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What are the causes of failure in calf contouring?

Let’s look at cases where a calf procedure did not produce satisfactory results.

The surgeon’s experience and skill in calf contouring are insufficient

As with all plastic surgery-related procedures, the surgeon’s skill and experience are the most important factors.

Even if good equipment is available, if the operating surgeon lacks skill and experience, unsatisfactory results can occur, leading to side effects.

Choosing the wrong calf procedure method

The foundation of calf contouring is muscle recession surgery.

The key issue is how effectively the gastrocnemius muscle, which causes bulky calves, can be reduced without side effects.

There are various methods for calf contouring, but most have both advantages and many disadvantages.

The principle of calf contouring is to choose a method with high effectiveness and no recurrence, which is very important.

If a procedure is performed from the start with a method that has no effect, or with a method that has a high recurrence rate, the results will not be satisfactory.

Only by understanding the advantages and disadvantages of the procedure can side effects and dissatisfaction be avoided.

What are the procedure methods for calf muscle recession?

1. Muscle resection

A method of making an incision of about 4 cm behind the knee and removing the gastrocnemius muscle with surgical instruments

2. Nerve resection

A method of making an incision of about 4 cm behind the knee and resecting the motor nerve leading to the medial gastrocnemius

3. Nerve lysis

A method of finding the nerve with a nerve locator and injecting phenol solution into the nerve to dissolve it

4. Botox procedure

A method of using Botox to block neurotransmitters at the nerve terminals and cause muscle atrophy

5. Medium- to high-frequency muscle cauterization

A method of burning and necrosing the gastrocnemius, which causes bulky calves, using a medium- to high-frequency cauterization device

6. Selective nerve block

A method of finding the gastrocnemius motor nerve with a nerve locator and electrically coagulating the nerve

7. Ultrasound-guided selective nerve block

A method of accurately identifying the nerve location with ultrasound and a nerve locator, then electrically coagulating it ​

What are the problems with the methods used for calf muscle recession?

Calf muscle resection

Scarring and contour irregularity of the calf

This method involves making a 4 to 6 cm incision behind the knee and removing the gastrocnemius itself with surgical instruments.

A large scar remains behind the knee, and because the muscle is resected irregularly, the shape is not good. Swelling and pain are severe, making it difficult to resume normal life immediately.

In other words, it does not allow a quick return to social life after the procedure, and because it can leave a large scar and cause contour irregularity in the calf, it is hardly suitable for cosmetic purposes.

It is now a method that is rarely used.

Calf nerve resection

Scarring and bow legs

This method involves making a 4 to 6 cm incision behind the knee, finding and resecting the medial motor nerve leading to the gastrocnemius. It leaves a large scar behind the knee, and because only the medial nerve is resected, the lateral muscle may become relatively more developed, which can result in bow legs.

Because it leaves a scar and can cause bow legs, it must be approached with great caution.

Calf nerve lysis

Insufficient effect and frequent recurrence

This method involves searching for the nerve with a nerve locator, then injecting medication (phenol) around the nerve to dissolve it.

Because the nerve search itself is not done properly, the procedure is not accurate, and after phenol is injected, the expectation is that the nerve will dissolve and disappear. However, the effect is often below expectations or nearly nonexistent.

As the phenol spreads, there is a possibility of damaging important nerves or blood vessels.

In other words, caution is needed because insufficient effect, recurrence rate, and side effects from medication spread may occur.​

Calf Botox procedure

Insufficient results and recurrence

This is a method that temporarily paralyzes the gastrocnemius with Botox to cause atrophy. However, the effect is weak, the cost is high, and it is a time-limited method that recurs after several months, so it is not a recommended method for calf recession surgery.

Botox is mainly effective when used for chewing muscles that cause a square jaw, but using it on calf muscles, which are tens of times larger, is an excessive approach, so it is rarely used.

Medium- to high-frequency calf muscle cauterization

Insufficient results, severe swelling and pain

Medium- to high-frequency muscle cauterization is a method of burning and necrosing the gastrocnemius with a medium- to high-frequency cauterization device. Because the muscle itself is damaged, it is a burdensome procedure, and side effects such as damage to tissues other than muscle may also occur.

Because scar tissue is formed as the muscle necroses, it can cause various problems such as insufficient results, recurrence, contour irregularity, and sensory disturbance, so caution is needed.

In other words, the effect is reduced, and contour irregularity and recurrence occur frequently.

Calf selective nerve block

Insufficient results and recurrence

The principle is to block the gastrocnemius nerve branching from the tibial nerve so that the gastrocnemius loses mobility.

Muscles whose nerves are blocked cannot contract and relax, so they lose mobility. This method uses the principle that the muscle atrophies over time.

