Q: Dr. Eppley, I am interested in buttock and calf augmentation. I prefer the fat from my body to be used. But I have one question… how long will the fat persist in my calfs and buttocks?
A: Thank you for sending your pictures. Fat injection calf augmentation can be done as long as one has enough fat to harvest to do the procedure. It would be very unlikely, however, that one would have enough fat to do both their buttocks and calfs. You would likely have to choose to place fat either in the calfs or the buttocks and choose an implant for the other location. Given that fat takes and persists better in the buttocks, it would make the most sense to use all of the available fat for the buttocks. Fat injections do not persist very well in the calfs and calf implants offer a simple, assured and permanent augmentation procedure.
When it comes to body contouring by fat injections it is important to understand that they work best in areas that already have some fat. Thus it is no surprise that fat injections work better for buttock augmentation than they do for calf augmentation.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in calf implants. I have thought about it for years. I am tired of being self-conscious in shorts. I’m almost 40 years of age and want to do something about it now. Here are some photos. In my opinion my calves do not match my body frame. Despite working them out daily, they refuse to grow.
A: Thank you for sending your pictures. Calf muscles are the hardest of all body muscles to increase in size due to their dense compact type of muscle fibers. Calf implants are the immediate cure for that problem. Placed through a small incision in the popliteal crease behind the knee, they are placed underneath the fascia on top of the calf muscles providing an instant augmentation. In looking at your calf pictures I would recommend medium size calf implants for the medial calf muscle and small calf implants for the lateral calf muscle for a total of four calf implants.
While calf implants are instantly effective (just like breast implants) there is a substantial recovery from them. The calf muscles will be tight and sore and walking can be initially difficult for the first few days after surgery. It takes about three weeks to have a near full recovery from calf implant surgery.
Dr. Barry Eppley
Q; Dr. Eppley, I was born with club foot and now my right leg is slightly smaller than the left. I’ve attached two pictures. Let me know if you need another. My basic concern is having to do multiple implants and have also been thinking about fat transfer. I believe to make my right leg look symmetrical I will need one of the longer implants, because it would need to follow down to very bottom of my leg if possible. I have no Achilles tendon and your able to see my fibula bone if I flex my leg.
A: Your best obtainable result is going to come from a combination of calf implants and fat transfer. Calf implants do not go all the way to the ankle nor can any implant go past midway between the knee and the ankle. (can not go past the gastrocnemius muscle/fascia) Below this level any augmentation has to be done with fat transfer although it is important to be aware that fat grafting below the calf survives very poorly due to the tight tissues. Given the small size of your calf you will need both medial and lateral calf implants.
Dr. Barry Eppley
Q: Dr. Eppley, I have mild muscular dystrophy that has left my right leg and ankle much smaller than my left. I have two calf implants in now but my ankle and the inside of my leg are still much smaller. Is there any way you think you could help?
A: Calf implants do a good job of increasing the size of the upper half of the lower leg between the knee and ankle. But its augmentation effect stops where the gastrocnemius and soleus muscle meets which is about halfway between the knee and ankle. One way to augment the lower half of the leg and continue the effects created by the calf implants are fat injections. As long as one has enough fat to harvest, fat injection augmentation can be done in the lower half of the leg. (leg fat grafting) Its biggest problem is in how well the fat will survive which can be difficult in the tight tissues of the lower half of the lower leg. Multiple fat injection sessions may be required.
Another option would be a custom made implant for the lower leg. But this has a much higher risk of complications than calf implants do because of its subcutaneous location as opposed to that of a subfascial one.
Dr. Barry Eppley
Q: Dr. Eppley, I contracted polio when I was an infant from a vaccination, which resulted in atrophy of my left leg. Would fat grafting or thigh and calf implants help to make my legs more symmetrical? I know the discrepancy looks severe so I don’t have expectations of perfection but I’m hoping something may be done to lessen.. possibly with the combination of both procedures.
A: Thank you for sending your pictures The easiest and less severe component of your leg asymmetry is that of the calf. One calf implant placed on the inner half would go a long way to improve symmetry below the knee. Two calf implants would produce near symmetry inj size to the other side.
The thigh deformity is the bigger part of the leg asymmetry and the more challenging to improve due to its magnitude. Injectable fat grafting would be the only treatment that can be done and its success is partially dependent on how much fat you have to harvest. This combined with how much fat survives determines that outcome. Based on the performance of the first procedure (and how much fat you have to harvest) you may need a second fat grafting session to get the best possible outcome.
