| The back ground and objectivesShort and thick leg is a popular aesthetic problem of oriental women. Thereare many of them want to reduce their calves by surgical means. A little part ofthem could be satisfied by liposuction, whose legs are thick because of fatty. Butmost of them have muscular legs and liposuction is not beneficial to them. Theshape of the triceps determines the shape of the calf. The triceps include the soleusmuscle and the gastrocnemius muscle. The later lies in the superficial layer of thecalf. The soleus lies in the deep layer. Most of women who have muscular legshave strong triceps. Calf reduction could be achieved by surgical means to reducethe triceps' volume. Now, calf reduction is to reduce the volume of thegastrocnemius not the soleus, because of the important function of the later.Another reason is that the gastrocnemius' shape influences the legs' shape most,which lies in the most superficial layer of the calf. There are three means for calfreduction nowadays. One is the part-resection of the gastrocnemius. Another is thelocal rejection of the "BOTOX" the kreotoxin. The third is the neurotomy of themotor nerves to the gastrocnemius. Theoretically, the part-gastrocnemius resection could control the amount of muscle needed to get rid off and get goodresult. But in fact, the serious edema, hematoma, nerve injury, irregular skinsurface and other complications happened after operation that made this surgicalway undesirable. "BOTOX" local injection is a good way to lower the localprojection of the leg. But its toxicity limits the amount of injection and has littlehelp to reduce the muscle volume. Further more, the result is impermanent.Neurotomy of the motor nerve to the gastrocnemius is very popular in Hong Kongand Korea and is seldom preformed in our country. There are little articles aboutthis technique in professional journals. Only one article had been found about theanatomy of this surgery after retrieved the professional journals 10 years recently.This surgical method was performed on cerebral palsy patient to relieve thegastrocnemius muscle spasm previously and was first performed for aestheticpurpose in Korea in about 2000. Because there are little articles about this method,the procedure and result of the surgery is not clear. The most important unclearthing is that if this surgical way is safe. If this way would influence the daily lifeof the person whose gastrocnemius would be paralyzed permanently after surgery.The purpose of this article is to found out these unclear things.MethodsNeurotomy of the motor nerve to the gastrocnemius would result topermanent paralysis of the muscle, so to be carefully, our research begun at animalstudies. After had got some knowledge about the safety and result of this way, westepped to the next study, the anatomic study, which would help us to determinethe procedure of the surgery. At last, we would perform this surgery in clinic andmade sure the results and safety of this surgical technique.1. Anatomic study of the rabbit triceps and tibial nerveTo observe the anatomic structure of the rabbit triceps and the tibial nerve, make sure the same and difference structure of the triceps between the rabbitand man. The purpose is to determine the methods of the operation and to setup proper animal study model.2. Neurotomy of the nerve to the medial gastrocnemius and the plantar of therabbitThe purpose is to observe the influence of the surgery to the rabbit'sactivity and to study the weight change of the denervated muscle and normalmuscle, which have the same function, to observe the pathological change ofthe muscle under microscope.3. Anatomic study about the neurotomy of the nerve to the gastrocnemius forcalf reductionThe purpose is to observe the fossa structure with topographic anatomytechniques, and measure the site, oriental point, length and width of the nervebranches from the tibial nerve in the fossa, to provide the anatomic idea forthe clinical surgery.4. Clinic study of the neurotomy of the nerve to the gastrocnemius for calfreductionThe purpose is to have a complete knowledge about the surgical technique,to make sure the results and safety of this surgery by the regular follow up anda serial of checking and measurement, the leg perimeter, photography, CTscan, myoelectricity and myodynamiaConclusions1. In some aspects the triceps' structure of the rabbit is same to the man. But thedeference between them is also obvious.①the soleus of the rabbit is verysmall, and the weight is less than the 1/6 of the weight of gastrocnemius.②the plantar of the rabbit is very big and strong. Its function is same to the triceps.③the lateral gastrocnemius is the heaviest part of the triceps and itcould be easily depart to three functional deferent parts anatomically.