Calf-Contouring Surgery of Gastrocnemius Hypertrophy: Selective Neurectomy of the Sural Nerve

Generally, Asians tend to have obese calves that are shorter and thicker than those of Caucasians. The cause of the enlarged calves is either an excess of subcutaneous fat or calf muscular hypertrophy, but some patients have both conditions. These features are accentuated by the contraction of the calf muscles when patients stand in tiptoe position or wear high heels. In the case of calf muscular hypertrophy without excessive subcutaneous fat, manipulation of the calf muscle is an effective method for reducing calf circumference. From January 2005 to December 2006, the authors performed selective sural neurectomy for 20 patients who complained of obese calves. Using a popliteal incision, the sural nerve branches to the medial and/or lateral gastrocnemius muscles were dissected from the posterior tibial nerve. Using a nerve stimulator, the branches with the most contractile portions were resected in 1 cm lengths at the distal ends. One medial branch was resected in 15 patients, and two branches were resected in 5 patients. In the case of a lateral neurectomy, only one branch was resected. Ultrasound-assisted liposuction was combined for five patients who also showed excessive subcutaneous fat. The patients ranged in age from 19 to 29 years (mean, 23 years). The follow-up period varied from 6 to 18 months. The circumferential change was checked 6 months postoperatively 15 cm below the medial condyle and 15 cm above the medial malleolus. These average circumferences were reduced, respectively, from 36.6 and 32.5 cm to 35.5 and 32.2 cm. In gait analysis performed at 6 months postoperatively, the calf muscle power was slightly reduced to 95% of the preoperative state, but still remained above the normal range. Subjectively, no patient complained of muscle weakness or gait disturbance. One patient showed lower leg edema after mountain climbing that subsided after 1 day of rest. The authors believe a selective neurectomy technique can be an effective method for treating obese calves.     

Botulinum Toxin A for Aesthetic Contouring of Enlarged Medial Gastrocnemius Muscle

BACKGROUND: Oversized, muscular calves can cause psychological stress in women. Botulinum toxin A has been used in the treatment of benign masseteric hypertrophy with correction of the squared facial appearance. It is believed that botulinum toxin might also be effective in reducing enlarged calf muscles. OBJECTIVE: This study was performed to investigate the effect of botulinum toxin A in reducing enlarged medial gastrocnemius muscles in volunteers with muscular legs. METHODS: Botulinum toxin A of 32, 48, or 72 U was injected in each medial head of the gastrocnemius muscle in six women. Clinical photography was taken and the leg circumferences were measured. The functional evaluations were performed by examining range of joint motion and motor and sensory examination. RESULTS: All of the enrolled subjects showed a reduction in the medial gastrocnemius muscle after the botulinum toxin injection. The reduction in medial calf was noticed even after 1 week and the effect of was well maintained for 6 months. Leg contouring was obtained by the botulinum toxin treatment. The middle leg circumference showed a slight decrease in five subjects. No functional disabilities were observed. CONCLUSION: Botulinum toxin A can be used to contour the aesthetic enlargement of the medial gastrocnemius muscle with slight reduction in volume. Botulinum toxin-induced atrophy of the muscle caused no functional disabilities and the clinical improvement was well maintained for 6 months after the botulinum toxin A injection.     

Innervation of calf muscles in relation to calf reduction

Plump and muscular calves, a so-called radish-like leg, embarrass young women and cause a feeling of inferiority in Korea. Damage to motor nerves innervating a muscle makes the muscle paralyzed and dystrophic, with loss of muscle volume. The authors studied the morphometry of the motor branches of the tibial nerve innervating the gastrocnemius and soleus muscle and sensory medial sural cutaneous nerve in popliteal fossa. Dissection and exploration of the tibial nerve were performed in the popliteal fossae of 70 legs (of 18 males and 17 females) of embalmed Korean cadavers. The main branch of the tibial nerve innervating medial and lateral gastrocnemius muscle originated 3 cm above and below the popliteal crease. The medial gastrocnemius muscle had an additional nerve (49%). The medial sural cutaneous nerve came off the nerve into the medial gastrocnemius muscle (30%) and diverged 5.5 mm from the tibial nerve. The nerve into the soleus muscle originated from the nerve innervating the lateral gastrocnemius muscle (30%) and was 12.3 mm away from it. Surgeons should keep in mind that the medial sural cutaneous nerve originates from the nerve to medial gastrocnemius in 30% and the nerve to soleus muscle originates from the nerve to lateral gastrocnemius in 30%.     

