[DuHan Plastic Surgery Calf Reduction Surgery] - [NO incision! Ultrasound-guided nerve block]

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Ultrasound-guided selective nerve block

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

DUHAN CALFS CLINIC

Ultrasound-guided selective nerve block

DUHAN CALFS CLINIC

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

At our clinic, we use non-incision ultrasound selective nerve block equipment along with ultrasound diagnostic devices to perform procedures with fewer side effects and a significantly lower recurrence rate.

This is a new concept in calf reduction surgery called ultrasound-guided selective nerve block, rather than incision-free gastrocnemius reduction surgery using mid-/high-frequency muscle cauterization, which involves no incision and causes significant swelling and pain.

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

DUHAN CALFS CLINIC

Basic equipment set for calf nerve block

The basic equipment for nerve block uses an integrated device that combines nerve detection and nerve blocking in one, allowing both to be done at once.

When the nerve touches the probe and the muscle responds with movement, the mode is switched so the nerve can be blocked immediately.

The basic nerve-detection device used for nerve block has the disadvantage that it is very difficult and time-consuming to find nerves that are not visible to the eye.

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

If the nerve is not found correctly, the treatment effect decreases, side effects may occur, and there can be various 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 locating the nerve quickly and accurately with ultrasound, multiple nerve branches can be effectively blocked in a short time.

The procedure with the advantages of improved results, fewer side effects, and a significantly lower recurrence rate is non-incision 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 examination tool, is used to quickly and accurately locate nerve branches.

With only the basic equipment, there are limits to finding nerves, and in the case of nerves with many branches or nerves traveling along unexpected routes, they are very difficult to locate.

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

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

Advantages of ultrasound-guided selective nerve block

★ Because nerve branches can be found quickly and accurately, the treatment effect is very high.

★ It significantly reduces procedure time compared to using only the basic equipment.

★ By accurately locating nerve branches, it does not damage tissue in other areas, so side effects are minimal.

★ Because the procedure time is shorter, there is less pain after the procedure and recovery is faster.

★ Because the procedure is performed with accurate nerve detection, the recurrence rate is significantly lower.

Causes of thick calves

The cause of thick calves or calves with clearly visible bulging muscles is muscle and fat, but in most cases, muscle is the main cause.

Anatomy of bulging calves

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

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 the soleus are several other muscle layers distributed in layers.

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

Selective nerve block aims to reduce the volume of the outermost gastrocnemius, which is the cause of bulging calves.

The movement of the leg involves several other muscle layers, including the soleus, in calf and foot movement, and the outer gastrocnemius has no special function. Even without the gastrocnemius, there is no problem with leg function.

Selective nerve block works by blocking the gastrocnemius nerve, which branches from the tibial nerve to the gastrocnemius, thereby eliminating the muscle activity of the gastrocnemius.

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

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.

This method leaves a large scar behind the knee and removes the muscle unevenly, so the appearance is not uniform and it is far from the current cosmetic demand.

(2) Nerve resection through incision

This method finds and cuts the nerve leading to the gastrocnemius through an incision behind the knee. It can only be performed on the medial side, which may lead to bow-legged appearance, and because it requires an incision, it leaves a large scar behind the knee, making it unsuitable for cosmetic purposes.

(3) Muscle reduction surgery using mid-/high-frequency cauterization

This method uses mid-/high-frequency energy to electrically coagulate the gastrocnemius and reduce the muscle.

It is a method of burning away the muscle, and due to the development of scar tissue from burn injuries inside the muscle, the effect of calf muscle reduction surgery 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 of the gastrocnemius

This method injects drugs around the nerve leading to the gastrocnemius muscle, but it is difficult to accurately inject along the nerve pathway, and the effect of nerve block from the drug is insufficient.

The treatment effect is somewhat limited or the recurrence rate is high.

In addition, there may be side effects caused by the drug spreading to unwanted areas.

Disadvantages of conventional surgical methods

○ Nerve resection or muscle resection leaves an unsightly scar behind the knee after surgery, which is far from the patient’s needs.

○ Muscle resection can cause an uneven contour due to irregular removal of muscle and may trigger varicose veins in the legs due to muscle resection.

○ Nerve resection leaves a large scar behind the knee and may cause bow legs as a sequela.

○ Neurolysis has inconsistent effects and may cause side effects from the drug spreading to unwanted areas.

