[Duhan Plastic Surgery Clinic Calf Contouring] - [Ultrasound-Guided Nerve Block]

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Ultrasound-Guided Nerve Block!

The best muscle-reduction method for creating a slim calf line

"Ultrasound-Guided Selective Nerve Block"

In recent aesthetic and plastic surgery trends, there is a continuing demand for methods that actively reflect patient needs, are minimally invasive, offer clear results, and ensure the safety of the procedure.

At our clinic, we use an ultrasound diagnostic device along with a non-incisional ultrasound selective nerve block system so that side effects are minimal and the recurrence rate is significantly reduced. This is not a procedure that requires an incision, and it is not a muscle reduction procedure using high-/mid-frequency muscle ablation that causes severe swelling and pain. It is a new concept in calf reduction surgery: a non-incisional ultrasound-guided selective nerve block.

CALFS CLINIC

http://www.calfs.co.kr

The best muscle-reduction method for creating a slim calf line

Basic equipment set for calf nerve block

The basic equipment for nerve block uses an integrated device that combines nerve search and nerve block in one unit so that both can be performed at once.

When the nerve contacts the nerve finder and the muscle moves in response, the mode is changed and the nerve is blocked immediately.

The main drawback of the basic nerve-search device is that finding invisible nerves is very difficult and time-consuming.

Also, if a nerve deviates from its normal course, it becomes very difficult to find, and in many cases the procedure is not performed properly.

If the nerve is not found correctly, the procedure may be less effective, side effects may occur, and the recurrence rate may be high.

To make nerve searching faster and more accurate, an ultrasound imaging device equipped with a high-frequency probe is used.

By checking with ultrasound and quickly and accurately locating the nerve, it is possible to effectively block multiple nerve branches within a short time.

The non-incisional ultrasound-guided selective nerve block is a procedure that improves treatment effectiveness, reduces side effects, and significantly lowers the recurrence rate.

Equipment for ultrasound-guided selective nerve block

In addition to the basic equipment for nerve block, an ultrasound diagnostic device, a visual examination tool, is used so that nerve branches can be found quickly and accurately.

With the basic device alone, there are limits to finding nerves, and if there are many nerve branches or if the nerve travels along an unexpected route, it is very difficult to locate them.

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

For this reason, ultrasound equipment helps improve the accuracy of the procedure and shortens the time required.

Advantages of ultrasound-guided selective nerve block

① Because nerve branches can be found quickly and accurately, the procedure is highly effective.
② It significantly shortens the procedure time compared with using only the basic device.
③ By accurately locating the nerve branches, it does not damage tissues in other areas, so side effects are minimal.
④ Because the procedure time is shorter, there is less pain after the procedure and recovery is faster.
⑤ Because the procedure is performed with accurate nerve search, the recurrence rate is significantly reduced.

Causes of thick calves

The causes of calves that are thick or clearly show bulging muscles are muscle and fat, but in most cases muscle is the main cause.

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

The gastrocnemius is divided into medial and lateral heads, and the medial side is usually more developed.

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

The gastrocnemius is usually 2 cm thick when relaxed, and when contracted it becomes 3 to 4 cm thick, creating a bulging calf.

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

For leg movement, the other muscle layers, including the soleus, are involved in moving the calf and foot, while the outer gastrocnemius has no special function, so even without it, 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, so that the gastrocnemius loses its mobility.

A muscle whose nerve has been blocked cannot contract or relax, so it loses mobility and inevitably atrophies over time.

The nerve is blocked by using the principle that unused muscles atrophy.