腓肠肌内侧头肌支神经切断小腿减肥术应用解剖及临床效果观察

目的介绍将腓肠肌内侧头肌支神经切断使之萎缩,改善小腿粗壮外形的方法。方法解剖20具尸体腿,观察、测量腓肠肌内侧头肌支神经,为手术提供解剖学基础。对16例腓肠肌内侧头肥大者行腓肠肌内侧头肌支神经切断小腿减肥术,测量并记录小腿周径和外形变化。结果腓肠肌内侧头肌支神经在窝处从胫神经发出,以独立1支走向肌门者占40%,中途分成2支者占30%,与腓肠内侧皮神经共干起始者占30%。以股骨内上髁水平线为基线,该肌支起点平均高度为(-6.6±13.7)mm,起始处宽度(2.3±0.4)mm,长度为(42±12)mm。16例术后小腿最大周径平均缩减(3.5±1.1)cm,内侧曲线平缓。术后早期可下地行走,无明显肿胀。随访半年,日常活动未受影响。结论腓肠肌内侧头肌支神经切断小腿减肥术简便、安全、效果明显,不影响受术者的行走功能。     

Soleus and gastrocnemius muscle loading decreases anterior tibial translation in anterior cruciate ligament intact and deficient knees

This study evaluated the effect of the gastrocnemius and soleus muscles on dynamic knee stability by studying the effect of passive calf muscle loading on anterior tibial translation in normal and anterior cruciate ligament (ACL) deficient knees. Anterior tibial translation was measured bilaterally in 12 anesthetized patients with unilateral ACL-deficient knees using a KT-1000 arthrometer. An ankle-foot orthosis was used to passively dorsiflex the ankle and generate tension in the calf muscles. As the ankle flexion angle was progressively changed from 30 degrees plantar flexion to 10 degrees dorsiflexion, anterior tibial translation decreased 43% and 37% with manual maximum force in normal and ACL-deficient knees, respectively (P < .0001). These findings suggest that the calf muscles may function as dynamic knee stabilizers. Anterior tibial translation also was measured in four cadaver knees. Significant decreases were seen in anterior tibial translation with progressive ankle dorsiflexion in ACL-intact specimens and after the ACL had been cut (P < .05). This effect persisted when the gastrocnemius muscle was cut, but was lost when the soleus muscle was released. The data suggest that the soleus muscle may play a role in dynamically stabilizing the knee.     

Side-to-side nerve bridges reduce muscle atrophy after peripheral nerve injury in a rodent model

Background

Peripheral nerve injury can result in muscle atrophy and long-term disability. We hypothesize that creating a side-to-side bridge to link an injured nerve with a healthy nerve will reduce muscle atrophy and improve muscle function.

Methods

Sprague-Dawley rats were divided into four groups (n = 7 per group). Group 1: transection only—a 10-mm gap was created in the proximal tibial nerve; group 2: transected plus repaired—the transected tibial nerve was repaired; group 3: transected plus repaired plus nerve bridge—transected nerve repaired with a distal nerve bridge between the tibial and peroneal nerves via epineurial windows; and group 4: transected plus nerve bridge—transected tibial nerve left unrepaired and distal bridge added. Gait was assessed every 2 wk. At 90 d the following measures were determined: gastrocnemius mass, muscle and nerve nuclear density, and axonal infiltration into the nerve bridge.

Results

Groups 3 and 4 had greater improvements in walking track recovery than groups 1 and 2. Group 3's gastrocnemius muscles exhibited the least amount of atrophy. Groups 1, 2, and 4 exhibited greater histologic appearance of muscle breakdown compared with group 3 and control muscle. Finally, most bridges in groups 3 and 4 had neuronal sprouting via the epineurial windows.

Conclusions

Our study demonstrated reduced muscle atrophy with a side-to-side nerve bridge in the setting of peripheral nerve injury. These results support the application of novel side-to-side bridges in combination with traditional end-to-end neurorrhaphy to preserve muscle viability after peripheral nerve injuries.     

