[Duhan Plastic Surgery Calf Reduction Surgery] - [Ultrasound-Guided Selective Nerve Block Guide]

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Simple Calf Reduction Surgery

A non-surgical selective nerve coagulation procedure for creating slimmer calves

Ultrasound-guided selective nerve block surgery for creating slimmer calves using ultrasound nerve-finding and coagulation equipment

The recent trend in the cosmetic surgery field is to actively reflect patient needs and continuously seek minimally invasive methods that are clearly effective and ensure procedural safety.

At our clinic, we perform procedures with low risk of side effects and a markedly reduced recurrence rate by using ultrasound diagnostic equipment together with a non-incisional ultrasound selective nerve block device.

This is a new concept in calf reduction surgery: a non-incisional ultrasound-guided selective nerve block, rather than a muscle recession procedure using medium/high-frequency muscle cauterization that requires no incision and involves significant swelling and pain.

Basic equipment set for calf nerve block surgery

The basic equipment for nerve block surgery uses an integrated device that combines nerve searching and nerve blocking in one unit.

When the nerve-finder touches a nerve and the muscle responds by moving, the mode is changed so the nerve can be blocked immediately.

What is ultrasound-guided selective nerve block surgery?

Using the basic nerve-finding equipment alone has the disadvantage of making it difficult and time-consuming to locate invisible nerves.

In addition, if a nerve deviates from its normal path, it becomes very difficult to find, and the procedure is often not performed properly.

If the nerve is not found correctly, the effect of the procedure may be reduced, side effects may occur, and the recurrence rate may be high, among other problems.

To make nerve searching 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, many nerve branches can be effectively blocked in a short time.

This procedure improves the effect, causes fewer side effects, and significantly lowers the recurrence rate: non-incisional ultrasound-guided selective nerve block surgery.

Equipment for ultrasound-guided selective nerve block surgery

In addition to the basic equipment for nerve block surgery, an ultrasound diagnostic device, a visual imaging tool, is used to quickly and accurately locate the nerve branches.

With the basic equipment alone, there are limits to finding the nerves, and in the case of many branches or nerves traveling along unexpected paths, finding them is very difficult.

The success of the procedure depends on accurately locating the nerve branches in a short time.

For this reason, ultrasound equipment helps improve procedural accuracy and shorten the time required.

Advantages of ultrasound-guided selective nerve block surgery​

1. The nerve branches can be found quickly and accurately, so the procedure is highly effective.

2. It significantly shortens the procedure time compared with using the basic equipment alone.

3. Because the nerve branches are found accurately, other tissues are not damaged, so side effects are minimal.

4. Since the procedure time is shorter, there is less pain after the procedure and recovery is faster.

5. Because the procedure is performed by accurately locating the nerves, the recurrence rate is significantly reduced.

Causes of thick calves

The causes of calves that are thick or have clearly visible muscle bulges 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 muscle, the outermost muscle of the calf.

The gastrocnemius is divided into medial and lateral portions, and in general the medial side is more developed.

Below the gastrocnemius is the soleus muscle, and beneath that are several other muscle layers arranged one over another.

The thickness of the gastrocnemius is usually about 2 cm at rest and becomes about 3 to 4 cm thick when contracted, creating bulging calves.

The purpose of selective nerve block surgery is to reduce the volume of the outermost gastrocnemius muscle, which causes bulging calves.

Leg movement involves the soleus and several other muscle layers in the movement of the calf and foot, while the outer gastrocnemius has no special function. Therefore, even if the gastrocnemius were absent, leg function would not be affected at all.

Selective nerve block works by blocking the gastrocnemius nerve, which branches from the tibial nerve to the gastrocnemius muscle, thereby eliminating the muscle's mobility.

A muscle whose nerve has been blocked can no longer contract or relax, so it loses mobility and gradually atrophies over time.

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

Conventional methods for reducing calf muscle size

1. Muscle resection through incision

This method involves making an incision behind the knee and inserting an instrument to pull out and tear away the gastrocnemius muscle.

Because this method leaves a large scar behind the knee and tears away the muscle unevenly, the shape is not uniform and it is far removed from current aesthetic demands.

2. Neurectomy through incision

This 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, which may end up creating bow legs, and because it requires an incision, it leaves a large scar behind the knee. It is therefore far removed from aesthetic purposes.

3. Muscle recession using medium/high-frequency cauterization

This method electrically coagulates the gastrocnemius using medium/high-frequency energy to make the muscle atrophy.

