only be found with great difficulty by repeatedly poking around with the search needle.

Therefore, when the nerve branches cannot be found properly,

the procedure is not performed correctly, the effect is very poor,

or in some cases there is almost no effect at all.

Only by finding and coagulating as many nerve branches as possible within a short time

can the desired muscle recession effect be achieved,

so the practitioner must have extensive experience and know-how,

and ultrasound imaging equipment must also be used together to improve treatment results.

Causes of nerve block failure

When the practitioner lacks experience with nerve block procedures
When the person has a constitution in which the nerve does not respond well to the detection needle
A careless procedure that blocks only one or two proximal sites without blocking many proximal and distal nerve branches
When the nerve cannot be found with the search needle because it deviates from the normal path due to variation
When the nerve going to the soleus deep muscle is blocked instead of the nerve going to the gastrocnemius, or when the sural nerve is blocked
When the gastrocnemius nerve is blocked too close to the back of the knee, causing damage to the tibial nerve as well

The biggest key to successful nerve block procedures is to find the nerve accurately

and block as many branches as possible.

If the nerve is not found properly, the procedure will not be effective or will quickly recur.

For this reason, using an ultrasound diagnostic device together

allows the practitioner to accurately identify the nerve path and perform the procedure,

maximizing the treatment effect.

Side effects of nerve block failure

Pain in the heel area or reduced sensation due to damage to the tibial nerve
Weakness in the leg due to damage to the nerve going to the soleus
Uneven, lumpy contours in the calf due to partial blockage of nerve branches or recurrence

Side effects of nerve block procedures occur when the exact nerve location is not found.

Only when the procedure is performed accurately in principle based on extensive experience

can the treatment effect be improved and side effects prevented.

If problems occur after calf recession surgery performed at another hospital

Recurrence due to nerve regeneration after nerve block

All tissues regenerate when damaged.

Nerves also have a very strong regenerative ability,

so if the procedure is incomplete, the nerves can regenerate.

Nerve regeneration means recurrence.

If recurrence occurs, the nerve block must be performed again,

but repeat surgery is much more difficult than the initial procedure.

The reasons are:

First, hard scar tissue forms around the nerve that was treated once,

and because it wraps around like a protective membrane, the nerve does not respond to the search needle,

so the nerve can hardly be found with the conventional method.

Second, even if the nerve is found, the nerve surrounded by hard scar tissue

is not properly blocked by the conventional coagulation heat.

Since the coagulation temperature does not exceed 90 degrees at most,

heat around 90 degrees makes it difficult to penetrate the hard scar tissue membrane and block the nerve.

To solve this problem, the nerve must be visually confirmed and its exact location identified,

and for that, the help of an ultrasound imaging device is essential.

In cases of recurrence, repeat treatment is almost impossible without the help of ultrasound imaging.

Also, the found nerve must be approached as closely as possible by the search needle after it penetrates the scar tissue membrane

and then be electrically coagulated.

The coagulation time must also be longer.

Recurrence due to muscle regeneration after medium/high-frequency treatment

All tissues regenerate when damaged.

Muscle tissue also has very strong regenerative ability,

so if the procedure is incomplete, the muscle can regenerate.

Also, areas that cannot regenerate are filled with hard scar tissue,

which reduces the effect of volume reduction.

The reasons for recurrence are:

First, even if the muscle is partially damaged and necrotized by medium/high frequency,

other muscle fiber cells replace it and regenerate.

Therefore, with most procedures, muscle cells almost always regenerate,

so the effect is inevitably reduced.

Second, even if some muscle tissue has been necrotized by the heat of medium/high frequency and cannot regenerate,

these areas are filled with collagen formed within the tissue,

and as it turns into hard scar tissue, the effect of volume reduction is weakened.

In other words, scar tissue takes the place of the muscle.

To solve this problem, rather than burning away the muscle again with medium/high frequency,

it is necessary to replace it with ultrasound-guided selective nerve block to naturally induce muscle atrophy.

Even if recurrence occurs after medium/high-frequency treatment, selective nerve block can still be performed.

When contours occur in the treated calf

Incomplete nerve block

After nerve block procedures, the calf line may become uneven and not smooth.

This is a recurrence, but it can be considered partial recurrence rather than complete recurrence.

In other words, among multiple nerve branches, some may have been blocked while others were not.

The muscle controlled by the blocked nerves atrophies and becomes smaller,

but the muscle controlled by the unblocked nerves remains at its original volume,

so the blocked and unblocked areas look uneven due to the difference in muscle volume.

In the end, this is an incomplete procedure or partial recurrence,

and if the nerve branches that were not properly treated are found

and accurately treated again, the contour will naturally disappear.

Incomplete muscle treatment with medium/high frequency

When muscle is cauterized with medium/high frequency, some parts regenerate, some are replaced by scar tissue,

or some areas may become somewhat sunken.

The reasons for contour irregularities are:

First, some parts of the muscle are necrotized by the heat of medium/high frequency and their volume decreases,

while other parts do not, creating contour differences in height.

In other words, the effect is not uniform and is seen only in certain areas.

Second, excessive necrosis of muscle tissue can cause parts of the calf to sink in like a pit.