Prevention of denervation atrophy by nerve implantation

Prevention of denervation atrophy in skeletal muscle by nerve implantation to a muscle belly was studied in a rat model. In the animals' legs, the tibial nerve branch innervating the lateral head of the gastrocnemius muscle was transected, and subsequently repaired by either simple nerve suture(n = 20) or interpositional nerve grafting (n = 20). The tibial nerve branch innervating the medial head was dissected out. The peroneal nerve was transected and implanted directly to the lateral head of the gastrocnemius muscle on one side and, as a control, the nerve on the other side was cut. After 6 months, isometric tension of the gastrocnemius muscle was greater on the implantation side than on the control side in the nerve-suture group ( p < 0.05), but no tension difference between the two sides was observed in the nerve-graft group. The effects of neurotization by an implanted nerve may compete with those by a repaired nerve, when neurotization of the latter is delayed. Only when the time interval between neurotization by an implanted nerve and reinnervation by a repaired original nerve is short, does nerve implantation attenuate denervation atrophy.     

Pathology of spastic muscles. Study of 26 patients

Spastic hypertonia is observed in various central neurological diseases. Pathology of spastic muscle is not well known. Tibial selective microsurgical neurotomy is used for the spastic foot treatment. Twenty-six hemiplegic patients, spastic since more than one year, underwent selective tibial microsurgical neurotomy. Biopsies of soleus, lateral and medial gastrocnemius muscles were performed during surgical treatment, after free patient consent and ethical committee approval. The aim of this study was to describe histopathological lesions of spastic muscles, with histological and histoenzymatic techniques. Histological studies revealed myogenic atrophy, concerning both types of fibers or only type II fibers. They also showed type I (slow fibers) to type II (fast fibers) transformation, in the three studied muscles. These results are similar to those described in the literature.     

Time-dependent expression of myostatin RNA transcript and protein in gastrocnemius muscle of mice after sciatic nerve resection

Myostatin, a member of the transforming growth factor-beta (TGF-beta) superfamily, has been identified as a negative regulator of skeletal muscle mass. To provide more data on the role of myostatin in denervation-induced muscle atrophy, we examined the time-dependent changes in myostatin mRNA and protein as well as Smad2 and phospho-Smad2 protein levels in the denervated gastrocnemius muscle of mice after sciatic neurectomy, using quantitative real-time RT-PCR and Western blotting, respectively. We conducted morphometric analyses to measure the wet weight ratio of the denervated muscle (the operated side/contralateral nonoperated side) and the cross-sectional area of muscle fibers, and observed the morphology of denervated muscle. The experimental results showed that in the early stage of denervation, the levels of myostatin mRNA and protein in the denervated gastrocnemius muscle increased instantly, reaching a peak at day 3 and day 7 after sciatic neurectomy, respectively, when compared with the normal values. In addition, the phospho-Smad2 protein was observed to have a similar expression profile to that of the myostatin mRNA. The present study perhaps opens a new window into myostatin modulation in muscle atrophy due to denervation.     

Isolated recession of the gastrocnemius muscle: the Baumann procedure

BACKGROUND: The Baumann procedure consists of intramuscular lengthening (recession) of the gastrocnemius muscle in the deep interval between the soleus and gastrocnemius muscles. The goal of the procedure is to increase ankle dorsiflexion when ankle movement is restricted by a contracted gastrocnemius muscle. Unlike the Vulpius procedure, the Baumann procedure truly isolates the lengthening site to the gastrocnemius muscle and does not lengthen the soleus muscle. The Baumann procedure has not previously been studied in cadaver specimens. METHODS: The gastrocnemius and soleus muscles of 15 normal cadaver specimens had four sequential releases: a single gastrocnemius recession, a second gastrocnemius recession, a single soleus recession, and an Achilles tenotomy. Ankle dorsiflexion was measured with a goniometer initially, after each muscle recession, and after the tenotomy. RESULTS: After the second gastrocnemius recession, the average increase in ankle dorsiflexion measured 14 degrees with the knee extended and 8 degrees with the knee flexed. CONCLUSIONS: The Baumann procedure treats equinus contracture of the gastrocnemius muscle by improving ankle joint dorsiflexion. The procedure is indicated when the results of the Silfverski?ld test are positive.     