○ In the case of mid-/high-frequency cauterization, scar tissue remains inside, the effect is limited, and swelling and pain are severe.

Non-incision selective nerve block

Concept: Using a nerve blocker, the pathway of the motor nerves that control the calf gastrocnemius is identified, and then only the motor nerves of the gastrocnemius are selectively blocked while minimizing damage to other tissues.

Non-incision selective nerve block - procedure

Non-incision selective nerve block selectively blocks only the branches of the motor nerve through local anesthesia using a special medical device (with functions to find, confirm, and block nerve branches).

Step 1 - Use ultrasound to confirm the location of the nerve and mark it on the skin.
Step 2 - While lying face down, apply a small amount of local anesthesia to the area where the needle will enter.
Step 3 - While confirming with ultrasound, identify the nerve location and insert the needle into the nerve area.
Step 4 - Check with the nerve detector whether the gastrocnemius nerve and the needle are in contact.
Step 5 - Switch to nerve-block mode and generate electrical heat at the needle tip to block nerve transmission and block the nerve. If blocking both the medial and lateral gastrocnemius, a total of four nerve sites are blocked on both sides.
Step 6 - Go home immediately after the procedure is finished.

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

Because the pathway and depth of the nerves differ from person to person, identifying the exact nerve course is an essential step for a successful procedure.

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

The nerve pathway is 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 smaller 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’s legs, the nerve pathways on the left and right sides are different, and the number of branches is often different as well.

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

In the operating room, after sedation and local anesthesia are administered, the nerve-block needle (search needle) is prepared in nerve-search mode.

Insert the nerve-block needle into the locally anesthetized area.

After confirming that it has passed through the fascia, the needle tip is advanced under ultrasound guidance toward the area where the gastrocnemius motor nerve is located.

Rapidly search for the nerve branches with ultrasound and block them.

To improve the treatment effect, the nerve branches must be accurately found and firmly coagulated in a short time so that the nerves do not regenerate and recur.

In addition, by preventing damage to other important tissues besides the nerves to be blocked, the procedure can be performed without side effects.

It is not that difficult to find blood vessels on ultrasound, but nerves can only be identified with significant experience.

Because the diameter of a nerve is only about 1 to 2 mm, it is difficult to search for, and with ordinary ultrasound, finding nerves is nearly impossible.

It is possible with a high-frequency ultrasound of 7.5 MHz or more, and the nerve must be accurately searched from the root to the branches.

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

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

After electrocoagulation is completed, 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 sites are blocked in one muscle, and blocking multiple nerve branches is more effective.

If all four muscles 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 clear 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 should raise your heel to check that the calf bulge does not reappear, then go home.

When leaving, you can wear a compression bandage.

The usefulness of ultrasound diagnostic devices in nerve block procedures

In nerve block procedures, the auxiliary equipment used 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 that need to be found are the main trunk and branches of the nerves leading 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 procedure result becomes.

To effectively find the nerve branches, rather than the conventional method of randomly probing here and there with a search needle, it is better to watch the ultrasound screen, accurately identify the nerve pathway, and advance the search needle directly to the nerve, which improves both accuracy and effectiveness.

Without ultrasound equipment, there are cases in which the procedure is almost impossible, especially when the nerve does not respond well to the search needle.

Only when the nerve responds can electrocoagulation be performed, but if the nerve does not respond even when the search needle touches it, the procedure becomes impossible.

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

The immediate effect after non-incision selective nerve block

After the procedure, when you raise your heel, you can visually confirm immediately that the bulging muscle is no longer tense.

This surgical method can produce satisfactory results with a single procedure, and because there are no scars or uncomfortable post-surgical issues, it is a highly welcomed procedure.

Recovery after non-incision 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 bandage provided by the hospital.

● Immediately after the procedure, you can raise your heel and confirm that the calf does not bulge.

● 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 gradual muscle atrophy, slight pulling and stiffness in the calf for about a month is a normal recovery process.

● A visible reduction in calf thickness 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 procedure effect is permanent.

Precautions after non-incision selective nerve block

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

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

The period until the pulling sensation disappears 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.

Because the muscle shrinks 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 a little at a time can help stretch the muscle, improve the procedure’s effect, and relieve pulling and stiffness sooner.