However, it is very difficult to locate invisible nerves by probing them with a locator, and the biggest problem is that if the nerve is not found properly or if the located nerve is incompletely blocked, the effect is reduced and recurrence is common.

Non-incisional ultrasound-guided selective nerve block for calves

Requires expensive equipment and accumulated experience and skill

This method uses both the nerve locator, which is the basic equipment for nerve block procedures, and an ultrasound imaging device to accurately find and block the nerve.

A disadvantage is that finding invisible nerves is tricky and time-consuming.

Also, if the nerve deviates from its normal path, finding it becomes very difficult, and procedures are often not performed properly.

If the nerve cannot be found properly, the effect is reduced, side effects may occur, and the recurrence rate is high.

What makes nerve search faster and more accurate is an ultrasound imaging device equipped with a high-frequency probe.

By confirming with ultrasound while searching for the nerve, it becomes possible to accurately locate it and effectively block many nerve branches within a short time.

This is a non-incisional ultrasound-guided selective nerve block, which has the advantage of increasing procedural effectiveness and significantly lowering recurrence without side effects.

It is the most advanced method of muscle recession surgery, but it requires expensive equipment and a great deal of procedural experience and skill.

What are the advantages of ultrasound-guided selective nerve block?

It can quickly and accurately locate nerve branches, so the procedural effect is very high.
It significantly shortens procedure time compared to using only basic equipment.
By accurately finding the nerve branches, it does not damage tissues in other areas, so side effects do not occur.
Because the procedure time is shortened, there is less pain after the procedure and recovery is faster.
Because the procedure is performed through accurate nerve search, the recurrence rate is significantly lower.

What are the problems with general selective nerve block?

■ Because invisible nerve branches must be found, it is technically difficult.

■ If the nerve branches are not found properly, the effect is greatly reduced or recurrence is likely.

■ In inexperienced hands, nerves or blood vessels other than the gastrocnemius motor nerve may be damaged.

In general, performing a procedure by finding invisible nerves with a basic nerve locator often fails to locate the nerves properly, so in many cases there is little effect from the start, or it seems effective at first but then recurs several months later.

A poorly performed nerve block can produce results worse than not doing it at all, so caution is needed.

Therefore, for selective nerve block to produce good results, it must not recur and the effect must be close to 100%, and unless the procedure is performed by directly finding the nerve with a visual device such as ultrasound imaging and confirming it visually, it is difficult to achieve good results.

What are the four principles of calf recession surgery?

No recurrence, definite effect, no side effects, immediate return to daily life

​★ There must be no recurrence.​

The most important thing is to ensure that recurrence does not occur through proper treatment.

★ The effect must be definite.​

The result of muscle recession must be reliable and close to 100%.

★ There must be no side effects.

There should be no side effects so that other tissues are not damaged.

★ It must be possible to return to daily life immediately.

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

What is the key to successful calf nerve block?

The core of successful nerve block procedures is how accurately and how quickly the nerve branches are found.

Because this is a non-incisional procedure, invisible nerve branches must be found quickly so that as many branches as possible can be blocked, allowing a satisfactory muscle recession effect.

The biggest limitation of nerve block procedures is that the basic search device’s probing needle cannot locate nerves quickly.

This is because, depending on the individual, nerves may not respond properly to the probing needle, and some nerves do not travel along their normal path.

In such cases, the probing needle has to be used to poke around here and there to laboriously find the passing nerve branches.

Therefore, if the nerve branches cannot be found properly, the procedure is not carried out correctly, the effect is reduced, or in some cases the procedure shows almost no effect at all.

To achieve the desired muscle recession effect, it is necessary to find and coagulate as many nerve branches as possible within a short time, so the procedure requires the operator’s extensive experience and know-how.

Also, using an ultrasound imaging device together is necessary to increase the procedural effect.

What are the causes of failure in calf nerve block?

① When the operating surgeon is inexperienced in nerve block procedures
② When the patient has a constitution in which the nerves do not respond well to the search probe
③ When only one or two proximal areas are blocked and many proximal and distal nerve branches are not blocked
④ When nerve branches cannot be found with the probe because the nerves deviate from their normal path due to anatomical variation
⑤ When the nerves leading to the gastrocnemius are not blocked and instead the nerves leading to the deep soleus muscle are blocked, or the sural nerve is blocked
⑥ When the gastrocnemius nerve is blocked too close to the knee crease, causing damage to the tibial nerve as well

★ In nerve block procedures, the key to success is to accurately find the nerve and block as many branches as possible.

If the nerves are not found properly, the effect is minimal or recurrence occurs within a short time.

For this reason, using an ultrasound imaging diagnostic device together allows the nerve’s course to be precisely identified during the procedure, maximizing the effect.

What are the side effects of calf nerve block?