Reinnervation of denervated muscle in a split-nerve transfer model

This study was performed to quantify the reinnervation of denervated muscle in a split-nerve transfer model and to determine any possible downgrading effects on the donor nerve and its end organ. Fifty-four adult Wistar rats weighing 200 to 250 g were used. The experimental design consisted of two groups. The motor nerve branch to the anterior tibial muscle and gastrocnemius muscle of the right hind limb were dissected in all rats. In the experimental group (N = 36), the motor nerve branch of the tibial nerve to the gastrocnemius muscle was exposed, cut, and ligated. The motor nerve branch to the anterior tibial muscle was split and transected longitudinally, and the medial half was routed posteriorly. End-to-end neural anastomosis was performed between this medial half of the split nerve and the distal stump of the gastrocnemius nerve. In the control group (N = 18), while the same surgical preparation was performed, the motor nerve branch to the anterior tibial muscle and gastrocnemius nerve were exposed and transected, and the nerve endings were ligated, but neural anastomosis was not performed between these nerves. The left hind limb of all rats served as a normal comparison side without any surgical intervention. Both of the groups were divided into three subgroups (12 rats each for the experimental groups and 6 rats each for the control group) to evaluate the results after periods of 1, 3, and 6 months. Electromyography, light microscopic and morphometric examination, and muscle weight measurements were used to document the results. Although stimulation of the peroneal and tibial nerves did not produce any compound muscle action potential (CMAP) recordings from either the anterior tibial or the gastrocnemius muscle in the control group, the normalized CMAP areas of the tibial nerve were (mean +/- standard deviation) 16.2 +/- 30.8% in the 1-month group, 63.4 +/- 34.7% in the 3-month group, and 72.4 +/- 16.3% in the 6-month group. For the peroneal nerve, the normalized CMAP areas were 17.0 +/- 32.2%, 53.4 +/- 29.4%, and 54.4 +/- 14.5% for the 1-, 3-, and 6-month groups in the experimental groups respectively. A high number of regenerating myelinated nerve fibers was identified in the distal part of the coapted motor nerve branch to the gastrocnemius muscle. The average number of myelinated fibers in the lateral half of the split nerve in the experimental group was 15,108 fibers per square millimeter, 14,167 fibers per square millimeter, and 19,830 fibers per square millimeter at months 1, 3, and 6 respectively. The average number of fibers proximal to the nerve anastomotic site was 15,423 fibers per square millimeter, 19,200 fibers per square millimeter, and 20,774 fibers per square millimeter. Distal to the nerve anastomotic site, the number of myelinated fibers was 17,941 fibers per square millimeter, 18,885 fibers per square millimeter, and 18,895 fibers per square millimeter at 1, 3, and 6 months respectively. There were no myelinated fibers in the control group sections. There were significant differences in muscle weight between the experimental and control groups at the end of month 6. The difference between the experimental side and the untouched normal healthy side was not significant in the weight measurements of both muscles. The results show acceptable reinnervation by split-nerve transfer with minimal functional impairment of the donor muscle. This study confirms that split-nerve transfer is a reliable method of reconstruction for paralyzed muscle with minimal donor area morbidity.     

Effects of Succinylcholine Chloride on the Response of Fast and Slow Muscle in the Cat

Fast and slow muscle fibres differ histochemically, electrophysiologically and pharmacologically. In vivo, the effect of 0.05, 0.075 and 0.1 mg X kg-1 succinylcholine on the response of the indirectly stimulated gastrocnemius (fast) and soleus muscle (slow) to single, train-of-four and tetanic stimuli was studied. There was a significant difference between the response of the two muscles. Maximum twitch suppression occurred 2 min after injection and was more significant in the gastrocnemius than the soleus. The duration of the neuromuscular blockade was 9 min or more in both groups. The train-of-four ratio dropped below 0.7 in the gastrocnemius preparation at all doses and in the soleus when 0.1 mg X kg-1 succinylcholine was used. Sustained tetanus was achieved in both muscles at 5 and 10 min, respectively. There was evidence of fatigue in the soleus muscle at the 5-min observation suggestive of the presence of a phase II block, a phenomenon not observed in the gastrocnemius.     

