{"id":8212,"date":"2015-07-02T07:48:30","date_gmt":"2015-07-02T07:48:30","guid":{"rendered":"https:\/\/onep.com.tr\/correction-of-leg-curvatures-with-tissue-injection\/"},"modified":"2015-07-02T07:48:30","modified_gmt":"2015-07-02T07:48:30","slug":"correction-of-leg-curvatures-with-tissue-injection","status":"publish","type":"post","link":"https:\/\/onep.com.tr\/en\/correction-of-leg-curvatures-with-tissue-injection\/","title":{"rendered":"CORRECTION OF LEG CURVATURES WITH TISSUE INJECTION"},"content":{"rendered":"

 <\/p>\n

Background:<\/strong> Slender or asymmetric calves can create body image issues. These deformities can be corrected with silicone calf implants or silicone injections, as well as with autologous fat or tissue cocktail. <\/p>\n

Methods:<\/strong> While the patient is standing, the slender and asymmetric parts of the legs are marked. Depressed areas are observed on the anteromedial aspect of the tibia, from the knee to the ankle. Adipose tissue is harvested under general anesthesia using a 4 mm cannula and syringe, centrifuged to eliminate blood and oil, antibiotics are added, and small amounts of fat grafts are injected into different layers with a 15-26 cm long and 3 mm diameter cannula. To prepare the tissue cocktail, tissues (dermis, fascia, and fat) are minced into 0.5 mm pieces that can pass through a 16-gauge needle. The amount to be injected varies according to the degree of deformity and the circumference of the legs. Rather than overcorrection, injections are repeated two to four times at 3-month intervals if necessary. <\/p>\n

\"leg-aesthetics\"<\/a>Results:<\/strong> Between 1992 and 2003, 77 patients underwent calf augmentation with autologous fat and tissue cocktail and were followed for one to eight years. The results were satisfactory in most patients. Minor irregularities and asymmetries were observed in 12 patients after the first injection and were corrected with a second injection. No patient developed an infection. <\/p>\n

Decision:<\/strong> Autologous augmentation and contouring provide scarless, long-lasting results, with no late complications or potential for corrections.<\/p>\n

Keywords:<\/strong> Calf augmentation, silicone implants\/prostheses, autologous fat injection, tissue cocktail injection<\/p>\n

INTRODUCTION<\/strong><\/p>\n

Recently, legs have become a very important secondary sexual characteristic in both women and men. Female patients with unilateral muscle atrophy and young male athletes may be unhappy due to their thin, slender, or asymmetric calves (also known as “skin and bone legs”) (1-5). Patients are increasingly seeking help from plastic surgeons to correct these leg deformities. Patients know that impaired functions will not improve, but they desire to wear short skirts or not attract attention in the swimming pool (6-8). The causes of unilateral or bilateral calf deformities are: a) congenital hypoplasia or aplasia of subcutaneous cellular adipose tissue; b) sequelae of clubfoot, cerebral palsy, and spina bifida; c) sequelae of poliomyelitis or osteomyelitis; and d) trauma and burn-related contractures after femur fractures (1-8). In our region, until 1985, we encountered requests for correction of bowleg deformities due to Rickets. <\/p>\n

The correction of these deformities was generally achieved with silicone calf implants or liquid silicone injections (1-13). However, autologous fat or tissue cocktail injections have always been our first choice for correcting these deformities (14-17). This is the first publication of this technique in the English literature. <\/p>\n

Since 1985, Erol has gained extensive experience in fat injections in our clinic and developed the “tissue cocktail injection” in 1989 (14). Since then, numerous modifications and improvements have made the use of this technique more practical and effective (14-16). This article describes Erol’s approach and experience in calf augmentation with fat and tissue cocktail injection in a series of 77 cases. <\/p>\n

MATERIALS AND METHODS<\/strong><\/p>\n

Harvesting and Preparation of Micro Fat Grafts<\/em><\/p>\n

This technique, developed and popularized by Erol, has evolved over time. In the first group of patients treated between 1985 and 1992 (who are not included in this paper), a vacuum machine with a sterile bottle that could be connected in between was used to collect fat. The fat graft was injected immediately without any processing. 18- and 16-gauge cannulas were used, and all patients were overcorrected to compensate for possible resorption. From 1992 to 1996, fat was harvested with a 4 mm cannula and syringe, washed with Ringer’s Lactate solution, and prepared by adding 1 gram of first-generation cephalosporin per 50 cc. Overcorrection was not performed because small grafts were observed to be much better vascularized than larger ones. <\/p>\n

In patients seen after 1996, fat grafts were again obtained under general anesthesia using a syringe and a 4 mm cannula. No local anesthetic was used to avoid damaging fat cells. The abdomen and waist, and occasionally the trochanteric region and buttocks, were preferred for fat harvesting. The obtained fat was centrifuged at 3000 rpm for 3 minutes (Figure 1), extracellular fat and blood were eliminated, and 1 gram of first-generation cephalosporin was added per 100 cc, making the fat ready for injection and cryopreservation (14-15). <\/p>\n

