Your Questions

Q: Dr. Eppley, I am interested in buttock and calf augmentation. I prefer the fat from my body to be used. But I have one question… how long will the fat persist in my calfs and buttocks?

A: Thank you for sending your pictures. Fat injection calf augmentation can be done as long as one has enough fat to harvest to do the procedure. It would be very unlikely, however, that one would have enough fat to do both their buttocks and calfs. You would likely have to choose to place fat either in the calfs or the buttocks and choose an implant for the other location. Given that fat takes and persists better in the buttocks, it would make the most sense to use all of the available fat for the buttocks. Fat injections do not persist very well in the calfs and calf implants offer a simple, assured and permanent augmentation procedure.

When it comes to body contouring by fat injections it is important to understand that they work best in areas that already have some fat. Thus it is no surprise that fat injections work better for buttock augmentation than they do for calf augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in fat injections to make my calfs and ankles bigger. My understanding is that fat injection is not a permanent solution. So if it is applicable in my case do I have to do it on regular basis?

A: While it is true that the lower legs (calf augmentation with fat) is not the best place for fat to take (due to the pressure of the overlying skin), the fat that does take can become permanent. So it is no true that fat is not a permanent procedure. It can be if enough fat is initially placed. The concept of lack of permanency in fat injections comes from the not rare scenario where a repeat fat injection treatment is done to finally get the desired result. This is not because it does not work, just that only a fraction of what was injected (maybe only 10% to 25% of the fat) survives and more fat injections are needed to get to a better end point. Think of it as adding layers to get to the desired result. In some patients, it is a one time procedure but in others a second procedure may be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very burning question about calf augmentation by fat injection .I know my appointment is coming up soon on the 22nd but the closer it gets, the more anxious I am. I know not to have too much expectations but is there a away to enhance the outcome, for example, do you add anything to the fat to make them more viable?And is there anything I can do to improve the results?I totally think my calves are the skinniest anyone can ever imagine and so will I really have enough fat to make them as bigger as possible? If I will need a touch up, do I have to go through the entire procedure or do you  preserve some fat from the first procedure. Thanks.

A: The methods to enhance fat injection graft take are how the fat is concentrated at the time of its harvest prior to its injection. Some enhancement of fat graft survival has been noted from adding PRP (platelet-rich plasma, a blood extract) but that evidence is not conclusive. Since it is your own blood extract it is perfectly safe. But whether it truly improves fat graft take is not clear.

Harvested fat can not be preserved for a secondary or touch-up procedure. It is technically possible to do so but it has been shown that none of that frozen fat will survive when injected later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in calf augmentation with fat grafting/lipo filling. I am a 33 year old man with over a decade of weight lifting and exercise experience. I have trouble building muscle particularly in my calfs. I am hoping fat grafting can give me the desired look I’ve been working so long for.

A: While I appreciate one’s desire to build body contours using one’s own tissues, there are several key issues about injectable fat grafting. First, one has to have enough fat to harvest that, after filtering and purification, has enough volume to augment the calfs as well as any other areas. Whether a young man who is most likely fit has enough fat to accomplish that remains to be seen. Secondly, fat grafts are not like implants. The predictability of their survival to maintain volume is far from assured. Injectable fat grafting is associated with a wide variability in fat volume retention and young lean people usually have a lower retention rate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about getting a calf implant. I had ruptured achilles on my right leg about 10 years ago and muscle never developed back properly.

A: One of the most common reasons for a calf implant is to improve lower leg asymmetry after such congenital problems as clubfoot or traumatic injuries. When the achilles tendon is ruptured, the soleus and gastrocnemius muscles which are attached to it can become atrophic due to immobility and subsequent muscle atrophy. Even with rehabilitation, the muscle volume does not come back. Calf implant augmentation can help restore some of the volume by adding volume under the fascia but on top of the muscle. Based on the size of the medial head of your gastrocnemius muscle (length and width) different sized calf implants are available to augment it. This is done an incision on the back of the knee.This is done as an outpatient procedure that usually takes about 30 minutes for the insertion of one calf implant. While calf augmentation surgery can involvhe significant recovery, having the surgery in just one leg makes it easier.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25yr old male who was born with club foot. I went through life playing sports and excelling in every aspect. At this point in my life I am currently coming to a financial point to pursue a calf implant surgery. Can you please inform me of what the procedure is all about, how often it is performed, success rate, and cost. Thanks you for your time and I look forward to moving this process along!

A:  Calf augmentation can be done by either an implant or more recently fat injections. The more guaranteed method of permanent calf augmentation is with an implant. Calf implants, like all body implants, are made of a very soft and spongy solid silicone rubber material which feels very much like muscle tissue. It is inserted through a small incision in the back of the knee in an outpatient procedure done under general anesthesia. The procedure is most commonly done in body builders or non-athletes who feel that their calfs are just too small. The most challenging patient in my experience is the club foot patient because, not only is the calf too small but the surrounding skin is very tight. This makes the insertion of an adequately-sized calf implant more difficult and it will not be possible to match the circumferential size of the smaller calf to the larger one. The club foot patient must be willing to accept improvement in calf shape but an ideal result will not be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my left calf muscle is 2 to 3 inches smaller than my right. I do have muscle in my leg but it just will not enlarge with exercise. I am interested in getting calf implants. I was wondering how long I would need to stay after surgery.