Dr. Barry Eppley
Q: Dr. Eppley, I need calf augmentation for club foot. I just read about Stem cell fat muscle augmentation. I would prefer that because its more natural and fat would be taken from the same body. Besides, I learnt that with age implants would have to be removed because of blood circulation. I want something permanent for the rest of my life. I am a size 8-10 and hoping you would find some fat in my thighs (though small) and other areas to work with. Kindly advice.
A: Unfortunately you have numerous misconceptions about fat grafting and calf implants. While fat grafting is an option for calf augmentation, you do not have enough fat to harvest to make the procedure worthwhile. Small thigh areas are not going to cut it for adequate fat donor sites. Besides the donor fat issue, there is also the variability of how well fat will take and persist. In thin people this is usually very poor. Tight tissues, like a small calf in clubfoot, also work against fat graft survival and ‘squeeze’ out most of the injected fat. Fat grafting still may work if one is willing to do two or three fat grafting sessions to bypass these issues, but again there has to be enough fat to repeatedly harvest for the procedure. Lastly anytime you see the phrase ‘Stem Cell’ associated with any plastic surgery procedure, that is all hype and marketing. There is no proven science that demonstrates the role that stem cells have in fat transplantation. It sounds good but, in the end, it is just fat grafting.
The only proven procedure for calf augmentation for clubfoot is an implant. That is the only way to assure a visible volume result that will be permanent. I have never heard or seen the issue of ‘implants having to be removed because of blood circulation’. If that have any validity every breast implant would eventually have to be removed because of it. This implant contention has no scientific basis.
Dr. Barry Eppley
Q: Dr. Eppley, This is a follow up question in regards to your response to the question about using calf implants to correct the affects of polio. Is it not possible to use some type of balloon to stretch the skin in order to increase the amount of area available to accommodate the implant (similar to what is done for breast implants when someone significantly increases their cup size)?
A: Your question regarding the use of tissue expansion for calf implants is a good one and has some merit. However there is one major problem with it.Tissue expansion works most effectively when it has something hard to push off against. This allows the effects of tissue expansion to go in one direction, outward to the skin which can be stretched. This is why it works so effectively for breast reconstruction (ribcage) and the scalp. (skull) In the calfs, what lies underneath the fascia (which is where calf implants are placed) is the soft gastrocnemius muscle. With a very tight overlying fascia (like a trampoline) and soft muscle underneath, the effects of tissue expansion would be displaced inward and would have little effect on stretching out the overlying skin. One could place the tissue expander above the fascia in the subcutaneous plane right under the skin with the objective of eventually placing the calf implants in that plane. It is associated with a higher rate of complications (infection, visible outline of the implant) but may be reasonable given few other calf implant options. Besides tissue expansion, one could also do a first-stage fat injection to help both stretch the skin and create a better vascular bed for the second stage implant placement.
Dr. Barry Eppley
Q: Dr. Eppley, my question is can I have calf augmentation implants because I have polio since 10 years old from feet to my knee. My right leg is really thin and my left leg is normal. Thank you!
A: There are many causes of calf asymmetry in which one calf is smaller due to gastrocnemius muscle atrophy or lack of development. Club foot and polio would be two examples that can result in smaller heads of this calf muscle. There is no reason why you could not get a calf implant into the affected leg. The question is how small or tight is the skin on that leg. In cases of severe muscle atrophy the enveloping skin may be very tight. This will control or limit whether a calf implant can be inserted and be big enough to make a visible difference. When using implants for correction of calf asymmetries, the question is never whether one can make the affected calf normal in size (because you can’t) but how much improvement can be obtained.
Dr. Barry Eppley
Q: Dr. Eppley, I have some questions about calf implant surgery. I have very small calfs, like toothpicks below my knees, due to being born with clubfeet. I know that I can never have normal size calfs but any improvement woutl be a plus. My questions about calf implants are:
-What is a conservative estimate of the recovery period?
-What is the likelihood of needing a follow up surgery?-Where is the surgery being performed and what is the rate of secondary infections there?
-What are the chances and risk of other complications/what complications?
-How extensive will scarring be?
-How is the size of the implants determined, what is the chance of them shifting, what would be the risk involved, and how would they be adjusted if necessary?