Traditional methods for reducing calf muscle

(1) Muscle resection through an incisionThis method involves making an incision behind the knee and inserting instruments to pull out and tear away the gastrocnemius muscle. This leaves a large scar behind the knee and removes the muscle unevenly, so the shape is not uniform. It is far from the current aesthetic demands.
(2) Nerve resection through an incisionThis method finds and cuts the nerve going to the gastrocnemius through an incision behind the knee. It can only be done on the medial side, which can easily create bow legs, and because it requires an incision, it leaves a large scar behind the knee. It is not suitable for aesthetic purposes.
(3) Muscle ablation using mid-/high-frequency energyThis method uses mid-/high-frequency energy to electrocoagulate the gastrocnemius and reduce the muscle. It burns the muscle away, and due to scar tissue development from internal burns, the effect of calf muscle reduction is limited. 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 gastrocnemiusThis method injects medication around the nerve going to the gastrocnemius muscle, but it is difficult to deliver it precisely along the nerve pathway, and the effect of drug-induced nerve block is insufficient. The treatment effect is somewhat limited and the recurrence rate is high. There may also be side effects caused by the medication spreading to unwanted areas.

Disadvantages of traditional surgical methods

Nerve resection or muscle resection leaves an unsightly 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 muscle, and it may cause varicose veins in the lower limbs due to muscle removal.
Nerve resection leaves a large scar behind the knee and can cause bow legs as a sequela.
Neurolysis has inconsistent effects and may cause side effects due to medication spreading to unwanted areas.
In the case of mid-/high-frequency ablation, scar tissue remains inside, the effect is not significant, and swelling and pain are severe.

Marking the nerve-blocking site before non-incisional ultrasound-guided selective nerve block

Non-incisional selective nerve block

After using a nerve blocker to identify the course of the motor nerve that innervates the gastrocnemius calf muscle, only the motor nerve branches of the gastrocnemius are selectively blocked while minimizing damage to other tissues.

Non-incisional selective nerve block - Procedure

Non-incisional selective nerve block uses local anesthesia and special medical equipment with functions for finding, identifying, and blocking nerve branches to selectively block only the motor nerve branches.

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 site 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 - Using the nerve finder, it is confirmed whether the calf 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 both the medial and lateral gastrocnemius are blocked, a total of four nerves are blocked on both sides.
Step 6 - After the procedure, the patient goes home immediately.

In the examination room, ultrasound is used to identify the path of the nerve.

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

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

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

The nerve is divided into medial and lateral nerves, and it branches out like tree limbs.

These small branches are also searched for and marked with ink.

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

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

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

In the operating room, after sedation anesthesia 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 site.

After confirming that it has passed through the fascia, the needle tip is advanced under ultrasound guidance to the location of the gastrocnemius motor nerve.

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

To improve the effectiveness of the procedure, the nerve branches must be accurately found and firmly coagulated within a short time so that the nerves do not regenerate and recur.

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

It is not that difficult to find blood vessels on ultrasound, but nerves can only be located accurately with a lot of experience.

Because the diameter of a nerve is only about 1 to 2 mm, searching is difficult, and with ordinary ultrasound it is almost impossible to find nerves.

It is possible to search with a high-frequency ultrasound of 7.5 MHz or higher, and accurate searching must be done from the nerve root to its branches.

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

After confirming muscle contraction, the nerve-search mode is switched to nerve-block mode and electrocoagulation is performed.

After electrocoagulation is finished, 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 must be permanent, the proximal part of the nerve is also checked and treated again.

Usually 7 to 8 sites are blocked in one muscle area, and the more nerve branches are blocked, the more effective it is.

If all four muscle areas on the medial and lateral sides of both 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 ends in about 30 minutes.

The patient can go home immediately after the procedure, and before leaving, the patient raises the heels to check that the calf bulge does not appear.

A compression band can be worn when leaving.

The usefulness of ultrasound diagnostic devices in nerve block procedures

In nerve block procedures, the auxiliary device used in addition to the basic equipment is the 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 success in nerve block procedures is how accurately and quickly the nerve branches can be found.

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

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

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

To find the nerve branches effectively, rather than the traditional method of randomly poking around with a search needle, it is better to improve accuracy and effectiveness by looking at the ultrasound screen, accurately identifying the nerve pathway, and guiding the search needle directly to the nerve at once.