It burns away the muscle, and due to scar tissue formation from burns inside the muscle, the effect of calf muscle recession is reduced. It also causes severe swelling and makes walking difficult after the procedure, so it is not commonly performed.

4. Neurolysis using drugs on the motor nerve to the gastrocnemius

This method injects medication around the nerve going to the gastrocnemius muscle. However, it is difficult to inject exactly along the nerve's path, and the effect of nerve block from the medication is insufficient.

The procedure effect may be somewhat reduced, or the recurrence rate may be high.

In addition, side effects may occur as the medication 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 what patients want.
Muscle resection can cause a bumpy contour due to irregular removal of the muscle, and muscle resection can cause varicose veins in the legs.
Neurectomy leaves a large scar behind the knee and may result in bow legs as a sequela.
Neurolysis has inconsistent effects and can cause side effects due to the spread of medication to unwanted areas.
In the case of medium/high-frequency cauterization, scar tissue remains inside; the effect is also limited, and swelling and pain are severe.

Non-incisional selective nerve block surgery

Concept: After using a nerve blocker to identify the path of the motor nerve that innervates the calf gastrocnemius muscle, this method selectively blocks only the gastrocnemius motor nerve while minimizing damage to other tissues.

Non-incisional selective nerve block surgery - procedure

Through local anesthesia, non-incisional selective nerve block uses special medical equipment (with the function of finding, confirming, and blocking nerve branches) to selectively block only the branches of the motor nerve.

Step 1 - The nerve location is confirmed by ultrasound and marked on the skin.
Step 2 - While lying face down, local anesthesia is lightly administered at the site where the needle will be inserted.
Step 3 - While confirming with ultrasound, the nerve location is identified and the needle is inserted into the nerve's location.
Step 4 - The nerve-finder is used to confirm whether the gastrocnemius nerve and the needle are in contact.
Step 5 - The mode is switched to nerve-block mode, and electrical heat that blocks nerve transmission is generated from the needle tip to block the nerve. If blocking both the medial and lateral sides of the gastrocnemius, a total of four nerves on both sides are blocked.
Step 6 - After the procedure, the patient goes home immediately.

The path of the nerve is identified through an ultrasound examination in the procedure room.

Because the nerve path and depth differ from person to person, accurately identifying the nerve's course is an essential step for a successful procedure.

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

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

The nerves are divided into medial and lateral nerves, and they branch out like tree limbs.

These smaller branches are also located and marked with ink.

The nerves in both legs often do not travel in exactly the same way.

Even in the same person, the nerve paths on the left and right sides are often different, and the number of branches is often different as well.

Accurate nerve searching can increase the success rate of the procedure and minimize recurrence.

In the operating room, after sedation and local anesthesia, the nerve-block needle (exploration 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, the needle tip is guided under ultrasound toward the location of the gastrocnemius motor nerve.

The nerve branches are quickly located with ultrasound and blocked.

To improve the effect, the nerve branches must be accurately found and firmly coagulated within a short time so that the nerve does not regenerate and recur.

This also prevents damage to other important tissues other than the nerve to be blocked, allowing the procedure to be performed without side effects.

It is not especially difficult to find blood vessels on ultrasound, but nerves can only be identified with a great deal of experience.

Since the nerve diameter is only about 1 to 2 mm, searching is difficult, and it is almost impossible to locate nerves with ordinary ultrasound alone.

Search is possible with a high-frequency ultrasound of 7.5 MHz or higher, and accurate identification from the nerve root to the branches is required.

When the needle tip touches the gastrocnemius motor nerve, the gastrocnemius begins repeated contractions.

After confirming muscle contraction, the mode is changed from nerve-search mode to nerve-block mode, and electrical coagulation is performed.

After the electrical coagulation is complete, the mode is switched back to nerve-search mode to confirm that the muscle no longer contracts.

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

Because the blocking effect should be permanent, the proximal part of the nerve is checked again and treated.

Usually, 7 to 8 areas are blocked in one muscle, and blocking multiple nerve branches is more effective.

If all four medial and lateral muscles in both calves are treated, about 30 nerve branches must be blocked in total to prevent recurrence and achieve a definite 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 is completed in about 30 minutes.

The patient can go home immediately after the procedure, and before leaving, the patient raises the heels to check that no calf bulge appears, then goes home.

When leaving, the patient can wear a compression band.