-What is the expected prognosis?—lifetime of implants? Eventual need for replacement implants? Longterm risk of side effects/complications?
-How will this overall affect Quality of Life?
-What are the other options and how do they compare?
A: in answer to your calf augmentation questions:
- Recovery from calf implants is related to the ability to walk and fully flex one’s foot. Most patients return to normal after about 3 weeks from surgery.
- Surgery is performed in my private outpatient surgery center. Because this is a facility where only elective surgery is done on healthy patients, unlike a hospital, the infection rate is very low. (way less than 1%)
- The biggest risks of calf implants are infection (< 1%) and potential visibility of the implant’s outline in patients with thin tissues. (10%)
- The implants are placed through a horizontal 3 cm wide incision in the skin crease behind the knee. (popliteal fossa) That scarring is minimal although in patients with more skin pigment there may be an initial hyperpigmentation reaction around the incision.
- Calf implant sizing is done by taking measurements of the medial gastrocnemius muscle and matching the implant size to muscle dimensions. Calf implant size options range from small (5cm x 15 cm, 70cc volume), medium (6cm x 20 cm, 135cc volume) to large. (6cm x 24 cm, 170cc v olume) Calf implant shifting is very rare since the tissue pocket made is very narrow and the tissues are naturally tight.
- Calf implants are made of soft low durometer silcioen elastomer material that will never degrade, break down or need to be replaced.
- Like all body augmentation surgery, this is an operation whose intent is to make you feel less subconscious about your congenitally small calf size. if this objective is achieved then your self-image and quality of life in theory should be improved.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 25yr old male who was born with club foot. I went through life playing sports and excelling in every aspect. At this point in my life I am currently coming to a financial point to pursue a calf implant surgery. Can you please inform me of what the procedure is all about, how often it is performed, success rate, and cost. Thanks you for your time and I look forward to moving this process along!
A: Calf augmentation can be done by either an implant or more recently fat injections. The more guaranteed method of permanent calf augmentation is with an implant. Calf implants, like all body implants, are made of a very soft and spongy solid silicone rubber material which feels very much like muscle tissue. It is inserted through a small incision in the back of the knee in an outpatient procedure done under general anesthesia. The procedure is most commonly done in body builders or non-athletes who feel that their calfs are just too small. The most challenging patient in my experience is the club foot patient because, not only is the calf too small but the surrounding skin is very tight. This makes the insertion of an adequately-sized calf implant more difficult and it will not be possible to match the circumferential size of the smaller calf to the larger one. The club foot patient must be willing to accept improvement in calf shape but an ideal result will not be achieved.
Dr. Barry Eppley
Q: Dr. Eppley, my left calf muscle is 2 to 3 inches smaller than my right. I do have muscle in my leg but it just will not enlarge with exercise. I am interested in getting calf implants. I was wondering how long I would need to stay after surgery.
A: Calf augmentation is done as an outpatient procedure. You could go home the same day, but if you live far away, you consider going home the next day.
A calf implant will help the size of the smaller calf but will not be able to make it match identically to the opposite normal side in shape or circumferential measurement. The tightness of the skin is the limiting factor in congenital calf asymmetry, the most challenging use of calf implants. In an ideal world congenital calf deficiency would be treated by a two-stage approach, a first-stage fat injection augmentation followed three months later by the placement of a calf implant. This is the ideal approach because the fat injections and the associated stem cells in it allows for some soft tissue expansion and a thicker soft tissue bed to ultimately receive the implant. But because of cost considerations, most patients have to go immediately for the implant.
Dr. Barry Eppley
Q: Dr. Eppley, I planned for long time to get calf augmentation and feel that now is the time. I am 170 cm tall and weigh about 72 kg and am very athletic. But I have skinny calves and they haven’t grown like the rest of me. My calves are 34 cm around. I am ready for this mentally and financially. I want to know which type of method is best for me and about the price and how much bigger will they be?
A: The most reliable method for calf augmentation is using soft very flexible solid silicone implants placed through a popliteal incision. The amount of calf size increase that can be obtained is based upon whether one (medial) or two (medial and lateral) calf implants are used and how tight or soft the calf skin is. Calf augmentation can also be done by fat injections but that method is limited by how much of the fat will survive and whether one has enough fat to harvest for the procedure. At your height and weight, I do not envision that you have any significant fat to use.I will need to see some pictures of your lower legs to see what may best for you. The price of surgery is based on how many implants are used so seeing the pictures first is important.