This is a severe case where not only muscle necrosis but also the fat layer above the muscle becomes necrotized as a complication.

Third, when scar tissue fills in the place where the muscle was necrotized, the areas where scar tissue forms remain the same in volume,

whereas areas where scar tissue does not form well become smaller in volume.

This creates uneven contours.

To solve this problem, rather than burning away the muscle again with medium/high frequency,

it is necessary to replace it with ultrasound-guided selective nerve block to naturally induce muscle atrophy.

If muscle atrophy is made uniformly across the calf with nerve block, the irregular contour can be improved.

Also, if excessive indentation occurs along with fat necrosis,

fat grafting can be performed after the muscle has completely receded to naturally fill in the sunken area.

When bow legs occur because the lateral muscle develops relatively more after medial neurectomy

Bow legs caused by lateral muscle development

In cases of neurectomy at another hospital, where an incision is made behind the knee to cut the medial nerve,

the lateral muscle often develops compensatorily because it was not treated.

In such cases, the calf bulges only on the outer side, creating very unattractive bow legs.

Because neurectomy is an aggressive surgery that causes complete muscle atrophy,

the lateral nerve is excluded from treatment in case of side effects,

which often leads to the problem of bow legs.

If bow legs develop, the lateral nerve can be treated with nerve block rather than surgery

to restore balance to the legs, so it is a good idea to consider nerve block in cases of bow legs.

Tiptoe-walking side effect caused by incorrect instructions after the procedure

Tiptoe walking where the heels do not touch the ground

The side effect of tiptoe walking, where the heels do not touch the ground,

is caused by wearing high heels continuously from right after the procedure.

It is absolutely not a side effect caused by a mistake in the procedure.

If tiptoe-walking side effects occur, you should walk around the room barefoot as much as possible

so that the tightened muscles are stretched and lengthened again.

Walking barefoot in the room, or wearing shoes with almost no heel outside,

will naturally stretch and straighten the muscle.

After tiptoe-walking side effects occur, taking off your shoes can make walking uncomfortable,

which may force you to keep wearing high heels.

But this makes the condition worse.

At the early stage of this problem, the best approach is to remove the high heels as quickly as possible,

switch to shoes with as little heel as possible, and keep practicing walking

until the muscles stretch back out and straighten.

Usually, if you practice walking in flat shoes within 6 months after the procedure,

most cases of tiptoe walking can resolve on their own.

Comparison of non-incisional selective nerve block with other surgical methods

Category	Incisional muscle resection	Incisional nerve block	Medium/high-frequency muscle recession	Neurolysis	Ultrasound-guided nerve block
Scar	3–4 cm behind the knee	3–4 cm behind the knee	No scar	No scar	No scar
Procedure time	1–2 hours	1–2 hours	40 minutes to 1 hour	30 minutes to 1 hour	30 minutes to 1 hour
Effect and prognosis	The leg may become lumpy due to irregular muscle removal.	The effect is high. Only the medial side is treated, so the lateral side becomes compensatorily thicker. It may appear bowed outward.	The effect is low. There is little reduction in thickness.	The effect is inconsistent, and drugs may spread to unwanted areas and cause side effects.	The effect is high. The calves become much slimmer. Both the medial and lateral sides are treated, sufficiently reducing the muscle.
Discharge and function	Severe swelling, bruising, and pain require 1–2 weeks of rest. Walking is very uncomfortable for about a month.	It is uncomfortable and difficult to walk for about 15 days. There is pulling pain for about a month.	Severe swelling and pain make walking uncomfortable for about a month.	You can return to daily life immediately, but there is pulling pain for about 3–4 weeks.	You can return to daily life immediately, but there is pulling pain for about 3–4 weeks.

Notes on calf procedures

There are many calf reduction methods, but not many suitable methods.
The choice of procedure is determined by the shape and cause of the thick legs.
A good procedure is one that has no side effects and delivers definite results.
You should choose a method that minimizes swelling and pain after the procedure.
Among muscle recession procedures, ultrasound-guided selective nerve block is the most preferred method.

​http://www.duhans.com

If there are bulging calves, muscle recession surgery should be performed.

As I keep saying in the consultation room,

calf procedures are absolutely not something just anyone can do.

As with all surgeries, the outcome depends on

how much experience and know-how

the surgeon has.

Having equipment alone does not mean the procedure can be done well.

The same applies to calf recession surgery:

the success or failure of the procedure depends on who performs it and how well it is done.

Even if surgery is performed, if the nerve block is not done properly,

the nerves regenerate and recurrence occurs.

The key to nerve block is to find many nerve branches in a short time

and coagulate them firmly to reduce the recurrence rate.

Simply blocking one or two nerves in an incomplete way

does not produce calf recession.

There are many clinics that perform calf procedures,

but there are almost no clinics other than ours that do them properly.

People often think calf procedures are very easy,

but that is absolutely not the case.

Many people think that if the procedure is done at any clinic,

the result will be good, but you should be careful.

Also, if calf nerve block is performed properly and according to principle,

it is a safe procedure, so you do not need to worry about recurrence, side effects,

or aftereffects.

Dr. Shin Duhan

http://www.calfs.co.kr