A: Calf augmentation is done as an outpatient procedure. You could go home the same day, but if you live far away, you consider going home the next day.
A calf implant will help the size of the smaller calf but will not be able to make it match identically to the opposite normal side in shape or circumferential measurement. The tightness of the skin is the limiting factor in congenital calf asymmetry, the most challenging use of calf implants. In an ideal world congenital calf deficiency would be treated by a two-stage approach, a first-stage fat injection augmentation followed three months later by the placement of a calf implant. This is the ideal approach because the fat injections and the associated stem cells in it allows for some soft tissue expansion and a thicker soft tissue bed to ultimately receive the implant. But because of cost considerations, most patients have to go immediately for the implant.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I planned for long time to get calf augmentation and feel that now is the time. I am 170 cm tall and weigh about 72 kg and am very athletic. But I have skinny calves and they haven’t grown like the rest of me. My calves are 34 cm around.  I am ready for this mentally and financially. I want to know which type of method  is best for me and about the price and how much bigger will they be?

A: The most reliable method for calf augmentation is using soft very flexible solid silicone implants placed through a popliteal incision. The amount of calf size increase that can be obtained is based upon whether one (medial) or two (medial and lateral) calf implants are used and how tight or soft the calf skin is. Calf augmentation can also be done by fat injections but that method is limited by how much of the fat will survive and whether one has enough fat to harvest for the procedure. At your height and weight, I do not envision that you have any significant fat to use.I will need to see some pictures of your lower legs to see what may best for you. The price of surgery is based on how many implants are used so seeing the pictures first is important.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am writing to inquiry about a calf implant for my daughter. She has developed a  rather significant difference in the size of her calfs now that she is a teenager. While it was slightly apparent as a child, it has become real obvious as a 15 year-old teenager. It bothers her to the point that she will not wear shorts or go to the pool with other teenagers. She walks fine and as no disability from the calf size difference. I know that calf implants can be done for body builders and others who want both calfs to look bigger, but can just one calf implant be done? I could not find anywhere where just one was done.

A: Calf augmentation with implants is an uncommon body contouring procedure. While it has been done for decades, it is far less common than breast or buttock implants. While most people think that only body builder types do the procedure, it may surprise you to know that their use for ‘reconstruction’ of congenital calf deformities makes up about half of all calf augmentation procedures.

Calf implants are made of specially-shaped soft flexible silicone rubber. They are surgically placed through a small incision behind the knee. They can not really be put inside the calf muscle but are placed on top under its fascial covering. They can be placed on either the inside, outside of the calf, or both. Most commonly, they are placed on the inside half (medial) which is where most of the calf’s definition can be visually seen.

For calf asymmetry, placing a calf implant on the smaller side can help make their size discrepancy less apparent. If your teenager is that bothered by it, I would seriously consider the procedure. It is really the only good plastic surgery option for such a calf problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I’ve read your article on calf augmentation using fat transfer. Since 2008, have you performed this procedure? I have finding very mixed feedback on this. Some surgeons are saying this is high risk and will be unsuccessful because the fat will all be absorbed. Another doctor in NY I’ve been in contact with says he has had great success and with little side-effects. Appreciate your feedback.

A: Calf augmentation is most reliably done with implants. There are specific silicone rubber implants made for the calf and they are placed through a small incision on the back of the knee. (popliteal fossa) Because an implant is used, the result is stable and consistent in the amount of size increase obtained. Conversely, because it is an implant there are the associated issues of the risk of infection, malposition and asymmetry as well as a significant recovery and discomfort.

Fat injections, no matter where they are considered and what they me be used for, always have the same appeal. Using a natural tissue that has virtually none of the risks of an implant-associated procedure. Despite those benefits, fat injections have one significant downside…their volume retention is unreliable. At this time, there are no standard techniques for fat preparation and injection and the science behind its survival once transplanted remains to be discovered and utilized for more stable outcomes.

Because of the differing techniques and injection methods, fat injections for larger volume areas (breast, buttocks, calfs) have widely variable results. With these inconsistent results come quite discrepant surgical opinions about their effectiveness. There is now to reconcile one plastic surgeon’s experience vs another at this time.

Calf augmentation with fat injections is relatively ‘new’ and the worldwide experience is still evolving. The issues with the calfs are no different than the buttocks or breasts. It is a very safe procedure with minimal downtime. But one has to accept the reality that how much fat survives is the risk of the procedure. And more than one session may be needed to get the best results. (more likely than not) My experience has been with just a few cases and the early results have been acceptable. But the key is patient selection…don’t ask the fat to do what an implant can do better. (mild enlargement, not big enlargement)  

Dr. Barry Eppley