① Pain or decreased sensation in the heel due to damage to the tibial nerve
② Weakness in the leg due to damage to the nerve leading to the soleus muscle
③ Bulging or uneven contour in the calf due to partial nerve block or recurrence

★ Side effects of nerve block procedures occur when the exact location of the nerve cannot be found.

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

When problems occur after calf recession surgery at another hospital

1. In cases of recurrence where bulges return in the muscle

◆ Recurrence due to nerve regeneration after nerve block

All tissues regenerate when damaged.

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

Nerve regeneration means recurrence.

If recurrence occurs, the nerve block must be done again, but repeat surgery is much more complicated and difficult 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 probing needle, making it almost impossible to find the nerve using conventional methods.

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

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

To solve this problem, the nerve must be identified visually and its exact position found, and for that, the help of an ultrasound imaging device is essential.

If recurrence has occurred, re-treatment is almost impossible without the help of ultrasound imaging.

Also, the found nerve must be coagulated by allowing the probing needle to penetrate the scar tissue and make close contact with the nerve as much as possible.

The coagulation time must also be longer.

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

All tissues regenerate when damaged.

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

In addition, areas that cannot regenerate are filled in with hard scar tissue, reducing the effect of volume reduction.

The reasons for recurrence are:

First, even if some muscle fibers are damaged and necrosed by medium- to high-frequency treatment, other muscle fibers can replace them and regenerate.

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

Second, even if some parts of the muscle tissue necrose due to heat from the medium- to high-frequency treatment and do not regenerate, those areas are filled in with collagen formed within 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, instead of burning away the muscle again with medium- to high-frequency treatment, it should be replaced with non-incisional ultrasound-guided selective nerve block to induce natural muscle atrophy.

Even if recurrence occurs after a medium- to high-frequency procedure, selective nerve block can still be performed.

2. When contour irregularity occurs in the treated calf

◆ Incomplete nerve block

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

This is 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.

Muscles controlled by blocked nerves atrophy and their volume decreases, but muscles controlled by unblocked nerves remain the same size as before, so the blocked and unblocked areas become uneven because of differences in muscle volume.

Ultimately, this is an incomplete procedure or partial recurrence, so contour irregularity can naturally disappear if the nerve branches that were not properly treated are found and accurately treated again.

◆ Incomplete muscle treatment with medium- to high-frequency procedures

When muscle is cauterized with medium- to high-frequency treatment, some parts of the muscle regenerate, some are replaced by scar tissue, or some degree of sunken contour may occur.

Reasons for contour irregularity:

First, some parts of the muscle are necrosed by the heat of the medium- to high-frequency treatment and lose volume, while other parts do not, creating height differences and resulting in contour irregularity.

In other words, the procedural effect is not uniform, and the effect appears only in certain spots.

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

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

Third, if scar tissue fills in the place where the muscle necrosed, the area where scar tissue forms retains its volume, while the areas where scar tissue does not form well lose volume.

This causes contour irregularity.

To solve this problem, instead of burning away the muscle again with medium- to high-frequency treatment, it should be replaced with non-incisional ultrasound-guided selective nerve block to induce natural muscle atrophy.

If the nerve block causes overall uniform muscle atrophy, contour irregularity may be reduced.

Also, if excessive depression occurs along with fat necrosis, fat grafting can be performed after the muscle has fully receded to naturally fill the depressed area.

3. When bow legs develop because the lateral muscle becomes relatively more developed after medial nerve resection

◆ Bow legs caused by lateral muscle development

In cases of nerve resection at another hospital, where an incision is made behind the knee and the medial nerve is resected, the lateral muscle often develops compensatorily because it is not operated on.

In such cases, only the outer side of the calf protrudes, creating very unattractive bow legs.

Nerve resection is an aggressive surgery that fully atrophies the muscle, so the lateral nerve is excluded from surgery out of concern for side effects. As a result, the problem of bow legs often occurs.

If bow legs develop, the lateral nerve can be treated with nerve block rather than surgery to restore balance to the leg, so it is a good idea to consider nerve block in such cases.

4. Side effects of tiptoe walking caused by incorrect post-procedure instructions

◆ Tiptoe walking where the heel does not touch the ground

The side effect of tiptoe walking, where the heel does not touch the ground, is caused by wearing high heels continuously from immediately after the procedure.

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

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

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

After the tiptoe-walking side effect appears, if you take off your shoes, walking may become uncomfortable and you may end up continuing to wear high heels.

However, this makes the symptoms worse.

At the early stage of tiptoe-walking problems, the best approach is to quickly stop wearing high heels and switch to shoes with as little heel as possible, then keep practicing walking until the muscle stretches back and straightens.

Usually, if you practice walking in flat shoes within 6 months after the procedure, the tiptoe-walking problem can resolve on its own in most cases.

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