25.1 Introduction

Calves, ankles, and knees are anatomic areas of common concern to many patients who desire both cosmetic and functional benefits. Universally, strong thighs tapering to thinner calves and delicate ankles are considered to be desirable characteristics. In addition, thin knees without bulging are desired by all women as well. The appearance of excess knee adipose tissue, especially in the medial region, is exacerbated with the legs crossed. While they are amenable to suction-assisted lipectomy (SAL) to decrease bulk, craft a more sculpted leg profile, decrease edema and provide the ability to fit into certain styles of boots, calves, ankles, and knees remain a relatively uncommon area for treatment by most plastic surgeons. In properly selected patients, liposuction of these areas can be done reliably and reproducibly to provide high patient satisfaction.

25.2 Preoperative Evaluation

Full history and physical examination with a focus on the lower extremities with laboratory values and medical clearance obtained as needed is conducted as in any body contouring workup. More specifically, the surgical plan of the leg must be approached in a three-dimensional and circumferential manner which takes into consideration the differences in the relative amounts of skin, fat, muscle, and bone depending at what level the calf and ankle are operated. Patients will present with differing complaints as well as disparate areas of fat deposition. Due to the dependent position of the leg, postoperative swelling is prolonged compared to other areas of the body and may persist for six months or longer. Even with compression stockings, the patient should be made aware of this during consultation. During the physical examination and history, the surgeon seeks physiologic reasons for increased caliber of the leg which would be contraindications to liposuction. Lymphedema, incompetent veins, cardiopulmonary causes of edema, and a host of other medical conditions must be first ruled out.

25.3 Markings

It is important to identify the muscular component contributing to the overall leg profile. In patients with particularly developed muscles especially with a low insertion of the soleus, the profile may not be significantly improved by fat removal. To differentiate this, the patient is examined in the “tip-toe” position so that the medial and lateral heads of the gastrocnemius muscle and soleus are easily identified and marked. If the distal Achilles tendon is short or the soleus muscle is wider than normal, for instance, a large improvement in contour with fat removal may not be possible. In contrast, removal of a relatively small volume of fat in patients with normal to long tendons can result in dramatic improvement in the profile. The distribution of fat also changes from more well defined proximally at the knee to more diffuse distally. It is noted that even in heavier patients, there is a paucity of fat overlying the anterior tibia and this is a region that rarely requires fat removal.

The head of the fibula is palpated and identified. Marking this clearly is important to determine the area which is not treated due to the proximity of a branch of the common peroneal nerve. Inadvertent contact by the instruments may causing neuropraxia and resultant foot drop and must be avoided. As mentioned above, the anterior pre-tibial area is marked with vertical lines as a region which rarely requires fat resection even in heavier patients. Any excess fat in the ankle region tends to be localized on either side of the Achilles tendon and overlying the medial muscle group. It is important to differentiate fat from muscle in this region using the simple pinch test.

Knees are treated medially where the excess bulging area marked in the standing position and exacerbated with outward rotation of the foot and the knee in flexion. This is generally medial to the patella and extends posteriorly to the border of the popliteal fossa. Superiorly, it extends to the quadriceps insertions and inferiorly to the medial tibial tubercle. For example, medial knee fat that is particularly visible with the legs crossed, is a good opportunity to improve a specific area of complaint while enhancing the overall leg profile in the standing position. The presence of the bony prominence of the femur exaggerates a relatively small amount of fat that, when resected, has a large impact. In contrast, the prepatellar fullness that is often accompanied with wrinkling should be approached with caution because the skin elasticity, presence of overlying quadriceps fullness, and excess fat may contribute to loss of support of the soft tissues if over-aggressive fat removal is undertaken.