Thick muscular legs are a common aesthetic problem for Asian women. The Chinese use a term “radish-like leg” to describe the problem. Comparing with Caucasians, Asian women are relatively shorter. Women with "radish-like legs" look shorter or more obese than they really are because of their thick legs. They are embarrassed to show their legs even in the summer time. Many men feel that thin legs are an important point of attraction second only to the breasts. The cause of "radish-like legs" in Asians is more often calf muscle hypertrophy(excessive development), in stead of fat accumulation. This is different from enlarged abdomen, buttocks, and thigh, which is often due to increased fat accumulation and can therefore be effectively treated with liposuction. However, liposuction is ineffective to deal with calf muscle hypertrophy because the problem is in the muscle, not fat.
The first medical report on the treatment of calf muscle hypertrophy was written by Dr. Lemperle in Germany . The gastrocnemius was totally excised resulting in a long scar on the posterior side of calf . Doctor and Professor Ing Gon Kim in Seoul, South Korea is a pioneer of calf reduction using small incisions. He published his result in 2000. He excised part of the gastrocnemius muscle through incision on the posterior side of knee joint 2 cm in length in each gastrocnemius head. His paper described 60 patients between 1994 to 1998. In 1999, Dr. Lih-Ren Jong, director of Lih-Ren Cosmetic Clinic, studied with Professor Kim and modified Dr. Kim's technique further.
An overview of the anatomy and function of the calf muscles and the various techniques to treat calf muscle hypertrophy is presented below.
Anatomy and function of Gastrocnemius
All of the leg muscles of women with radish-like legs are hypertrophic. But the treatment of radish-like legs focus on Muscle Gastrocnemius because sacrificing Gastrocnemius do not lead to disability. Gastrocnemius is located on the superficial part of posterior calf . It is composed of a medial(medial gastrocnemius,MG) and lateral head( lateral gastrocnemius, LG). Deep to the gastrocnemius is the soleus muscle(Sol). All of these muscles share a common insertion (the Achilles tendon). The Achilles tendon is common seen and felt as the strong band that points toward the heel of the foot.
The gastrocnemius muscles participate in flexion of the knee joint and plantar flexion of the ankle. Sol serves only in ankle plantar flexion. All of these muscles play an important role in standing , walking, running or jumping.
In reconstructive surgery, gastrocnemius can be sacrificed and used to fill the defect around knee joint. There is no obvious functional disturbance after operation because Sol function is similar to gastrocnemius. But the operation consideration is different when women come for cosmetic reason.
Functionally muscle cells can be divided into three types: FF cells (Fast-twitch, Fatigable),FR cells (Fast-twitch, fatigable-Resistant) and S (Slow-twitch and resistant to fatigue ) cells. Most type FF cells produce large force output than type FR cells, while type S cells have uniformly small force outputs. Most of the muscle cells in MG are FF cells, but Most of the muscle cells in Sol are S cells. The attached picture shows that different cell types are recruited in different actions. In standing , the S cells in MG (including S cells in Sol ) are recruited. In walking and running, FR cells are recruited. The large population of strong but fatigue-sensitive type FF cells in MG are required for movements that demand near-maximum force output, such as gallop or jump. In another words, Sol plays a major role in standing. MG plays a major role in gallop and jump. Sol and Gastrocnemius are not functionally identical . After calf reduction operation, the function of MG will be lost partially or totally. Sol will get hypertrophic in some degree (compensatory hypertrophy) to replace the lost function of Gastrocnemius. In fact, the compensatory Sol can not replace all of the lost function of Gastrocnemius. If you are active in taking exercise involving legs, after operation your score will be affected more or less. Additionally the compensatory Sol will affect the final appearance of legs. Calf reduction surgery is not indicated for women who are active in taking exercise.The loading of weight on legs are higher for obese people. The leg muscles will get thicker to provide the necessary power of movement. Our recommendation is that it is better to lose weight before calf reduction surgery.
Treatment of calf muscle hypertrophy
What is the ideal size of calves? The analysis of ideal size of legs focus on Oriental women with average 162cm and 49 Kg weight showed that the length of legs for women with ideal shape of legs is 43 cm. The circumference of calf at its widest part is 32 cm.
