Calf Augmentation and Volumetric Restoration: A Systematic Review and Meta-analysis

Abstract

PURPOSE: According to the American Society of Plastic Surgery (ASPS) National Clearinghouse of Procedural Statistics, 655 documented calf augmentation cases were reported during 2018 in the United States, representing a 27.43% increase from 2015. Due to the recent attention that has been brought to the aesthetics of the leg, outcomes in the literature are underreported and require further investigation. We summarized the available evidence on the surgical techniques to augment the volume and dimension of the calf based on clinical outcomes and satisfaction rates METHODS: An electronic search was conducted across PubMed MEDLINE, Web of Science, Scopus, and Ovid MEDLINER(R) in accordance with the PRISMA statement. Data collection included the patients’ characteristics, surgical techniques, and postoperative outcomes. Satisfaction among patients was determined when satisfaction was stated above a numeric threshold in a score or when a patient was explicitly reported to be ‘satisfied’. Pooled estimates were calculated with a random-effect meta-analysis using the DerSimonian-Laird model. RESULTS: Forty-eight studies were included in the systematic review. We included 2455 patients. 508 were males (20.7%) while 1176 were females (47.9%). The average age and follow-up were 33.15 years and 33.58 months, respectively. Unilateral calf augmentation was reported in 446 patients (18.16%), while 1565 patients (63.74%) received a bilateral calf augmentation. The indications for calf augmentation were aesthetic concerns in 1196 patients (48.7%) and reconstructive in 558 patients (22.7%). The most common technique for calf augmentation was subfascial implant placement (70.2%) followed by fat transfer (17.6%), submuscular implant placement (10.1%), fasciotomy only (1.71%), reconstruction with free flaps (0.12%), dermal-fat graft (0.04%), subcutaneous implant placement (0.08%) and non-specific implant (0.04%). Overall, the pooled satisfaction rate following calf augmentation was 95.4% (95%CI 93.7%- 97%). The pooled satisfaction rate for implant placement and fat transfer was 96.7% (95%CI 94.4%-97.9%) and 87.2% (95%CI 78.5%-96%), respectively. The most common complications following subfascial implant placement were seroma formation (3.83%), hyperpigmentation or hypertrophic scar formation (2.9%), and pain or discomfort (2.14%). The most common complications after lipotransfer were asymmetry or contour irregularities (4.16%) and pain or discomfort (2.54%). The pooled incidence of implant removal was 1.3% (95%CI 0.7%-2%). The pooled estimate for additional fat grafting procedures following initial fat transfer was 54.1% (95%CI 38.3%-70%). From the patients who underwent reconstruction with a free flap, one patient required the revision of the anastomosis (33.33%) and one had significant blood loss (33.33%). CONCLUSION: Overall, calf augmentation is a safe procedure. Subfascial placement of the implant was the most common technique as it is less invasive and reproducible. However, the rate of minor and major complications may be higher in comparison to other procedures. Fat grafting can be used to improve the outcomes following implant placement. When fat grafting is implemented as a single surgical modality the volumetric expansion is modest versus implant placement, and further fat grafting is required in almost half of cases to achieve satisfactory outcomes.