3. If you continue to wear high heels immediately after the procedure, the muscle length may shorten, which can cause the side effect of standing on tiptoe with the heel not touching the ground, so caution is needed.

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

4. Some clinics with insufficient experience in calf procedures may tell patients to wear high heels after the procedure.

This should absolutely not be done.

Wearing high heels keeps the muscle in a contracted state, so if this continues, it is natural for the muscle to shorten.

If the muscle shortens, the heel will not touch the ground.

This is an uninformed statement that ignores the principle of muscle atrophy, and it can lead to side effects that should not occur, so please keep this in mind.

Before-and-after results of non-incision 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 there is no recurrence.
● The effect must be clear. The result of muscle reduction must be close to 100%.
● There must be no side effects. There should be no side effects by preventing damage to other tissues.
● Daily life must be possible immediately. Bruising, swelling, and pain must be minimized so that daily life is possible right after the procedure.

Important key to successful nerve block procedures

The key to success in nerve block procedures is how accurately and quickly the nerve branches can be found.

Because the procedure is performed without an incision, it is necessary to quickly find the invisible nerve branches and block as many branches as possible to achieve a satisfactory muscle-reduction effect.

The biggest drawback 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 travel along the normal pathway. In such cases, the practitioner must probe here and there with the search needle to painfully find the passing nerve branches.

Therefore, if the nerve branches cannot be found properly, the procedure is not performed correctly, and the effect may be very poor or even almost nonexistent.

To achieve the desired muscle-reduction effect, as many nerve branches as possible must be found and coagulated within a short time. This requires the practitioner to have extensive experience and know-how, and the procedure can only be improved by using ultrasound imaging equipment together.

Causes of nerve block failure

Inexperienced nerve-block procedure experience
A constitution in which the nerve does not respond well to the search needle
A careless procedure that blocks only one or two proximal sites without blocking many proximal and distal nerve branches
Cases where the nerve deviates from its normal pathway and cannot be found with the search needle
Cases where the nerve leading to the gastrocnemius is not blocked and instead the nerve leading to the deep soleus muscle is blocked, or the sural nerve is blocked
Cases where the gastrocnemius nerve is blocked too close to the knee crease, damaging the tibial nerve

In nerve block procedures, the greatest key to success is accurately locating the nerve and blocking as many branches as possible.

If the nerve is not found properly, the procedure will have no effect or will quickly recur.

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

Side effects of failed nerve block procedures

Pain in the heel or reduced sensation due to damage to the tibial nerve
Weakness in the leg due to damage to the nerve leading to the soleus
Uneven calf contours due to partial nerve block or recurrence

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

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

If problems occur after calf reduction surgery at another hospital, guidance for treatment at our clinic

① In cases of recurrence where the calf bulge returns

● Recurrence due to nerve regeneration after nerve block

All tissues regenerate when injured.

Nerves are also highly regenerative tissues, so if the procedure is incomplete, the nerves will regenerate.

Nerve regeneration means recurrence.

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

The reasons are:

First, dense scar tissue forms around the previously treated nerve and surrounds it like a protective barrier, so the nerve does not respond to the search needle and cannot be found with the conventional method.

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

The coagulation temperature does not exceed 90 degrees at most, so heat at around 90 degrees has difficulty penetrating the dense scar tissue layer to block the nerve.

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

In recurrent cases, retreatment is almost impossible without ultrasound imaging.

Also, the found nerve must be blocked by letting the search needle penetrate the scar tissue layer and contact the nerve as closely as possible.

The coagulation time must also be longer.

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

All tissues regenerate when injured.

Muscle tissue is also highly regenerative, so if the procedure is incomplete, the muscle will regenerate again.

Also, the parts that cannot regenerate are filled in by hard scar tissue, which reduces the effectiveness of volume reduction.

Reasons for recurrence:

First, even if muscle is partially damaged and necrotic due to mid-/high-frequency energy, other muscle fiber cells replace it and regenerate.

Therefore, with most procedures, the muscle cells will almost always regenerate, so the effect is inevitably reduced.

Second, even if there are parts of the muscle tissue that are necrotic from the heat of mid-/high-frequency energy and do not regenerate, these parts are filled by collagen formed within the tissue, which turns into firm 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 necessary to replace it with ultrasound-guided selective nerve block to naturally induce muscle atrophy.