Calf reduction should consider not only the postoperative size but also the shape and function . There are two ways to reduce the size of legs ; one is non-surgical (Botox injection ) and surgical ( i.e. selective neurectomy, total excision of Gastrocnemius and partial excision of Gastrocnemius). After Botox injection, the injected muscle will shrink in size. In Asian, it is a common practice to inject the Botox into the masseter muscle to shrink the muscle. The masseter muscle is located on side of cheek and assists in mastication. After injection,the face will change from square to a more oval shape. The women are quite satisfied with the post-injection result. It will last 6 to 9 months. But gastrocnemius is a sizable muscle. It needs high dose of Botox to achieve the desired result. It costs a lot but lasts less than 6 months.
above shown a case one month after Botox injection into gastrocnemius. The before circumference of calf was 33cm. It was reduced to 31cm after Botox injection.
There are two surgical ways to reduce the calves. One will sacrifice all of the function of Gastrocnemius ( Selective neurectomy and total excision of Gastrocnemius). The other is partial excision of Gastrocnemius.
Selective neurectomy The meaning of selective neurectomy is to cut the nerve which controls the MG. After neurectomy, the surgeon expects MG to shrink in size. Some of surgeons will also cut the nerve of LG. The surgeon should be careful in doing the procedure, because the nerve of LG and nerve of Sol is very close. The nerve of Sol should not be cut accidentally. The advantage of selective neurectomy includes a more quick procedure, a less invasive and a quicker recovery time. Some of the patients are satisfied with the postoperative result. The major disadvantage of neurectomy is that the amount of volume reduction following neurectomy is unpredictable, making the result of the technique suboptimal.
Above was an example of a patient following neurectomy. MG bulge improved when she stand on her toes 3 months after the operation. However, the patient felt that the results were inadequate since her calf circumference reduced by only 1 cm. She noted that the muscle(MG) bulged out agin 4 years after neurectomy.
The other disadvantage of neurectomy is compensatory hypertrophy of the remaining calf muscles which has been mentioned before.
The above case underwent neurectomy in other clinic three years ago. After operation, the MG shunk in size. But because of compensatory hypertrophy of LG and Sol, the calf bulged out in lateral side(hypertrophy of Sol) and lateral-posterior side(hypertrophy of LG).
Above was a patient who underwent neurectomy one year ago. The MG shrunk in size, but after operation there was noticeable depression ( arrow point) . The depression is the junction between the shrunk MG and the hypertrophic Sol.
Above illustrated is the case report by Korean Doctors in 2006. The patient underwent selective neurectomy for calf reduction one and half years ago. Her right MG shrunk in size but unfortunately the right medial Sol became larger( compensatory hypertrophy). You can see the muscular bulge in the lower half of right calf ( big arrow), especially when she stood on her toes. The other complication noted after the surgery was that the nerve to the left Sol was accidentally cut. You can still see the bulge in the left upper calf ( small arrow) which is the intact left MG. Because Sol is a major muscle in the calf, her left leg was easily fatigued when she walked.
In 2000, Korean Doctor Suh reported 15 complicated cases he experienced in 7th International Congress of Oriental Aesthetic Plastic Surgery . They were: remained or recurred hypertrophy, calf bowing due to compensatory hypertrophy of Sol or LG, inadequate decrease of circumference, posterior tibial nerve irritation , gait disturbance(due to accidently cut the nerve controlling LG or Sol) and hypertrophic scar.
Below illustrations showed the effect of neurectomy on the cross section of legs.
The above illustrations showed that how MG shrunk in size was unpredictable.
The above illustrations showed that after neurectomy of MG the compensatory hypertrophy of LG and Sol will change the contour of legs.
The above illustrations showed that after neurectomy of MG and LG the legs would look broader due to the compensatory hypertrophy of Sol.
Total excision of Gastrocnemius
Intuitively the legs will get smallest after total excision of Gastrocnemius. But we emphasize that contour is more important than size. Comparing with leg muscles of women with slim legs, the leg muscles of women with radish-like legs are thicker.Therefore surgeons have to do is to thin the muscles, in stead of taking all of them away. The contour of legs after total excision of Gastocnemius will be unnatural.
The circumference of legs of left woman is 38cm. The MG(between two arrows) thickness,measured by ultrsound, is 2 cm. The circumference of right woman is 32cm. The MG thickness is 1.6 cm. If the left woman wants to slim her legs to ideal size, similar to right woman, is it necessary to excise all of her MG ?
If the woman with big breasts, like the left picture, wants to reduce her breasts, after operation what kind of breasts do she prefer? Middle picture or right picture? Analogously the leg muscles of women with radish-like legs are thicker than women with slim legs. Surgeons have to do is to thin them, rather than to excise them.
The legs are composed with many muscles. Could you image the contour of legs if you loss one or two major leg muscles?
