The legs are often overlooked when it comes to modification by plastic surgery. There are numerous procedures that can be done that focus on the thigh, knees and ankles. But before considering what to do, one has to know what makes a leg attractive. Most people know when they see a good looking pair of legs but describing why they look so is more difficult.

Whether it be female or male, the first important feature is a leg that is well proportioned to the rest of the body. It can not be too thick or too thin compared to the body frame onto which it is attached. The shape of the leg may even be more important with emphasis on its inner aspect. A straight line from the top of the thigh down to the ankle is desired with curves inward at the knee, top of calf and the ankle. As the line of the thigh crosses the knee, there should not be an outward bulge. Once below the knee, the line should curve inward and then out again at the top of the calf. The line then descends gradually inward towards the ankle. It is the straight inner line combined with curves around the knee that define an attractive leg.

These leg attractiveness concepts are important for a variety of plastic surgery procedures but none more significant than liposuction. While liposuction can not make a large leg small, it can create better shape. The bulges of the outer and inner thighs can be reduced to make the silhouette of the upper leg more straight.  While this  is commonly done, the knees and ankles are often overlooked. Many patients tell me they didn’t even know that these areas could be treated.

Liposuction of the knee can be one of the most gratifying areas to treat and the amount of fat removed can be substantial.  The knee bulge can be eliminated and a straight line made that extends from the thighs across the knees. When suctioning the knees, it is important to create an indentation below the knee and at the top of the calf, creating an in and out line below the knee. This provides a separation of the knee and the calf.

A more shapely ankle can also be created with small cannula liposuction.  The ‘cankle’ problem is the result of having no separation between the two. By removing fat from just above the angle on both its inner and outer aspects, the leg line can continue to move inward as it approaches the ankle. Liposuction can also be extended to the lower end of the calf to make it thinner also. Combining lower calf and upper ankle fat reduction helps make for greater definition of the bottom half of the lower leg.

Besides liposuction, there is another leg contouring procedure done below the knee….calf implants. Whether it is for calf asymmetry or calfs that are simply too thin, implants can be used to create the appearance of more muscle mass or bigger calfs. It is virtually impossible for ordinary people to build up the calf muscles through exercise. While the gastrocnemius muscle has two heads (inner and outer), most aesthetic augmentations are done on the medial or inner muscle head. This is because creating the outer bulge of the inner calf makes for a curvilinear shape below the knee. Calf implants, while creating a few centimeters of circumferential size increase, create their effects more by providing an increased calf outline and contour.

Greater leg attractiveness is desired for a variety of reasons which is almost an exclusive female concern. Being able to comfortably wear skirts and shorts is a primary objective. Through the artful use of liposuction, and occasionally calf implants, legs can be reshaped with a silhouette and lines that are more appealing.

Dr. Barry Eppley

Indianapolis, Indiana

1. What is body implant surgery?

While everyone has heard of breast implants, few are aware that there are other locations for the placement of implants to enhance the contours of one’s body. All of these body implants are for the purposes of enhancing certain muscles. Think of body implants as muscle contouring surgery. These include traditional areas of the chest, buttocks, and calfs as well as newer implants for the arm (biceps and triceps), hip and deltoid areas. The majority of body implant patients are male.

Some may think that the use of these implants is cheating, as opposed to muscle growth through working out, but many of these procedures are used for reconstructive purposes as well. Some  patients may use them to help with genetic or injury-related body deformities caused by such conditions as pectus excavatum, spina bifida, and clubfoot. These cause deformities marked by muscle atrophy, underdevelopment or asymmetry.

2. Aren’t pectoral implants in men a lot like breast implants in women?

Yes and no. Pectoral implants, commonly referred to as breast implants for men or male chest implants, is done to  enhance the appearance, size and outlines of the pectoral muscles. Like breast implants, they are very effective at creating that change and are associated with no greater amount of risks or complications. From the standpoint of location under the existing pectoralis muscle, they are very similar to breast implants in that regard.