Usefulness of ultrasound diagnostic devices in nerve block surgery

The device used as an adjunct to nerve block surgery, in addition to the basic equipment, is an ultrasound imaging device.

An ultrasound diagnostic device equipped with a 7.5 MHz high-frequency probe is useful for identifying the location of structures such as blood vessels and nerves.

The key to a successful nerve block procedure is how accurately and effectively the nerve branches can be found.

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

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

The greater the number of nerves blocked, the better the effect of the procedure.

To find the nerve branches effectively, rather than the conventional method of randomly poking around with an exploration needle, it is better to look at the ultrasound image, accurately identify the nerve path, and guide the exploration needle directly to the nerve at once. This improves accuracy and effectiveness.

If there is no ultrasound device, in some cases the procedure may be nearly impossible when the nerve does not respond well to the exploration needle.

The nerve must respond for electrical coagulation to be possible; if the exploration needle touches the nerve but there is no response, the procedure becomes impossible.

In such cases, if the ultrasound image confirms that the exploration needle is touching the nerve, electrical coagulation can still be performed even if the nerve does not respond clearly, which is useful.

Immediate effects after non-incisional selective nerve block surgery

After the procedure, when the heels are raised, it can be visually confirmed immediately that the bulging muscle does not tighten.

This surgical method can produce satisfactory results with a single procedure and has no scar or postoperative inconvenience, making it a very welcome treatment.

Post-procedure course of non-incisional selective nerve block surgery

If only the medial calf is treated, the procedure takes about 30 minutes. After the procedure, simply wear the compression band provided by the hospital.
Immediately after the procedure, you can confirm at once that a calf bulge does not appear when you raise the heels.
There may be a slight pulling pain after the procedure, but it does not interfere with daily life.
There is almost no swelling or bruising.
Due to the gradual atrophy of the muscle, a slight pulling and stiffness in the calf for about a month is a normal part of the recovery process.
A visible reduction in calf thickness can be noticed after about 15 days to a month.
The maximum effect appears after 3 to 6 months, and if there is no recurrence, the treatment effect is permanent.

Precautions after non-incisional selective nerve block surgery

1. Due to the gradual atrophy of the muscle, a slight pulling and stiffness in the calf for about a month is a normal part of the recovery process.

There may be some discomfort when walking, but if you naturally stretch the muscle while walking, the pulling sensation will gradually disappear.

The period until the pulling sensation disappears may 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.

Because the muscle is shrinking as it atrophies, there may be a pulling sensation.

To address this, wearing low-heeled shoes or sneakers and doing light exercise such as walking little by little can help stretch the muscle, improve the procedure effect, and relieve the pulling and stiffness more quickly.

3. If you live in high heels immediately after the procedure, the muscle length may shorten, which can cause a side effect of toe-walking, where the heels do not touch the ground.

However, if you live in low-heeled shoes or sneakers for about a month, this problem will absolutely not occur.

4. In some clinics with insufficient experience in calf procedures, patients are sometimes told to wear high heels after the procedure.

This should never be done.

If you wear high heels, the muscles remain contracted, and if that condition continues, it is natural for the muscle length to shorten.

If the muscle length shortens, the heels will not touch the ground.

This is said without understanding the principle of muscle atrophy, and it can create side effects that should not occur, so please keep this in mind.

Before-and-after results of non-incisional selective nerve block surgery

The 4 Principles of Calf Recession Surgery

It must not recur.

Performing the procedure properly so that it does not recur is the most important thing.

It must be clearly effective.

The result of muscle recession should be as close to 100% as possible.

There must be no side effects.

Other tissues must not be damaged, and side effects must not occur.

Daily life must be possible right away.

Bruising, swelling, and pain should be minimized so that daily life is possible immediately after the procedure.

Important key to successful nerve block surgery

The key to successful nerve block surgery is how accurately and quickly the nerve branches can be found.

Because the procedure is performed without an incision, the invisible nerve branches must be found quickly and as many branches as possible blocked to achieve satisfactory muscle recession.

The biggest flaw of nerve block surgery is that the exploration needle of the basic search equipment cannot find nerves quickly.

Depending on the individual, the nerve may not respond properly to the exploration needle, and some nerves do not travel along the normal path. In such cases, the nerve branches that pass through must be found painstakingly by poking around with the exploration needle.

Therefore, if 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.

To find as many nerve branches as possible within a short time and coagulate them, the operator must have extensive experience and know-how, and ultrasound imaging equipment must also be used together to improve the effect.