Operation method: The incisions were made on the posterior side of knee. The wound should be longer ( around 5 cm) to take a whole pierce of MG out. The LG could be excised in the same time. The other wound was made in the center portion of posterior calf to cut the lower end of Gastrocnemius . The method sacrifices whole function of Gastrocnemius. The other calf muscles will get compensatory hypertrophy, similar to selective neurectomy.
Above illustrated is a case after total MG excision. Although a reduction of calf volume is achieved with this technique, concavity inferior to the knee at the medial aspect of the upper calf after surgery was noted. The result is suboptimal aesthetically.
The above case underwent total excision of MG 4 years age at the other clinic. After operation, there is a obvious depression on her medial legs. Becaue of compensatory hypertrophy, the legs look broader and 0 shape.
The below left picture demenstrated how compensatory hypertrophic Sol affected leg shape. When Sol got hypertrophic after surgery, there will be a bulge in medial and lower legs when you looked down. Below right picture is a normal leg for comparision.
Below illustrations showed effect of total excison of Gastrocnemius on contour of leg.
After total excision of MG, the LG and Sol will bulge out due to compensatory hypertrophy.
After total excision of MG and LG, the hypertrophic Sol affect the contour of legs ( anterior-posterior distance of legs shorter and medial-lateral distance longer).
Partial excision of muscles ( muscle sculpture)
The basic principle of the treatment is to selectively excise part of muscles(MG,LG and Sol) to thin the muscles. Most part of the muscles is preserved. The muscles are excised pierce by pierce till the ideal shape is achieved. The surgeon sculpts the leg similar to an artist sculpting a piece of art. This is why this procedure is named"muscle sculpture”. The average weight of MG is 250 gm. Depending on the severity of calf muscle hypertrophy, 30 to 120 gm of muscle of MG is excised to achieve the ideal shape of medial calf. The study of Professor Kim showed that ankle power returns to its preoperative level at 6 months to one year after operation.
Partial excised muscles still keep their function?
The preoperative circumference of the below case was 33cm. After partial excision of MG, LG and Sol, the circumference reduced to 29.5cm, measured two and half months after operation. The preoperative thickness of MG was 19mm(the muscle between two white arrows is MG). After sugery, it was reduced to 11 mm. When muscles contract, the fiber angle(the angle between two yellow lines) become greater. The fiber angle of relaxed MG after surgery was 12 degree. The fiber angle of contracted MG( when patient stands on toes) after sugery was 20 degree. It means that the MG muscle was still functioning after surgery. It is the reason why compensatory hypertrophy is less likely to occur after muscle sculpturing (partial excision of muscles).
Muscle sculpture of calf muscles
The basic principle of muscle sculpture can be used not only in MG, but also in other calf muscles, such as LG or Sol. The MG is related with the curvature of medial calf. The MG and LG are related with the curvature of post calf. The Sol is related with the curvature of lateral calf.The Sol can be partial excised , leading without sequelae. Using concept of muscle sculpture, we can sculpt a part of or the entire calf. Selective neurectomy or total excision concept can not use on Sol, because the function of Sol can not be sacrificed. If the fat of the calf or thigh is too thick , we can also perform liposuction at the same time to sculpt the entire lower limbs.
Below illustration showed how muscle scupture worked.
When MG was partially excised but LG was not treated, LG would seem to bulge out. Usually we will recommend patients to treat MG, LG and Sol at the same time.
After partial excision of MG, LG and Sol, the legs can be reduced to better shape and size.
Procedure of muscle sculpture
The operation is usually done under spinal anesthesia. The wounds ( about 1.5cm in length)are located on the posterior side of knee. It takes about 2 to 3 hours to do the operation.We will insert drains into the wounds and they will be removed 1-2 days later to prevent the occurrence of hematoma (blood accumulated under the leg skin).
Postoperative Care:
1)Wearing high-heel will be more comfortable (about 2 inches high with broad base) in the early period after surgery. After recovery patients can wear flat shoes. Because we experienced one case whose leg muscles got a little bit thicker after long term wearing of high-heel, we recommend patients to decrease the time of wearing high-heel after recovery from surgery.
2)Compression stockings can decrease leg swelling. We recommend patients to wear compression stockings for three to six months.
3)We recommend patients to take bed rest with legs elevated for 5 days after operation. After 5 days , patients can resume their daily activity gradually. We recommend patients not to walk too much in the first two weeks. We will appoint with patients the day back to clinic for checking the existence of hematoma . Hematoma will be aspirated with needle.
4)Rehabilitation program includes 1) keep knee straight. 2) ankle range of motion.
Please follow physician instruction to do ankle exercise.