Without ultrasound equipment, there are cases where the procedure is nearly impossible if the nerve does not respond well to the search needle.

The nerve must respond in order for electrocoagulation to be performed, and if the nerve does not respond even when the search needle touches it, the procedure cannot be performed.

In such cases, if the ultrasound screen confirms that the search needle is touching the nerve, electrocoagulation can still be performed even if the nerve does not respond, which is useful.

The immediate effect after non-incisional selective nerve block

After the procedure, when the heels are raised, it can be visually confirmed immediately that the bulging muscle is no longer tense.

With this surgical method, satisfactory results can be achieved with a single procedure, and because there are no scars or uncomfortable post-procedure issues, it is a very welcome treatment.

Post-procedure course after non-incisional selective nerve block

If only the medial calf is treated, the procedure takes about 30 minutes. After the procedure, the compression band provided by the clinic should be worn.
Immediately after the procedure, it is possible to check right away by raising the heels that the calf bulge does not appear.
There may be some mild pulling pain after the procedure, but it does not interfere with daily life.
Swelling and bruising are almost nonexistent.
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 sense that the calf has become thinner can usually 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.

Precautions after non-incisional selective nerve block

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 while walking, but if you naturally stretch the muscle by walking, the pulling sensation will gradually go away. The period until the pulling sensation disappears may be as short as 2 weeks or as long as more than a month.
2. For about a month, it is better not to wear very high heels. Because the muscle shrinks as it atrophies, there may be a pulling sensation. To address this, stretching that lengthens the muscle is helpful, so wearing low-heeled shoes or sneakers and doing light exercise such as walking little by little can improve the treatment effect and relieve the pulling and stiffness more quickly.
3. If you wear high heels and continue daily life immediately after the procedure, the muscle may shorten and cause a tiptoe-like side effect in which the heel does not touch the ground, so caution is needed. However, this problem will never occur if you spend about a month wearing low-heeled shoes or sneakers.
4. Some clinics with little experience in calf procedures may tell patients to wear high heels after the procedure. This is absolutely not acceptable. Wearing high heels keeps the muscle contracted, so if this continues, it is only natural that the muscle will shorten. If the muscle shortens, the heel will not touch the ground. This advice ignores the principle of muscle atrophy and can create 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 reduction 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 atrophy must be close to 100%.
There must be no side effects. There must be no damage to other tissues.
The patient must be able to return to daily life immediately. Bruising, swelling, and pain must be minimized so that daily life is possible right after the procedure.

The key factor for successful nerve block treatment

The core of successful nerve block treatment is how accurately and quickly nerve branches can be found.

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

The biggest limitation of nerve block treatment is that the search needle of the basic search device cannot find nerves quickly.

Depending on the individual, nerves may not respond properly to the search needle, and some nerves do not travel along their normal course, so in these cases the practitioner must poke around with the search needle to find the nerve branches as they pass by.

Therefore, if the nerve branches cannot be found properly, the procedure is not performed correctly, the effect is greatly reduced, 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 atrophy be achieved. This requires extensive experience and know-how from the practitioner, and using an ultrasound imaging device together is also necessary to improve the treatment effect.

Causes of nerve block treatment failure

○ When the practitioner lacks experience with nerve block treatment
○ When the patient has a constitution in which nerves do not respond well to the search needle
○ When only one or two proximal sites are blocked carelessly, without blocking many nerve branches in the proximal and distal areas
○ When nerves cannot be found with the search needle because they deviate from the normal course
○ When the nerve to the gastrocnemius is not blocked and instead the nerve to the deep soleus muscle is blocked, or the sural nerve is blocked
○ When the gastrocnemius nerve is blocked too close to the area behind the knee and the tibial nerve is damaged as well

The most important factor for successful nerve block treatment is to accurately find the nerves and block as many branches as possible.

