Calf and Ankle Liposuction

Lipoplasty of the lower extremities has become increasingly popular in the last 2 decades. Although it was once considered a procedure that was fraught with complications and unsatisfactory results, improvements in technique are addressing these concerns. Emphasis on an aesthetic lower extremity has now replaced previous experiences with liposuction, in which legs became thinner but remained tubular and lacked curves. Liposuction can now reduce the bulky look of the calves and result in slimmer, tapering lower legs.

As early as 1964, Schrudde treated the ankle using small incisions strategically placed about the ankle and contoured the area using sharp curettage. Illouz popularized liposuction as opposed to curettage in 1977. He recommended suctioning the deep layer of fat in areas with a defined superficial and deep layer. These areas were typically the outer and inner thighs. In 1982, Teimourian and Fisher reported a case using both sharp curette and suction for the ankle.

Mladick began to suction the upper calf in selected patients in 1983. Further advances in 1985 and 1987 were the introduction of cross-tunneling and the accelerator-tip cannula, respectively. He then reported his first case of circumferential liposuction of the lower legs in 1990.[1]

In 1994, Gasperoni and Salgarello, using small cannulae and incisions, popularized superficial liposuction 1-2 mm below the skin.[2] Over the last several years, Rohrich et al discussed using internal ultrasound-assisted liposuction for the upper one half of the lower leg.[3] Hoppmann et al have recommended liporemodeling as an alternative to silicone implants in reshaping the calf.[4]

Liposuction of the lower extremity from thigh to ankle is an important adjunct to many plastic surgeons' practice.[5]  Having succeeded in reducing particular bulges in the thigh, lower extremity liposuction has now advanced to providing a curvy lower extremity with techniques of circumferential[6] and superficial liposuction.

Patients who are considering this procedure must be examined to see if liposuction of the calves and ankles can adequately address their concerns. Larger lower extremities can be secondary to hypertrophy of muscle tissue, in which case liposuction would be of little benefit.

In selecting a patient for liposuction of the calves and ankles, legs are classified as circumferential or localized heavy legs. In the circumferential type, specific fat distributions are not well-defined and the leg, as a whole, is considered fat. Areas in exception to this are between the perimalleolar regions and over the Achilles tendon distally, rarely having significant fat deposits. In the localized type, the lower calves and ankles tend to have definite bulges over the lower lateral fibular, medial tibial, and ankle regions. Excess fat over the transition between the gastrocnemius muscles and the inferior leg can lead to a tubular-appearing leg.

The pinch test can be used to assess fat deposits. This is performed with patients standing on a stool flat-footed and then standing on their toes. The pinch test can also be carried out with the leg rested horizontally on a chair and the knee bent 90° while the patient stands on the other leg. The minimum pinch test result should be 2 cm in the calves and 1 cm in the ankles.

The ideal patient is in good health, is aged 20-30 years, and has good skin tone. If the patient is older than 50 years and has good skin tone, he or she is a suitable candidate.

While the motor nerves and most vessels lie deep to the investing fascia, certain structures within the fatty tissue must be taken into consideration when carrying out liposuction of the calves and ankles.

Posterior to the femoral and tibial condyles, the greater saphenous vein descends from behind the knee along the medial leg and then anteriorly to the medial malleolus (see first image below). In the foot, it courses dorsomedially and merges with the medial marginal vein in the sole of the foot through small tributaries (see second image below). The marginal vein courses along the dorsolateral aspect of the foot behind the lateral malleolus and becomes the small saphenous vein as it courses superiorly.

Accompanying the vessels, the saphenous nerve courses along with the greater saphenous vein, and the sural nerve courses with the small saphenous vein at the lower one third of the leg (see image below).

Importantly, stab incisions must not enter the saphenous veins or injure the nerves. Likewise, liposuction should never be performed at the popliteal fossa because of a high risk of injuring the neurovascular structures.

In the thigh, the greater saphenous vein is the only anatomic structure superficial to the fascia that may be injured. The vein is 1.5 in below the inguinal ligament, medial to the femoral artery, and ascends on the anterior and medial aspect of the thigh.

Surgical anatomy

When performing liposuction of the lower extremity, understanding the anatomy of the specific areas and the differences in fat layers is important.

Traditionally, both deep and superficial fat layers are found throughout many areas of the body. However, a deep layer is not present from the mid portion of the anterior and posterior thigh, in the calves, and in the ankles. When considering layers of fat, the subdermal layer is approximately 1-2 mm below the skin. The intermediate or superficial layer is 0.5-1 cm below the skin, and the deep layer is approximately 1-2 cm below the skin. Understanding these layers and the anatomy of the lower extremity helps determine whether superficial or deep liposuction can be performed and helps predict the expected results.