5)After drain tubes are removed, the wounds will close spontaneously in two or three days. After wounds are healed, we recommend patients to tape the scars. The scars will take more than half an year to fade out.
Possible complications:
1)Numbness on lateral side of foot. The sensory nerve of lateral foot may be injured in operation, but numbness usually is temporary.
2)Irregular surface on legs when the surgery left with irregular surface on muscles.
3)Asymmetric. Usually there will be some asymmetric in size of legs before operation. Probably there will be some asymmetric (but not obvious) between the sizes of legs.
4)We never experience cases who can not walk after recovery from surgery.
5)Compensatory hypertrophy is not a big issue for patients treated with partial excision of leg muscles, comparing with neurectomy or total excision of muscles. If patients are active in taking exercise involving legs, compensatory hypertrophy will affect the final contour of legs more or less .
Dr. Jong developed instruments to facilitate the operation. Under endoscope guide, the chance of first two complications is reduced. The attached picture show endoscope assistance to locate the nerve of lateral foot.
Cases report
Case 1 This is the first calf reduction case done in our clinic in 1997. The patient had poliomyelitis which resulted in shrinkage of her right leg. To compensate for the lost function of right leg, her left calf muscles got larger(hypertrophic). To make her legs symmetric, silicone prothesis was implanted into her right leg and the hypertrophic calf muscles of her left leg were partially excised. The patient was quite satisfied with the final result.
Case 2, After excision of MG 30 gm, the circumference of calf decreased from 33 cm to 31 cm. The legs look slender after operation. When she stands on her toes, the MG ( the circle on the third picture) looked smaller.
Following is the movie taken 6 months after operation movie
She walks and jumps normally. The scar will take time to fade away.
Case 3, After partial excision of her MG ( 200 gm muscle of both side of MG was excised) and liposuction of calf, the circumference of calf decreased from 38 to 34 cm two monts after operation.
Case 4, The case underwent muscle sculpture and liposuction of her legs. 240 gm muscle of both side of MG and 130gm muscle of both sides of LG and Sol were excised. The circumference of calf decreased from 38 to 34 cm two months after operation.
Case 5, The patient underwent neuectomy half an year ago at another clinic. She was not satisfied with the result. The circumference of calf was 33.5cm(left-handed picture). She visited our clinic. After undergoing muscle sculputre surgery, she is happy with the result. The calves reduce to 31cm(right-handed picture).
Case 6,Above shown a case after liposuction of calves and total calf muscle sculputre. The amount of excised MG,LG and Sol was 160gm totally. The extracted fat was 400c.c. The before calf circumference is 40.5 cm. It was reduced to 35 cm. after operation.
Case 7, The above case underwent partial excision of her MG. The circumference of her legs before operation was 36cm. The legs reduced to 33cm after operation. The above picture was taken after two years after operation.
Case 8, The circumference of legs of the above case was 36cm before operation( left picture).The operation procedure was partial excision of MG, LG and Sol and some liposuction of her legs. The circumference of her legs became 32cm three weeks after operation(right picture). The scars on her posterior knee would fade away gradually. Below showed the sonographic pictures of her legs. MG was the part between two arrows. Left picture showed the thickness of MG before operation was 2cm. After operation MG thinned to 1cm(right picture).
Case 9:
The preoperative circumference of Case 9 is 35cm. There is obvious bowing of lateral curvature of her legs. After muscle sculpture, including MG,LG and Sol, the circulference became 32cm. The pictures on left sides are taken one and half an year after operation.
Muscle suclpture technique can improve bowing of legs.On the contrary,neurectomy or total muscle excision will deteriorate bowing due to the compensatory hypertrophy of Sol muscle.
Case 10,
The medial calf of the above case was not so bulged, but the lateral calf , especially lower lateral calf,bulged out due to fat accumulation. After liposuction and muscle sculpturing(included MG, LG and Sol), the circumference of calf was reduced from 34cm to 30 cm one month after operation. The right picture was taken one month after operation. Legs would get smaller later on.
Case 11:
The preoperative circumference of above case was 37 cm. After muscle sculpturing of legs(partial excsion of MG, LG and Sol), the legs, which were measured at three weeks after operation,were reduced to 32 cm. The ultrasound examination showed that the thickness of MG( the area between two arrows) was reduced from 2.1cm to 1.0 cm.
The pictures showed the result on seven months after operation. The circumference of legs reduced from 37cm to 32cm. The leg scars on Oriental people take time to fade away.
Case 12:
The preoperative circumference of the above case was 33 cm. Her legs did not look very thick, but she liked to slim her legs. Using the principle of muscle sculpturing, we trimmed her MG, LG and Sol. After 14 months the leg size was reduced to 30cm. The beautiful shape of legs was kept. No compensatory hypertrophy was noted.