Causes of nerve block surgery failure

Lack of experience with nerve block surgery
A constitution in which the nerves do not respond well to the search needle
A careless procedure that blocks only one or two proximal areas without blocking many proximal and distal nerve branches
Cases where the nerves cannot be found with the exploration needle because they deviate from the normal path due to anatomical variation
Cases where nerves to the soleus are blocked instead of nerves to the gastrocnemius, or where the sural nerve is blocked
Cases where the gastrocnemius nerve is blocked too close to the back of the knee, damaging the tibial nerve

The greatest key to success in nerve block surgery is accurately locating the nerves and blocking as many branches as possible.

If the nerves are not found correctly, the procedure will not be effective or will recur quickly.

For this reason, using ultrasound imaging together allows the nerve path to be identified accurately during the procedure, maximizing the effect.

Side effects of nerve block surgery failure

Pain or reduced sensation in the heel due to damage to the tibial nerve
Weakness in the leg due to damage to the nerve going to the soleus muscle
Uneven bulging in the calf due to partial blocking of nerve branches or recurrence

The side effects of nerve block surgery occur when the exact location of the nerve is not found.

Only when the procedure is performed accurately in principle based on extensive experience can the effect be improved and side effects prevented.

Our clinic's procedure guidance for problems after calf recession surgery at another hospital

In cases of recurrence where the muscle bulge appears again

• Recurrence due to nerve regeneration after nerve block surgery

All tissues regenerate when damaged.

Nerves also have strong regenerative ability, so if the procedure is incomplete, the nerves regenerate again.

Nerve regeneration means recurrence.

If recurrence occurs, the nerve must be blocked again, but repeat surgery is much more difficult and complicated than the initial procedure.

The reasons are:

First, dense scar tissue forms around the nerves that were previously treated, surrounding them like a protective barrier, so the nerves do not respond to the exploration needle, and the conventional method can hardly find them.

Second, even if the nerve is found, the nerve surrounded by dense scar tissue cannot be properly blocked by the conventional coagulation heat.

Since the coagulation temperature does not exceed 90 degrees at most, it is difficult for heat of about 90 degrees to penetrate the dense scar tissue membrane and block the nerve.

To solve this problem, the nerve must be identified visually and its exact location found, and for that, ultrasound imaging is essential.

In recurrent cases, re-treatment is almost impossible without the help of ultrasound imaging.

In addition, the found nerve must be approached as closely as possible by having the exploration needle pierce the scar tissue membrane and contact the nerve directly, followed by electrical coagulation.

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 regenerates again.

In addition, areas that cannot regenerate are filled in by forming hard scar tissue, which reduces the effect of volume reduction.

The reasons for recurrence are:

First, even if the muscle is partially damaged and necrosed by medium/high-frequency energy, other muscle fibers are replenished and regenerate.

Therefore, with most procedures, the muscle cells almost regenerate, so the effect inevitably decreases.

Second, even if there are areas where the muscle tissue is necrotic from the heat of medium/high-frequency energy and does not regenerate, those areas are filled in with collagen formed within the tissue, which turns into hard scar tissue and reduces the effect of volume reduction.

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 energy, it is necessary to replace it with ultrasound-guided selective nerve block surgery and induce natural muscle atrophy.

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

If a contour develops in the treated calf

• Incomplete nerve block

After nerve block surgery, the calf line may become uneven and bumpy.

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 muscles innervated by blocked nerves atrophy and become smaller in volume, but the muscles innervated by unblocked nerves remain at their original volume, so the blocked and unblocked areas become uneven due to the difference in muscle volume.

Ultimately, this is an incomplete procedure or partial recurrence, and the contour will naturally disappear if the improperly treated nerve branches are found and treated accurately again.

• Incomplete muscle cauterization with medium/high-frequency energy

When muscles are cauterized with medium/high-frequency energy, some areas regenerate, some are replaced by scar tissue, and some become somewhat sunken.

Reasons for the contour:

First, some parts of the muscle become necrotic and reduce in volume due to medium/high-frequency heat, while other parts do not, creating a height difference and thus a contour.

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

Second, excessive muscle necrosis can cause part of the calf to sink in like a hollow.

This is a case in which, along with muscle necrosis, the fat layer above the muscle is also necrosed as a complication, resulting in severe indentation.

Third, when scar tissue fills in the area where the muscle necrosed, the area where scar tissue formed keeps its volume, while areas where scar tissue does not form well lose volume.

This causes contour irregularities.