Harvesting and Preparation of Tissue Cocktail<\/em><\/p>\n

Mini-micro dermis-fascia-fat grafts were prepared from excised scar tissues, or from tissues removed during abdominoplasty or breast reduction. Tissues (dermis, fascia, fat) were minced into very small pieces, 0.5 mm in diameter, to pass through a 16-gauge needle, and antibiotics were added before injection (Figure 1) (14-16). <\/p>\n

Cryopreservation<\/em><\/p>\n

The remaining tissue cocktail and fat were cryopreserved. The pieces were placed in 50 cc sterile tubes, labeled, and immersed in a liquid nitrogen tank \"leg-thickening-tissue-injection\"<\/a>and frozen at -196 degrees, then stored in a deep freezer (Electrolux UF 601 medical freezer) at -80 degrees Celsius.<\/p>\n

Preoperative Planning<\/em><\/p>\n

First, standard photographs of the legs were taken. The thin and asymmetric parts of the legs to be thickened were marked while the patient was standing. Depressed areas were observed on the anteromedial aspects of the tibia, between the knee and the ankle. Photographs showing the marked areas were taken to assist during surgery (Figure 1). <\/p>\n

Surgery<\/em><\/p>\n

An anesthetic mixture containing 20 cc of 0.5% bupivacaine, 0.25 mg of adrenaline, 20 cc of physiological saline, and 20 mg of triamcinolone acetonide was injected into the planned injection areas. The purpose of administering this solution is to reduce postoperative edema and ecchymosis and to reduce the risk of embolism by causing vasoconstriction. <\/p>\n

Between 75 and 200 cc of fat or cocktail was injected into each leg (Figure 2). Small amounts of micro-mini grafts were injected using long cannulas 15 to 26 cm in length and 3 mm in diameter (14,17-19). Overcorrection was not performed to ensure maximum revascularization. Injections were repeated between two and four times at three-month intervals as needed. <\/p>\n

RESULTS<\/strong><\/p>\n

Between 1992 and 2003, 144 calf augmentations were performed in 77 patients with an average age of 25 (ranging from 20 to 35 years). Autologous tissues were used in all patients (tissue cocktail in 12 patients, fat injection in the rest). A total of 75 to 200 cc (average 132 cc) of fat or tissue cocktail was injected into each leg. Repeated injections were performed at three-month intervals: twice in 17 patients, three times in 37 patients, and four times in 23 patients (Figures 3-7). Follow-up ranged from one to eight years (average 3.5 years). <\/p>\n

The results were satisfactory in the majority of patients, and the planned shape was achieved in all patients after one to four injections. Mild irregularities or asymmetries were observed in 12 patients after the first injection, but these were corrected with the second injection. No infection was observed in any of the patients. <\/p>\n

DISCUSSION<\/strong><\/p>\n

Aesthetic beauty is to learn, and while beauty is obvious to everyone in appearance, it is extremely difficult to define and explain. The perception of beauty is a semi-conscious state localized not in the cognitive part of the brain (neo-cortex) but in the primitive brain part called the limbic system (9,10,13). Ricketts (20) analyzed the structure, harmony, balance, and proportions of the human body using mathematical and geometric calculations. The aesthetically ideal golden ratios were known in ancient Egypt and applied in art and architecture by the ancient Greeks. In 1202, the Italian mathematician Filius Bonacci determined the dimensions of the golden ratio as 1:1.618, and in the 16th century, the German scientist Johannes Kepler called it the sacred ratio (10). <\/p>\n

The ideal dimensions of the calves were defined by Howard (5), and Leonardo da Vinci’s drawings were taken as the basis for the analyses. The golden ratio in calf aesthetics was determined as the distance between the ankle and the lower border of the gastrocnemius muscle being equal to the distance between the knee and the most prominent part of the medial curvature of the gastrocnemius muscle. The total length of the gastrocnemius muscle is 1.6 times the previous value. Von Szalay (9) determined that the calf circumference in attractive women is between 33 and 36 cm and stated that legs much thicker or thinner than this are aesthetically unacceptable (7-10). <\/p>\n

Calf augmentation is performed for cosmetic reasons or to correct trauma, disease, and congenital underdevelopment (\/2-13,15,16). Today, an increasing number of patients are requesting calf augmentation to improve their overall appearance (1-9). <\/p>\n

The shape of the calf is determined by the development of the gastrocnemius and soleus muscles, the length and placement of the calf bones, and the distribution of subcutaneous fat (4-11). Attempting to change bones for purely aesthetic reasons is both difficult and, in many cases, unrealistic (8-12). In contrast, inappropriate fat distribution can be corrected with liposuction, and underdeveloped muscles can be augmented with implants. Soft tissue fillers cannot replace implants as a method of calf augmentation, but they can be used as an alternative to ready-made implants for correcting minor calf surface irregularities (5-11). <\/p>\n