Case 13,
Althogth the legs of above case are not thick(the preoperative circumference of leg is 33cm), the patient asked for slim legs. The size has been reduced to 29.5cm one month after operation(left picture). The medial and lateral curvature of legs also became more straight after operation.Below is the follow-up picture of the case 16 months after.
Case 14,
Before operation, the MG and LG were quite bulged when patient standed on her toes. The right picture was taken on 10 months after operation(partial excision of MG, LG and Sol). The legs were not muscular after surgery.
Case 15:
She underwent neurectomy 2 years ago. After neurectomy, her legs got smaller. But in these months she noted that her legs became thicker. Ultrasound check revealed that fiber angle of her MG increased when she stood on her toes. It means that her MG could contract when she stood on her toes, maybe because the nerve controlled the MG was growing into the muscle again.After muscle sculpture operation in our clinic, the legs got slimmer. The lateral and medial curvatures of legs became more straight.
Case 16:
Case 17:
Case 16 and 17 underwent partial excision of their MG. The postoperative pictures, taken on six months after operation, revealed that the legs got slimmer. The leg muscles looked smaller when they stood on their toes.
Case 18:
The above pictures showed the result of calf reduction by partial excision of MG, LG and Sol on 8 months after operation. The leg became slimmer.
Case 19:
After partial excision of MG, LG and Sol, the circumference of legs of above case was reduced from 36 to 32 cm.
Case 20:
After calf reduction surgery, the circumference of legs was reduced from 37cm to 32cm. The bird-eye view also revealed how the leg's contour was sculptured to slim shape.
Case 21:
The preoperative circumference of the legs of above case was 35cm. After muscle sculpturing, the circumference became 30 cm, measured at three weeks after operation.
Case 22:
The before circumference of legs of above case is 37 cm. After muscle sculpture, the size reduced to 32 cm on three months after operation.
Case 23:
The above pictures showed the result of calf reduction surgery on a gentleman after half an year. The size reduced from 39 cm to 36cm. The shape of legs changed a lot.
Case 24:
The above case underwent calf reduction with neurectomy with neurectomy 5 years ago. The left MG became atrophy after neurecotmy, but right MG did not . The ultrasound examination in our clinic showed that left MG was dense and thinner, signs of muscle atrophy, but right MG was thicker without signs of atrophy. She underwent muscle sculpture and calf liposuction in our clinic. The before size of legs were left:34.5 cm right:35.5 cm. Postoperative size is 32cm.
Case 25,
The above case was an athlete when she was a student. About 30 % of our cases have been athletes in their studentship. Although they are no more active in exercise when they graduated, the sizes of their legs did not shrink. The preoperative size of above case was 37 cm. Her legs were quite muscular. After muscle sculpture, the sizes of legs reduced to 32 cm. The above are pictures of before and one year after.
Case 26,
The size of above girls was reduced from 35cm to 31cm.
Case 27:
After muscle treatment and liposcution of legs, the size of above case reduced from 36.5 to 32.5cm on 5 months after surgery. Ultrasound examination on one year after surgery showed that thickness of MG has been reduced from 21 mm to 13 mm. MG function is well.
Case 28:
The leg size of above case was reduced from 34 cm to 31 cm after muscle treatment and liposuction around ankles and medial knees. The legs looks quite slim after surgery. The shape of Achilles tendons could be easily identified after liposuction.
Case 29:
The MG of the above case were quite thick. LG and Sol are normal in size. The case wanted to treat his thick MG. The three-month after picture showed that his leg shape improved a lot after partial excision of his MG. Ultrasound examination showed that before thickness of MG was 16 mm. The thickness of MG has been reduced to 11mm. The 5 mm reduction in thickness improved leg shape, but would not effect leg funcion.
Following is the table comparing these operations.
Calf Augmentation:
On the contrary, some persons like to have bigger calves.Take the below case for example, Mr Chang likes to take exercise. But no matter how he trained his leg muscles, his calves were smaller, comparing with his thighs. He visited our clinic for improving his thin calves. We implanted four silicone blocks into his calves to imitate the shapes of Gastrocnemius. After surgery, he was quite happy with the shapes of his legs.
If you live abroad and are interested in calf reduction, you may write down the questions you have. Take the pictures of your legs (pictures of your posterior legs and picture of legs standing on toes) following the same way as the below examples . Measure the circumference of your legs at their widest part and mail to our e-mail address: mail @LRclinic.com.tw We will reply as soon as possible.