They do differ in that the end goals are not the same. Breast implants are trying to make a rounded or tear-drop mound that sits up and away from the chest wall and has some compressibility. Pectoral implants are only trying to push out the existing muscle and, as a result, need less volume to do so. A muscle also has more of a firm feel to it rather than displacement to the touch like a breast. Therefore,  pectoral implants are smaller in size and are composed of a soft but solid silicone elastomer. They are not fluid or gel-filled like breast implants.

3. What is the best way to achieve a larger and rounder buttocks?

There has been a significant increase in the number of buttock enlargement/enhancement requests. Fueled by increasing multiracial population growth and popular figures like Jennifer Lopez, more women are pursing an increased curvature to the buttocks through different forms of augmentation.

The debate in buttock augmentation is whether to do it through the use of an implant or with fat injections. There are surgeon advocates for both procedures and, when done well, satisfying results can be achieved either way. This is why it is important to look at each one’s advantages and disadvantages.

Buttock or gluteal implants have the advantages of a bigger and immediate result that will not change after surgery. Its downside is that it is a more invasive procedure, takes a lot longer to recover, and runs the risk of infection and implant displacement.

Fat injections have the advantage of a more ‘natural’ procedure that is not associated with any of the potential complications related to a foreign body. It also gives one the extra benefit of fat reduction from the donor site. Its disadvantages are that it can not usually achieve the same buttock size as that of an implant (at least in one fat grafting session) and the take of the fat graft is not completely predictable.

4. Can an implant make my calf bigger?

Calf augmentation creates fullness in the gastrocnemius muscle of the  lower leg by placing implants in subfascial pockets overlying the muscle. It can help those men and women who can’t achieve the size of the calf muscle they desire. The calf muscle is one of the more difficult muscles in the body to enlarge due to its very compact muscle fibers. This form of lower leg  sculpting can also correct muscle imbalance as a result of such congenital defects as disproportionate calf development, clubfoot, bowleggedness, and just plain skinny calfs. (aka ‘chicken legs’)

The calf muscle is a two-headed muscle in which one or two implants which may be used in each leg. A person may desire to have only the inner head of the muscle enlarged, the outer head, or both. They are inserted through a small incision in the skin crease behind the knee.

The biggest issue with calf implants is the recovery period. Because they are in the lower part of the legs, some significant swelling can occur. And it usually takes up to three weeks before one can walk more normally. Working out and other unrestricted activities will take at least a month or two following surgery.

Recent reports have seen the use of fat injections for calf augmentation. But this approach is just in its infancy and consistent long-term outcomes remain to be seen.

5. I have heard there are implants for the arms. Is this true?

Bicep and tricep implants will create muscular definition and perceived enlargement of the muscles in both the front and back of the upper arms. This procedure is done exclusively for those who can’t achieve the upper arm size they want even after significant efforts at muscular exercise. Generally, two implants are placed in each arm to give the greatest overall change.

6. Are there any new areas where body implants are being used?

The newest uses of body implants are for the hip and deltoid areas. Deltoid implants are used to rebuild or augment deficiencies of the deltoid muscle group caused by  congenital deformities (Sprengel’s deformity or scapular hypoplasia) or traumatic injuries. (motor vehicle accidents) Hip implants are exclusively done for cosmetic augmentation. For those women who feel that their hips are too narrow and want more of an hourglass figure, hip implants can give them more curvature.

7. What complications can occur with body implants?

Placing an implant always has the standard medical risks of infection, displacement, and chronic pain as well as the cosmetic risks of over- or undercorrection. Unlike the face, body implants are always placed in areas exposed to constant motion and stress and are much larger in size. As a result, they have a higher incidence of fluid collections and displacement.