The principle of volume and shape correction or restoration with silicone implants is well known and has proven itself in breast surgery over the last 5 decades (4-12). Calf implants are made from solid, semi-soft silicone\/gel that can be sculpted by hand, or from thick solid silicone shells containing cohesive silicone (1-13). Calf augmentation can be performed by placing one or more implants in the medial and lateral parts of the legs (2-12). For the first time in 1979, Carlsen and Glicenstein pointed out the problem of calf augmentation, and this was followed by different studies (2-12). In all these presentations, silicone gel-filled or silicone rubber implants were used, placed beneath the deep fascia of the calf (1-9). Silicone implants have problems such as visible capsular contraction, infection, and extrusion. Although patients like the calf shape with soft rubber implants, the edges can be palpable, and the area where the implant is placed is harder than the surrounding muscle (2-10). Calf prostheses cannot correct deformities in the ankle region and have disadvantages such as displacement, capsular contraction, and extrusion (2-13,15,16). <\/p>\n

New techniques have been developed to reduce or eliminate the disadvantages of solid implants, and prostheses have been placed intramuscularly (11), subperiosteally with fasciotomy (12), with microsurgical transfer of transverse rectus abdominis myocutaneous (TRAM) flaps (21,22), and more recently with newly developed combined calf-tibia implants (13). This prosthesis was designed to augment and correct both the calf and the area between the calf and the ankle (12,13,15,16). However, like other prostheses, this implant is a foreign material, not autologous tissue. After 35 years of follow-up, the disadvantages of prostheses such as capsular contraction, infection, visibility, palpability, displacement, abnormal hardness of the leg, prosthesis rupture, and erosion of the bone surface are well understood (3,6,9,10,12). <\/p>\n

The use of autologous tissue injections has been developed to overcome the disadvantages of silicone injections and implants (14-19). A literature review has shown that TRAM free flaps (21,22), autologous tissue cocktail (14-16), and fat injections (14-16) yield excellent results in correcting calf contour deformities (17-19,23,24). Muscle mass can be changed with sports and physical activity, but subcutaneous fat is the only area that can be easily modified. We have applied our experience in volumetric facial rejuvenation with regional fat and tissue cocktail to this area as well. The technique described in this article offers the advantage of being able to add tissue wherever desired and seeing the result immediately after injection. Since this is a graft, not a flap, some resorption may occur, but results become apparent after three months, and if necessary, more tissue can be provided with additional injections (14-19). <\/p>\n

Our experience has shown that fat injection is very effective, easy to apply, long-lasting, and has a very short recovery period post-surgery. The only disadvantage of fat injection is the need for repeated injections and touch-ups. The tissue cocktail is a mixture of mini-micro dermis-fascia-fat grafts, and since it mostly consists of dermis microparticles, it has a higher survival rate compared to fat grafts, and one or two injections are sufficient for appropriate and permanent results. However, obtaining a tissue cocktail is more complicated than harvesting fat, and the main disadvantage of this technique is the availability of tissues that can be injected. <\/p>\n

CONCLUSION<\/strong><\/p>\n

Calf augmentation was performed with autologous tissues in 77 patients, and no significant complications were encountered during a follow-up period of 1 to 8 years. Tissue injection using autografts offers many advantages such as small, inconspicuous scars, absence of late complications, the opportunity for minor corrective injections, and long-lasting results. We recommend the use of this technique for calf augmentation in selected patients. <\/p>\n","protected":false},"excerpt":{"rendered":"

  Background: Slender or asymmetric calves can create body image issues. These deformities can be corrected with silicone calf implants or silicone injections, as well as with autologous fat or tissue cocktail. Methods: While the patient is standing, the slender and asymmetric parts of the legs are marked. Depressed areas are observed on the anteromedial […]<\/p>\n","protected":false},"author":1,"featured_media":8214,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[86],"tags":[],"class_list":["post-8212","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-blog"],"_links":{"self":[{"href":"https:\/\/onep.com.tr\/en\/wp-json\/wp\/v2\/posts\/8212","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/onep.com.tr\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/onep.com.tr\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/onep.com.tr\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/onep.com.tr\/en\/wp-json\/wp\/v2\/comments?post=8212"}],"version-history":[{"count":0,"href":"https:\/\/onep.com.tr\/en\/wp-json\/wp\/v2\/posts\/8212\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/onep.com.tr\/en\/wp-json\/wp\/v2\/media\/8214"}],"wp:attachment":[{"href":"https:\/\/onep.com.tr\/en\/wp-json\/wp\/v2\/media?parent=8212"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/onep.com.tr\/en\/wp-json\/wp\/v2\/categories?post=8212"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/onep.com.tr\/en\/wp-json\/wp\/v2\/tags?post=8212"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}