To solve this problem, rather than burning away the muscle again with medium/high-frequency energy, it is necessary to replace it with ultrasound-guided selective nerve block surgery and induce natural muscle atrophy.

If uniform muscle atrophy is achieved through nerve block surgery, the contour irregularity can be reduced.

Also, if excessive indentation occurs along with fat necrosis, fat grafting can be performed after the muscle has completely atrophied to naturally fill the sunken area.

If O-shaped legs occur because the lateral muscle developed relatively more after medial neurectomy

• O-shaped legs caused by lateral muscle development

In neurectomy performed at another hospital by making an incision behind the knee and removing the medial nerve, the lateral muscle often develops compensatorily because it was not treated.

In such cases, only the outside of the calf bulges out, creating very unattractive O-shaped legs.

Neurectomy is an aggressive surgery that causes the muscle to atrophy completely, so in consideration of possible side effects, the lateral nerve is excluded from the surgical target, which is why O-shaped legs often occur.

If O-shaped legs develop, the lateral nerve can be treated with nerve block surgery rather than surgery, helping balance the legs. Therefore, if O-shaped legs occur, it is good to consider nerve block surgery.

Toe-walking side effects caused by incorrect instructions after the procedure

• Toe-walking where the heels do not touch the ground

The side effect of toe-walking, where the heels do not touch the ground, is caused by wearing high heels continuously immediately after the procedure.

It is absolutely not a side effect caused by an incorrect procedure.

If toe-walking side effects occur, you should move around barefoot in the room as much as possible so that the tightened muscle stretches and lengthens again.

Walking barefoot in the room or wearing shoes with almost no heel outside will naturally stretch the muscle and help it straighten out.

After toe-walking side effects occur, removing your shoes may make walking uncomfortable, so you may end up continuing to wear high heels.

However, this makes the symptoms worse.

At the early stage of toe-walking, the best thing to do is to quickly take off the high heels, switch to shoes with as little heel as possible, and keep practicing walking until the muscle stretches and straightens again.

In most cases, if you practice walking in shoes without heels within 6 months after the procedure, the toe-walking problem can resolve on its own.

Comparison of non-incisional selective nerve block surgery with other procedures

Category	Incisional Muscle Resection	Incisional Nerve Block Surgery	Medium/High-Frequency Muscle Recession	Neurolysis	Ultrasound-Guided Nerve Block Surgery
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	Uneven legs may result from irregular muscle removal.	The effect is high. Only the medial side is treated, so the lateral side thickens compensatorily. It may appear O-shaped.	The effect is low. Thickness reduction is small.	The effect is inconsistent, and the medication may spread to unwanted areas and cause side effects.	The effect is high. The legs become much slimmer. Both the medial and lateral sides are treated, sufficiently atrophying 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.	Immediate return to daily life is possible, but there is pulling pain for about 3–4 weeks.	Immediate return to daily life is possible, but there is pulling pain for about 3–4 weeks.

Precautions regarding the procedure

There are many methods for calf reduction surgery, but not many are suitable.
The choice of method is determined by the shape and cause of the thick legs.
A good procedure method is one with no side effects and a clearly effective result.
You should choose a method that causes the least swelling and pain after the procedure.
Among muscle recession procedures, ultrasound-guided selective nerve block surgery is the most preferred method.

http://www.duhans.com

Hello,

We are Duhan Plastic Surgery, dedicated to providing the best service.

If you have bulging calves, muscle recession surgery is needed.

We say this again and again in the consultation room, but calf procedures are absolutely not something just anyone can perform.

As with all surgeries, the outcome depends on the surgeon's experience and know-how.

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

The same applies to calf recession surgery: success depends on who performs it and how well it is done.

Even if surgery is performed, if nerve blocking is not done properly, the nerve can regenerate and recurrence can occur.

The key to nerve block surgery is finding many nerve branches within a short time and making sure they are electrically coagulated in order to reduce the recurrence rate.

Simply blocking one or two nerves carelessly does not produce calf recession.

Although many clinics perform calf procedures, there are almost no clinics other than ours that do them properly.

If you receive treatment from a clinic that only imitates the procedure, you may easily end up disappointed.

People often think calf procedures are very simple, but they are absolutely not.

Please be aware that many people think results will be good just because the procedure was performed at any clinic, but that is not the case.

Also, if calf nerve block surgery is performed properly and according to principle, it is a safe procedure, so there is no need to worry about recurrence, side effects, or sequelae.

http://www.calfs.co.kr