Dr. Barry Eppley
Q: I have semi-thin calfs, and I will like to know if there is a common fat injection for calf augmentation without the need of surgery procedures. Thanks.
A: The traditional method of calf augmentation is the insertion of synthetic implants. A newer method is the use of fat injections instead of implants. Whether this will end up being as successful as an actual implant remains to be seen. But do not think that the use of fat injections is not surgery as it most certainly is. Fat has to harvested elsewhere on the body through liposuction to acquire the injection material and then it has to be injected into then calf region. While it may not be as invasive as the placement of a calf implant, it is still surgery.
The biggest risk of fat injection calf augmentation, like fat injections anywhere else on the body, is their survival after transplantation. Even with the best methods that we have today, the reliability of fat injection results remains unpredictable. Any patient considering fat injections must be willing to assume that risk.
One advantage that fat injections does have over implants to the calfs is the ability to augment areas that an implant can not traditionally do. Fat can be injected in a more ‘sculpting’ approach as opposed to the mass augmentation effect of an implant.
Q: I am writing to inquiry about a calf implant for my daughter. She has developed a rather significant difference in the size of her calfs now that she is a teenager. While it was slightly apparent as a child, it has become real obvious as a 15 year-old teenager. It bothers her to the point that she will not wear shorts or go to the pool with other teenagers. She walks fine and as no disability from the calf size difference. I know that calf implants can be done for body builders and others who want both calfs to look bigger, but can just one calf implant be done? I could not find anywhere where just one was done.
A: Calf augmentation with implants is an uncommon body contouring procedure. While it has been done for decades, it is far less common than breast or buttock implants. While most people think that only body builder types do the procedure, it may surprise you to know that their use for ‘reconstruction’ of congenital calf deformities makes up about half of all calf augmentation procedures.
Calf implants are made of specially-shaped soft flexible silicone rubber. They are surgically placed through a small incision behind the knee. They can not really be put inside the calf muscle but are placed on top under its fascial covering. They can be placed on either the inside, outside of the calf, or both. Most commonly, they are placed on the inside half (medial) which is where most of the calf’s definition can be visually seen.
For calf asymmetry, placing a calf implant on the smaller side can help make their size discrepancy less apparent. If your teenager is that bothered by it, I would seriously consider the procedure. It is really the only good plastic surgery option for such a calf problem.
Dr. Barry Eppley
Q: I’ve read your article on calf augmentation using fat transfer. Since 2008, have you performed this procedure? I have finding very mixed feedback on this. Some surgeons are saying this is high risk and will be unsuccessful because the fat will all be absorbed. Another doctor in NY I’ve been in contact with says he has had great success and with little side-effects. Appreciate your feedback.
A: Calf augmentation is most reliably done with implants. There are specific silicone rubber implants made for the calf and they are placed through a small incision on the back of the knee. (popliteal fossa) Because an implant is used, the result is stable and consistent in the amount of size increase obtained. Conversely, because it is an implant there are the associated issues of the risk of infection, malposition and asymmetry as well as a significant recovery and discomfort.
Fat injections, no matter where they are considered and what they me be used for, always have the same appeal. Using a natural tissue that has virtually none of the risks of an implant-associated procedure. Despite those benefits, fat injections have one significant downside…their volume retention is unreliable. At this time, there are no standard techniques for fat preparation and injection and the science behind its survival once transplanted remains to be discovered and utilized for more stable outcomes.
Because of the differing techniques and injection methods, fat injections for larger volume areas (breast, buttocks, calfs) have widely variable results. With these inconsistent results come quite discrepant surgical opinions about their effectiveness. There is now to reconcile one plastic surgeon’s experience vs another at this time.
Calf augmentation with fat injections is relatively ‘new’ and the worldwide experience is still evolving. The issues with the calfs are no different than the buttocks or breasts. It is a very safe procedure with minimal downtime. But one has to accept the reality that how much fat survives is the risk of the procedure. And more than one session may be needed to get the best results. (more likely than not) My experience has been with just a few cases and the early results have been acceptable. But the key is patient selection…don’t ask the fat to do what an implant can do better. (mild enlargement, not big enlargement)
Dr. Barry Eppley