If the nerves are not found properly, the treatment will have no effect or will quickly recur.

Using an ultrasound diagnostic device together allows the practitioner to accurately identify the nerve pathway and perform the procedure, thereby maximizing the treatment effect.

Side effects of nerve block treatment 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
Bumpy contours in the calf due to partial nerve blocking or recurrence

Side effects of nerve block treatment 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.

Clinic guidance for problems after calf reduction surgery performed at another hospital

In cases of recurrence where the bulging muscle comes back

1. Recurrence due to nerve regeneration after nerve block treatment

All tissues regenerate when they are damaged.

Nerves also have a very strong regenerative capacity, so if the procedure is incomplete, the nerves can regenerate.

Nerve regeneration means recurrence.

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

The reasons are as follows.

First, dense scar tissue forms around the nerves that were treated once, surrounding them like a protective barrier, so the nerves do not respond to the search needle and cannot be found with the traditional method.

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

The temperature of coagulation heat does not exceed 90 degrees at most, so heat of around 90 degrees has difficulty penetrating the dense scar tissue and blocking the nerve.

To solve this problem, the nerve must be visually confirmed and its exact location identified, which requires the help of an ultrasound imaging device.

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

Also, the found nerve must be reached by the search needle penetrating the scar tissue barrier as closely as possible to the nerve for electrocoagulation.

The coagulation time must also be longer.

2. Recurrence due to muscle regeneration after mid-/high-frequency treatment

All tissues regenerate when they are damaged.

Muscle tissue also has a very strong regenerative capacity, so if the procedure is incomplete, the muscle can regenerate again.

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

The reasons for recurrence are as follows.

First, even if some muscle fibers are damaged and necrotized by mid-/high-frequency energy, other muscle fiber cells are replaced and regenerate.

Therefore, with most procedures, the muscle cells tend to regenerate, so the effect is inevitably reduced.

Second, even if some muscle tissue is necrotized by the heat of mid-/high-frequency energy and does not regenerate, those areas are filled in with collagen formed by the body, which then 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 mid-/high-frequency energy, it is better to replace that approach with ultrasound-guided selective nerve block to induce natural muscle atrophy.

Even if recurrence occurred after a mid-/high-frequency procedure, selective nerve block can still be performed.

When contours develop after calf treatment

1. Incomplete nerve block

After nerve block treatment, the calf line can sometimes become uneven rather than smooth.

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

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

The muscles controlled by blocked nerves atrophy and decrease in volume, while the muscles controlled by unblocked nerves remain the same size as before. This difference in volume between the blocked and unblocked areas creates a bumpy contour.

In the end, this is an incomplete procedure or partial recurrence, so if the nerve branches that were not properly treated are found and accurately treated again, the contour will naturally smooth out.

2. Incomplete muscle ablation with mid-/high-frequency energy

When muscle is ablated with mid-/high-frequency energy, some areas regenerate, some are replaced by scar tissue, and some areas sink to a certain degree.

Reasons for the contours are as follows.

First, some parts of the muscle are necrotized by the heat from the mid-/high-frequency energy and decrease in volume, while other parts do not, creating differences in height and causing contours.

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

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

This is a severe depression caused by muscle necrosis and, in addition, necrosis of the fat layer above the muscle layer.

Third, if scar tissue fills in the area where the muscle was necrotized, the volume in that area remains the same, while areas where scar tissue does not form well lose volume.

This creates contours.

To solve this problem, rather than burning away the muscle again with mid-/high-frequency energy, it is better to replace that approach with ultrasound-guided selective nerve block to induce natural muscle atrophy.

If the entire muscle is made to atrophy uniformly with nerve block treatment, the contours can be softened.

Also, in cases where excessive depression occurs along with fat necrosis, fat grafting can be performed after the muscle has completely atrophied to naturally fill the depressed area.