Chamosa has categorized the anatomy of the knee.[7] Area 1 is above the kneecap and is in the shape of a banana. It can appear as a flap of fat lapping down over one half of the kneecap. Area 2 is the medial knee, and area 3 is the lateral knee. Areas 4 and 5 are below the kneecap and represent 2 small areas of fat distribution. The lateral fat is usually greater than the internal or medial fat. Area 6 is the area from the inner lower kneecap to the upper calf. This gives the leg a tubular appearance.

Chamosa also describes the ankle and distal portion of the leg as a rhomboid prism.[8] He describes the major axis in the anterior-to-posterior direction, with 4 edges and 4 rectangular sides. The anterior edge is a prolongation of the anterior crest and tendon of the tibialis anterior muscle. The dorsal edge is the tendon calcaneus. The medial edge is the internal border of the tibia and medial malleolus. The lateral edge is the tendon of the peroneus longus and brevis muscles, which finish in the lateral malleolus.

The 4 sides of the rhomboid prism are seen in the frontal view as anteromedial and anterolateral and in the dorsal view as posteromedial and posterolateral. Adiposities of the ankle zone extend from the line between the lateral malleolus and medial malleolus. With exaggerated lipodystrophies, the malleoli prominences remain hidden.

In addition to excess fat over the malleoli, fat can overlie the inferior gastrocnemius muscles, leading to loss of definition.

Patients with a history of hypercoagulability, including deep venous thrombosis or thromboembolic events, should not undergo surgery. Active phlebitis is an absolute contraindication to this procedure. Checking for superficial vascular patterns and signs of a tendency toward venous insufficiency (ie, hemosiderin deposition, edema, varicose veins, spider veins) is important. Vein stripping for severe varicosities should precede liposuction by at least 3 months.

Evaluate the patient for lower extremity edema or venous disorders. Peripheral edema is generally not exacerbated by lipoplasty, but it may cause disappointing long-term results. In general, if venous competency is in question, refer the patient to a vascular surgeon for evaluation prior to liposuction.

Instruct the patient to stop aspirin, nonsteroidal anti-inflammatory drugs, vitamin E, alcohol, and all tobacco products and to decrease sodium intake 2 weeks prior to surgery. The patient should be hydrated adequately preoperatively. If fitted compressive garments are to be used postoperatively, the patient should be fitted before the procedure.

While the patient is standing, mark his or her lateral and medial thigh bulges with wide peripheral limits. Mark the anterior and posterior thighs, extending to the inferior limits of the saddlebags.

Mark the calves and ankles while the patient is in a sitting position with the legs dangling. Also mark the areas with the patient in tiptoe position. This allows for differentiation of the thickness of the fat bulges from the underlying muscles and tendons.

First, outline the inferior limits of the largest fat accumulation in the ankle region. Mark the malleoli and Achilles tendon area and the area overlying the tibia so as to avoid liposuction in these areas. Then, draw a line posteriorly and anteriorly from the medial knee to the ankle region. Mark the transition zone where the inferior calf muscles narrow and taper toward the ankle. Mark the superior limits of a heavy calf circumferentially just below the knee. Mark the medial, lateral, and superior knee bulges. Then, mark 4 incisions in the ankle and knee region (medial and lateral). Also place incision marks in the anterior groin and posterior buttock crease.

Other asymmetric 2-mm incision sites may be marked and used to achieve access and contour. Grid patterns can also be made with methylene blue after the patient is prepared and draped to further delineate boundaries and landmarks.[9]

Typically, place the patient in the supine position. Either general anesthesia or spinal anesthesia with sedation can be used.

Perform liposuction of the anterior legs with the patient's legs straight, fanning out from the groin. Suction the inner thighs with the patient in the frogleg position. For the lateral thigh area, the patient can be turned at the waist and the hips can be placed in the lateral decubitus position. For the posterior thigh, the leg can be lifted into a knee-cheek position or the patient can be placed in the prone position.

Important principles to practice to obtain satisfactory results include using the superwet local anesthesia technique, pretunneling, using 2- to 4-mm accelerator cannulae, and using a 1-hole concave and convex cannula. The average amount of superwet infiltration of the ankle and calf combined is approximately 750-800 mL. For the ankle alone, it is approximately 200-300 mL. Sterile tourniquets can also be used at the beginning of operations to minimize postoperative edema.

In the thigh, liposuction of distinct fat accumulation, such as in the outer and inner thighs, can be performed in the usual manner. To liposuction a thigh circumferentially, liposuction must occur at all 3 fat levels. First, place the cannula at the deep level, which is 1-2 cm below the skin in the deep subcutaneous level. Second, perform liposuction in the intermediate level, which is 0.5-1 cm below the skin at the base of the subdermal fat. Third, perform liposuction 1-2 mm below the skin with the hole facing away from the skin. The cannula must be passed beyond the anterior and posterior midline areas through each incision to provide circumferential liposuction.