④thenerve to the soleus of the rabbit is very tiny and branches from the nerve tothe lateral gastrocnemius in the septa of the lateral gastrocnemius muscle. It isreally difficult to expose and isolate this nerve. The muscles in the back of theleg are very different anatomically and functionally between thefour-feet-animals and erect-man. The functional significance of the lateralgastrocnemius of the rabbit is same to the soleus of man. The soleus of therabbit is not valuable. So, we should cut off the nerve to the medialgastrocnemius and the plantar to set up the animal model. Firstly, by this waythe functional important part of the triceps is left. Secondly, the weight ratioof the denervated muscle to the triceps is similar to the ratio after clinicalsurgery. So, this way is accord to the principles of setting up animal modeland has some value to anticipate the result of clinical surgery.2. In one month after the surgery of neurotomy of the nerve to the medialgastrocnemius and plantar, the rabbits liked to repose and didn't like to move.2 month later, the rabbits recovered. There were no difference of the activitiesbetween the rabbits had had the surgery and the normal rabbits. The weight ofthe denervated muscle decreased very quickly to 50 percent in 4 weeks aftersurgery. 16 weeks later, the muscle fiber of the denervated muscle rarelyexisted and fibrosis could be seen. The soleus muscle begun to becompensatory hyperplasia at 4 weeks after operation and the weight increased30% at 16weeks. The main appearances of the denervated muscle fiber undermicroscope were atrophy, degeneration, adipose infiltration and fibrosis. Theatrophy and degeneration were notable at 4-8 weeks after operation andnormal structure fibers could not be found at 12 weeks. The fibers' structurechanges under electron microscope were degeneration, regeneration and degeneration of the regenerative fibers. These results indicated that 50%muscles of the triceps (include the plantar) lost would influence the activity ofthe rabbit at early stage after operation. The denervated muscles would neverbe renerved again and atrophy permanently, fibrosis in the end. The othermuscles had the same function would happen to compensatory hyperplasiaand the lost muscle strength would be partially compensated. These resultsalso indicated the result of clinical surgery.3. The tibial nerve lies in the fossa, the superficial of the popliteal vessels. Thereare 4 nerves branch from the tibial nerve, the nerve to the medialgastrocnemius, the nerve to the lateral gastrocnemius, the medial suralcutaneous nerve and the nerve to the soleus. There are two variation existed.①the medial sural cutaneous nerve branches from the nerve to the medialgastrocnemius.②the nerve to the soleus branches from the nerve to thelateral gastrocnemius. The nerve to the medial and lateral gastrocnemiusbranches from the tibial nerve at the field between 3cm below and above themidline of the popliteal. The width of the nerve is about 0.2cm and the lengthabout 4-5cm. The originate point of the nerve to the gastrocnemius muscle ispermanent relatively. And the nerve is easy to expose and isolate. Through a3-5cm long transverse incision at popliteal skin could easily expose and cutoff the nerve. The surgeon should keep in mind the variation of the nerve andmake sure not to injury other nerves.4. The tibial nerve branches were exposed and isolated from the trunk of tibialnerve through a 3-5cm long transverse incision at popliteal crease. With thehelp of the nerve stimulator the nerve to the gastrocnemius were determinedand cut off. 1cm long nerve segment should be resected and the proximal endof the nerve was fixed 180°reversal in case of the muscle got renerved. Weperformed the nerve to the medial gastrocnemius neurotomy on the most cases in case of the serious loss of the muscle strength. The weight of themedial gastrocnemius is about 25%-30% of the weight of triceps. We alsoperformed the nerves to the medial and the lateral gastrocnemius neurotomyon 1 case for experiment. Good results were gained on every case. The scaron the popliteal region is indiscoverable. The longest leg perimeter reduced1-5cm, 3cm averagely. The medial line of the leg became straight. Distortionbecause of soleus compensatory hyperplasia was not found. 12 of the 15persons who were performed nerve to the medial gastrocnemius didn't feltuncomfortable after surgery, and 3 of them felt the soreness of the leg afterhad walked a long way. The strength of the triceps didn't decrease at thestage of rapid and slow movement. But it decreased 25% when the angularspeed of the muscular checking system was set to 180°/sec. The results of theCT scan and the myoelectrical checking indicated the medial gastrocnemiusmuscle atrophy and no other nerves had been injured. The person whoreceived the nerves to the medial and the lateral gastrocnemius neurotomy feltpowerless of the leg, and recovered gradually after half year post-operation.Except obvious scar of 3 persons because of local infection, there were noother complications found. The technique of the nerve to the medialgastrocnemius neurotomy was safe and simple. Good result could be expectedfor the patient who's muscular legs because of the strong medialgastrocnemius muscle. The patients' daily life would be influenced if thenerve to the lateral gastrocnemius had been cut off at the same time. Thecompensatory hyperplasia of the soleus muscle could lead to undesirabledistortion of the leg, but this problem is still in disputation. |
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