When the lateral muscle develops relatively more after medial nerve resection, resulting in bow legs

Bow legs caused by lateral muscle development

In cases of nerve resection performed at another hospital by making an incision behind the knee to remove the medial nerve, the lateral muscle often develops compensatorily because it was not treated.

In such cases, only the outer calf bulges out, creating a very unattractive bow-legged appearance.

Nerve resection is a drastic operation that causes complete muscle atrophy, so to avoid possible side effects, the lateral nerve is excluded from the surgical target, which is why bow legs often occur.

If bow legs occur, the lateral nerve can be treated with nerve block rather than surgery to restore balance to the legs, so it is advisable to consider nerve block in such cases.

Tiptoe side effects caused by incorrect post-procedure instructions

Tiptoe posture where the heel does not touch the ground

The tiptoe side effect, in which the heel does not touch the ground, is caused by continuously wearing high heels immediately after the procedure.

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

If the tiptoe side effect occurs, you should walk around the room barefoot as much as possible so that the contracted muscle stretches and lengthens again.

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

After the tiptoe side effect occurs, taking off your shoes can make walking uncomfortable, which may force you to keep wearing high heels.

However, this makes the condition worse.

At the early stage of the tiptoe problem, the best approach is to quickly stop wearing high heels, switch to shoes with as little heel as possible, and keep practicing walking until the muscle lengthens and straightens again.

Usually, if you practice walking in shoes without heels for up to 6 months after the procedure, the tiptoe problem will resolve on its own in most cases.

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

Category	Incisional Muscle Resection	Incisional Nerve Block	Mid-/High-Frequency Muscle Atrophy Procedure	Neurolysis	Ultrasound-Guided Nerve Block
Scar	3 to 4 cm behind the knee	3 to 4 cm behind the knee	No scar	No scar	No scar
Procedure time	1 to 2 hours	1 to 2 hours	40 minutes to 1 hour	30 minutes to 1 hour	30 minutes to 1 hour
Effect and prognosis	May result in bumpy legs due to irregular muscle removal.	Highly effective. Only the medial side is treated, so the lateral side becomes compensatorily thicker. It may appear bow-legged.	Low effectiveness. Little reduction in thickness.	The effect is inconsistent, and medication spread may act on unwanted areas and cause side effects.	Highly effective. The calves become much thinner. Both the medial and lateral sides are treated, sufficiently inducing muscle atrophy.
Discharge and function	Severe swelling, bruising, and pain require 1 to 2 weeks of rest. Walking is very uncomfortable for about a month.	Uncomfortable for about 15 days and difficult to walk. 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 3 to 4 weeks.	Immediate return to daily life is possible, but there is pulling pain for 3 to 4 weeks.

Important notes about calf procedures

There are many calf reduction methods, but not many are appropriate.
The choice of procedure is determined by the shape and cause of the thick legs.
A good procedure is one with no side effects and clear effectiveness.
A method with minimal swelling and pain after the procedure should be selected.
Among muscle atrophy procedures, ultrasound-guided selective nerve block is the most preferred method.

If you have bulging calves, you need muscle atrophy surgery.

I keep saying this in the consultation room, but calf procedures are absolutely not something just anyone can do.

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

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

The same goes for calf reduction surgery: who performs it and how well they do it determines success or failure.

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

The key to nerve block is to find many nerve branches within a short time and perform electrocoagulation firmly to reduce the recurrence rate.

Blocking just one or two nerves poorly will not result in calf reduction.

There are many hospitals that perform calf procedures, but there are almost no hospitals other than ours that perform them properly.

If you receive treatment at a hospital that merely imitates the procedure carelessly, you are likely to be disappointed.

Many people think calf procedures are very easy, but that is absolutely not the case.

You should be careful not to assume that getting the procedure at any hospital will lead to good results.

Also, if calf nerve block is performed properly and according to principles, it is a safe procedure, so you do not need to worry about recurrence, side effects, or aftereffects.

http://www.duhans.com