Neurectomy of Nerve Branch to Medial Gastrocnemius Muscle for Calf Reduction

In Orientals, hypertrophy of calves frequently found. In 1990, Mladick and Watanabe presented extensive and specific operative techniques for reduction of calves and ankles. however, they cautioned that liposuction should be restricted in the muscular type of calf because their anatomic characteristics led easily to complications and low satisfaction rate. the chief reason for this problem is due to hypertrophy of lower legs that is caused by muscular hypertrophy. In preoperative considerations for the patient selection, most patients have hypertrophy of the gastrocnemius muscles. Calf muscles composed of the medial, lateral gastrocnemius and soleus muscles. To identify the muscle hypertrophy clinically, the patient should stand on toe-tip posture and check out the pinch test for the measurement of fat thickness. Muscular hypertrophy of the calves is divided into 3 types, such as medial upper half, lateral upper half and total hypertrophy with or without excess fat of lower legs. The indications of calves reduction depends on the excess fat of lower leg, calf muscle hypertrophy and combined excess fat and muscle hypertrophy. The methods of calves reduction are as follows weight control, liposuction, calf muscle resection and combined procedures. But the postoperative results are not as dramatic as abdomen and have low satisfaction rate because there are many postoperative complications, such as surface irregularities, asymmetrical shape, scars with hyperpigmentation and infection. I reported that the neurectomy of medial gastrocnemius muscle is the new ideal method on calf muscle hypertrophy with medial bulging by the contraction of medial gastrocnemius muscle on toe tip stance especially in 1993. Recently this method are popular but the procedure needs expert skill. So muscular disuse atrophy by botox injection to medial gastrocnemius muscle is introduced temporarily. Other method such as muscle reduction by RF, denervation method by RF or alcohol injection to the area near nerve branches to medial gastrocnemius below popliteal fossa are also introduced but they are effected temporarily due to reinnervation of neurotization and neuroma in conduits. The surgical procedure is simple, easy and safe method and it can be done under the local anesthesia with sedation. The transverse incision 2 cm in length was done over the distal crease of popliteal fossa, and divided fascia and exposed the tibial nerve. and identify and confirm the 4 branches of medial gastrocnemius, sural, soleus and lateral gastrocnemius with nerve stimulation by electric current and then the nerve branch to medial gastrocnemius muscle has to be divided and removed above 3 cm in length. Skin closure was done with meticulous hemostasis. The postoperative care is simple. The wound was dressed with mild compression and changed daily. The patients can walk and go home immediately after surgery. We recommended early exercise and wearing the pressure garments to support shrinkage and smooth contouring of medial bulging area on calves during 3 months. The postoperative results are very satisfied from 1 to 3 month and there are no functional deficit and no edema, indurations and irregularity. The calf reduction rate was about 10% shrinkage(34cm in diameter on the superior 1/3 calves portion was reduced to 31cm in diameter, mean reduction is 2.5-3cm in diameter.) due to the muscular atrophy caused by neurectomy of medial gastrocnemius. In this report, I described that neurectomy of nerve branch to medial gastrocnemius muscle is a new ideal method for calf reduction and this procedure induce the superior results than the other procedures on calf muscle hypertrophy with 13 years long term follow up. I think my procedure is more rational and also effective, simple, easy, and safe for significant reduction of calves circumference and improvement of cosmesis on hypertrophy of lower leg.

Effect of Intermittent Electrical Stimulation of Sciatic Nerve on Expression of Neuronal Nitric Oxide Synthase (nNOS) Protein in the Soleus and Medial Gastrocnemius Muscles following Hindlimb Suspension in Rats / 대한정형외과학회잡지

PURPOSE: The present study was designed to evaluate the effect of intermittent electrical stimulation (ES) of the sciatic nerve on the expression of neuronal nitric oxide synthase (nNOS) protein in the soleus and in the medial gastrocnemius muscles 2 weeks following hindlimb suspension (HS). MATERIALS AND METHODS: In the HS+ES group, a pair of stainless steel electrodes were placed at the midportion of the unilateral sciatic nerve during hindlimb unloading. Square wave pluses with a 5 seconds ON-OFF pattern were applied to the sciatic nerve 4 hours a day for 14 days. The electrical stimulation parameters were 20 Hz, 0.3 ms, 1-5 voltage. 14 days later the sciatic nerve stimulation maximal twitch response was measured in the soleus and medial gastrocnemius muscles using an isometric tension transducer and polygraph. Western blot was used to analyze the expression of nitric oxide synthase (nNOS) protein in hindlimb muscles. RESULTS: The soleus muscle consisted of slow-twitch muscle fiber and showed a prominent decrease in maximum twitch tension and muscle weight than the medial gastrocnemius muscle 2 weeks after hindlimbs suspension. Hindlimbs suspension caused a reduction in the relative quantity of nNOS protein by 89% and 55% in the soleus and the medial gastrocnemius muscles, respectively, after 2 weeks of unloading compared with the ambulatory controls. However, intermittent electrical stimulation of the sciatic nerve delayed reduction significantly with respect to the expression of nNOS protein and twitch tension during hindlimb unloading. CONCLUSION: The results suggest that application of electrical stimulation to the sciatic nerve has a significant effect on NO signal transduction by regulating nNOS expression in atrophied hindlimb extensor muscles.