Selective nerve block is possible even if recurrence occurs after a mid-/high-frequency procedure.

② In cases where contours develop in the treated calf

● Incomplete nerve block

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

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

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

The muscle controlled by the blocked nerves atrophies and decreases in volume, but the muscle controlled by unblocked nerves remains the same size, so the difference in muscle volume between the blocked and unblocked areas causes an uneven contour.

Ultimately, this is a case of incomplete treatment or partial recurrence, so if the nerve branches that were not properly treated are found and treated accurately again, the contour will naturally disappear.

● Incomplete muscle cauterization with mid-/high-frequency energy

When muscle is cauterized with mid-/high-frequency energy, some areas regenerate, some are replaced by scar tissue, and some areas may become somewhat sunken.

Reasons for contour irregularity:

First, some parts of the muscle necrose due to the heat of mid-/high-frequency energy and shrink in volume, while other parts do not, creating differences in height and resulting in contour irregularity.

In other words, the treatment effect is not uniform and appears in patches.

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

This is a severe sunken area caused by muscle necrosis and, along with the complications of muscle necrosis, necrosis may also affect the fat layer above the muscle.

Third, if scar tissue fills the area where the muscle has necrosed, the area with scar tissue remains the same in volume, while areas where scar tissue does not form well will have reduced volume.

This causes contour irregularity.

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

If the whole muscle atrophies evenly through nerve block, the contour irregularity can be reduced.

Also, if excessive sinking occurs due to accompanying fat necrosis, fat grafting can be performed after the muscle has fully atrophied to naturally fill the sunken area.

③ In cases where the lateral muscle developed relatively 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 in the knee crease and removing the medial nerve, the lateral muscle often develops compensatorily because it was not treated.

In such cases, only the outer side of the calf becomes bulged, creating very unsightly bow legs.

Because nerve resection is an aggressive surgery that causes complete muscle atrophy, the lateral nerve is excluded from the surgical target out of concern for side effects. As a result, bow legs often occur.

If bow legs develop, balance can be restored by treating the lateral nerve with nerve block rather than surgery, so it is advisable to consider nerve block in such cases.

④ Side effect of standing on tiptoe due to incorrect instructions after the procedure

● Tiptoe posture where the heel does not touch the ground

The side effect of standing on tiptoe with the heel not touching the ground is caused by wearing high heels continuously starting immediately after the procedure.

This is absolutely not a side effect caused by a poorly performed procedure.

If this side effect occurs, you should walk barefoot around the room as much as possible so that the shortened muscle is stretched and lengthened again.

Walking barefoot indoors or wearing shoes with almost no heel outdoors will allow natural stretching and help the muscle relax.

If the tiptoe side effect occurs and you take off your shoes, walking may become uncomfortable, leading you to keep wearing high heels.

However, this will only make the condition worse.

In 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 stretches and straightens again.

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

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

Category	Incision-based muscle resection	Incision-based nerve block	Mid-/high-frequency muscle reduction	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	Uneven legs may result from irregular removal of muscle.	High effect. Only the medial side is treated, so the lateral side becomes compensatorily thicker. It may appear bowed into an O shape.	Low effect. Only a small reduction in thickness.	The effect is inconsistent, and drug spread to unwanted areas may cause side effects.	High effect. The calves become much thinner. Both 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 inconvenient for about a month.	Uncomfortable and difficult to walk for about 15 days. Pulling pain for about a month.	Severe swelling and pain make walking inconvenient 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.

Notes on the procedure

There are many methods for calf reduction surgery, but not many are suitable.
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 a clear result.
Choose a method that causes as little swelling and pain as possible after the procedure.
Among muscle-reduction procedures, ultrasound-guided selective nerve block is the most preferred method.

​http://www.duhans.com

If there is a bulging calf, muscle-reduction surgery should be performed.

I say this over and over in consultations, 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 performed well.

The same applies to calf reduction surgery: who performs it and how well it is done determine success or failure.

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

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

perform electrocoagulation firmly to reduce the recurrence rate.

Blocking only one or two nerves in a rough manner does not lead to calf reduction.

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

If you undergo the procedure at a clinic that merely imitates the technique, you are likely to be disappointed.

People often think calf procedures are very easy, but that is absolutely not the case.

Many people think that because a procedure was 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 principles,

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

​http://www.calfs.co.kr