Dr. Barry Eppley

Indianapolis, Indiana

Augmentation of the calfs is most consistently done with a synthetic implant. Most patients who seek calf augmentation are typically body builder types, those born with very thin calfs who have been unable to build them up, or sosmeone with significant calf asymmetry. Despite an implant’s predictable improvement in the size and shape of the calfs, calf implants are not without problems. Implant placement into and on top of the calf muscles makes recovery uncomfortable and having to stand and walk around early on afetr surgery makes it possible for the implant to shift, develop a fluid collections (seroma) or possibly even get infected.
Because of these implant concerns, the alternative treatment of fat injections or free fat grafting has emerged. A recent article in Plastic and Reconstructive Surgery presents a patient series using fat injections for calf augmentation. Their reported experience is encouraging. Fat grafting to the calfs has numerous potential advantages such as the elimination of the need for a synthetic implant, the use of a patient’s own body tissues, an easier recovery with few limitations, and a very low risk of bleeding or infection. Such advantages over an implant gives serious thought to its use.
All of these advantages of free fat fat grafting is counterbalanced by one significant disadvantage….an unpredictability of after surgery shape and size. How much fat survives and is retained is widely variable. No plastic surgeon can guarantee or predict with 100% accuracy how much fat will survive on a consistent basis. The article reports using 75 – 125cc per calf with good volume retention.The burning question through the past several decades is…how to make fat grafting work better. The injection technique is, of course, important but is only half of the answer. How the fat is prepared after harvest in the oeprating room is the other half. Everyone agrees that concentration is very important after harvest. This is the mechanical process of removing the liquids from the more solid fat components. Whether this is done by a centrifuge or passing the fat aspirate through a strainer or sieve are two methods of which one has not been proven to be better than the other. Additives to the fat are theoretically appealing but there is no universal magical additive. Currently, I add platelet-rich plasma (PRP) to the concentrated fat prior to injection. Whether this aids fat survival is not proven but since it is a product of the patient, there is no risk in so doing. PRP is a concentrate of a patient’s own blood done at the time of surgery. While there is no standardized amount of PRP to add to fat, I would envision adding 3cc of PRP per calf graft site.
Having done a few cases of calf augmentation with fat injections, the technical aspect of this approach is straightforward. Careful marking of the patient while standing beforehand is critical to get the proper areas augmented. Like all fat injection surgeries, the patient must accept that the amount of fat that will survive is unpredictable. It may require more than one injection session to obtain the best result. Most fat grafting methods will not achieve the degree of volume enhancement that a calf implant will. In reviewing the before and after photos from the above mentioned article, that observation seems to be true.
Dr. Barry Eppley

Indianapolis, Indiana

Calf Implants and Augmentation

The use of calf implants to give the lower leg more shape is not as uncommon as you think. There are many different reasons why someone wants calf implants; from the bodybuilder who can’t get the calfs big enough compared to the rest of the thighs, a birth defect or surgically-induced problem where one calf is much smaller than the other (asymmetry), or someone that just has extremely thin calfs since they were born. (stick legs) Calf muscles are some of the hardest muscles to build up by exercise and are extremely resistent to getting bigger without a herculean effort at weight-lifting.

Calf implant surgery is based on two important concepts; the placement of calf implants to simulate the two calf muscles on both sides of the calf (although not every patient requires two implants per calf) and the use of rubbery (semisolid, not liquid) silicone implants that come in a variety of sizes and shapes. The location and size of the implants should be determined in the office in advance of surgery by measurements.

Calf implants are placed through an incision in the back of the knee and pockets into which the implants are placed developed within the calf muscles. After which, the implants are slipped into place. The surgery does not take long but you need to be prepared for some recovery after surgery. While the procedure is done as an outpatient, calf implant surgery can be quite painful and full recovery is going to require some time. Be prepared to do the following after calf implant surgery; plan to take two weeks off work, rest your legs and elevate your ankles for several days after surgery and use crutches to get around, plan to walk in heeled shoes for a while (walking flat footed initially is very uncomfortable), walk with knees slightly bent, don’t work out for 4 to 6 weeks after surgery, and avoid running for two to three months after surgery. The biggest complication of calf implant surgery is the implants shifting from their place or a fluid collection occurring around them (seroma). Both of these problems are caused by too much calf activity after surgery! Also, expect stiff and sore calves for a month or so after surgery.

Calf implants can definitely give a better shape and a more muscular appearance to the lower legs but you have to be prepared for the recovery period. Calf implants take the longest to recover from any other body implant surgery in my experience. (pectoral, biceps, triceps, buttocks)

Dr Barry Eppley

Indianapolis, Indianapolis