Perform liposuction of the calves and ankles at a superficial and intermediate level. Pretunneling in the calf is 0.5 cm below the skin (2-3 mm in the ankle). Suction the calves. For the medial calf, suction down through the medial knee incision with the patient's legs abducted in the frogleg position. For the lateral calf, turn the trunk at the waist, placing the legs in a lateral decubitus position. For each incision, suction downward and then circumferentially past the anterior and posterior midline. Less liposuction is performed at the proximal third of the leg to avoid a tubular appearance and to maintain the transition of the muscular calf to the thinner ankle.

To reach around the anterior and posterior calves, use a concave accelerator cannula, suctioning horizontally or obliquely through both the medial knee and ankle incisions. A convex cannula allows suctioning in the midlateral and medial areas in a vertical direction.

Suction the transition zone transversally and obliquely with the 2-mm concave cannula through 2 small incisions positioned 3-cm medial and lateral to the midline. Suction between the marked horizontal lines and in an anterior-to-posterior direction. Pass the cannula 20-30 times, angling slightly upward toward the back of the leg. Suction the medial transition zone aggressively; suction the lateral transition zone lightly.

For ankle suctioning, place 2 medial and 2 lateral incisions anterior and posterior to the malleoli. Do not suction over the Achilles tendon. The procedure requires cross-tunneling up to the transition zone in a vertical, longitudinal, and oblique direction. Aggressive suctioning in this area maximizes the amount of subdermal fat removed.

Internal ultrasound may be used on the upper one half of the lower leg for 1-2 minutes. Decrease the ultrasound to 40% maximum energy, with the endpoint being loss of cannula resistance.

The endpoints of suctioning are a pinch test result of 1-1.5 cm, when aspirate turns from mostly fatty to mostly bloody, and when both legs are symmetric in appearance and in removed aspirate. Tourniquets, if used, are not deflated until the procedure is complete.

Mladick proposes intraoperative maneuvers to decrease swelling postoperatively.

Tourniquets are inflated while dressings are applied. After the first leg is suctioned, roll out the fluid accumulation through the incision, thereby milking the leg. Wrap a sterile 6-inch elastic bandage prior to suctioning the other leg. After suctioning the second leg, unwrap both legs, measure them, and observe them for contour. Dress wounds with 2 x 2 gauze pads. Then, wrap both legs with 0.5-inch, soft, nonadhesive foam. Wrap the entire leg with a 6-inch elastic bandage. Tourniquets are deflated at this time.

In the recovery room, elevate the legs and apply compression boots. Patients should attempt to remain supine with legs elevated for the first week postoperatively. Allow the patient to ambulate to the bathroom on the first postoperative day, and increase activity thereafter. Instruct the patient to place his or her heel down to avoid heel-cord shortening.

Change the dressing on postoperative day 4. Sequential compression is applied for 2 months during the night. The compression stockings are maintained during the day.

Rohrich et al use the pneumatic compression device almost continuously for the first 3 weeks, with full-length compression stockings for the first 3 months. External ultrasound can be applied 2-3 times per week for the first 3-4 weeks to facilitate edema resolution. Leg elevation is still emphasized and manual lymphatic massage should be started as soon as the patient can tolerate it. Using these measures, postoperative edema is minimal at 2-3 months.

A reported complication specific to the knee is a perforation of the capsula articularis. The use of a blunt cannula, multiple incisions, and extension of the knee is recommended to avoid this complication. If it occurs, treat the injury with an elastic bandage and antibiotics.

In the ankle, hyperpigmentation, telangiectasia, and depressions have been reported as most likely secondary to the dependent location and thinness of the overlying fat. Superficial blistering over the Achilles tendon is rare and probably caused by increased pressure. If this occurs, release the compression stocking over the Achilles tendon. Decreased big toe sensation immediately in the postoperative period has also been reported, but it resolves over time. Postoperative pain can also be severe. Recovery time is longer for liposuction in the calves and ankles than in other body areas secondary to factors including edema.

Infection, skin slough, phlebitis, posttraumatic tendonitis, and arthritis are rare.

The most frequent complication is persistent ankle thickness in 10% of patients, partly due to edema and underresection of the ankles. Contour deformities can occur, as in other areas of liposuction.

In summary, although lower extremity liposuction was once considered fraught with complications, advances have led to improved outcome. Minimal complications are involved, but patients and physicians must expect a slower and longer recovery than with liposuction in other areas of the body. This is because of the dependent position of the legs and the increased propensity for edema. With realistic expectations and careful perioperative management, patient and physician satisfaction can be attained.

For excellent patient education resources, see eMedicineHealth's patient education article Liposuction.

Laser liposuction for use in the upper extremity is currently under investigation.[10, 11]