Characterization of the train-of-four response in fast and slow muscles: effect of d-tubocurarine, pancuronium, and vecuronium

The in vivo cat soleus and gastrocnemius muscles were used to compare isometric contraction strength and the train-of-four (T4) response (2 Hz for 2 s) of two muscle types (fast and slow) during onset of competitive neuromuscular blockade in order to determine the extent of the correlation between twitch depression and T4 fade. Prior to drug administration the muscles that were studied differed significantly in that the T4 ratio was 1.0 in the gastrocnemius and only 0.87 in the soleus. Three competitive neuromuscular-blocking agents were compared: d-tubocurarine, pancuronium, and vecuronium. d-Tubocurarine was found to produce a close correlation between the degrees of twitch strength depression and T4 for both muscles. However, these muscles demonstrated significantly different ED50 values (105 micrograms/kg for gastrocnemius, 150 micrograms/kg for soleus). Pancuronium also produced a similar relationship between twitch strength depression and T4 decrement for each muscle. In this case, however, there was little difference in their ED50 values for twitch depression (11.5 micrograms/kg for gastrocnemius, 13 micrograms/kg for soleus). The effects of vecuronium were quite different from the other two muscle relaxants. Although vecuronium produced a comparable correlation between twitch tension and T4 fade in fast muscle, no such relationship was found to exist in slow muscle. Even when the twitch strength was blocked to 18% of control, the soleus T4 response was depressed to only 75% of control. These results highlight major differences among competitive neuromuscular-blocking agents and suggest multiple sites of action.     

Unterschenkel-Muskelatrophie bei Arthrose des oberen Sprunggelenks und deren Rehabilitation nach Implantation einer Sprunggelenksprothese

The aim of this orthopaedic-biomechanical study was to evaluate lower leg muscle function in ankle osteoarthritis (OA) patients and muscle rehabilitation after the implantation of a total ankle replacement (TAR). Patients with a severe unilateral ankle OA were assessed with an orthopaedic and biomechanical examination before and one year after TAR surgery. Visual analogue pain score, American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, ankle range of motion for dorsi- and plantar flexion (ROM DF/PF), and calf circumference difference between affected and contralateral healthy leg were measured. Isometric maximal voluntary torque for ankle dorsiflexion and plantar flexion were measured simultaneously with surface electromyography (EMG; mean frequency and intensity) of the anterior tibial, medial gastrocnemius, soleus, and peroneus longus muscle. Data were compared to a group of age- and gender-matched normal subjects. The mean calf circumference difference between legs did not significantly decrease from preoperative to one year follow-up. The mean dorsiflexion torque and plantar flexion torque of the affected ankle increased significantly. The atrophic muscles were characterized by a reduction of the mean EMG intensity and mean EMG frequency. In the rehabilitation process, the mean EMG intensity recovered and was not significantly different for all muscles, however, not for EMG frequency, which remained low and unchanged. This study reports for the first time in the literature the clinical and biomechanical facts of lower leg muscle atrophy in ankle OA as well as the amount of the muscle rehabilitation after a total ankle replacement. Patients with a symptomatic ankle OA achieve better function with a total ankle replacement; however, one year after the operation neuromuscular and biomechanical deficits may still be present.     

Assessment of muscle flap sensibility by evoked potentials in the rat

This study investigated whether the sensory-to-motor reinervation of the muscle flap provides a better sensory recovery of an overlying skin graft. Fifty-four animals were studied in three groups of 18 rats each: group I (control): 1 cm of the gastrocnemius muscle motor nerve was excised and no repair was performed; group II (motor-to-motor repair): the motor nerve of the gastrocnemius flap was transected and repaired; group III (sensory-to-motor repair): the motor nerve of the gastrocnemius muscle and sural nerve were transected and their distal and proximal ends, respectively, were repaired. At follow-up periods of 6, 12, and 24 weeks, evaluation of hair growth, muscle atrophy, and sensory evoked potentials was performed. Somatosensory evoked potentials (SSEP) at 6 weeks in the sensory-to-motor repair (group III) revealed a significant (P < 0. 05) increase (104.4% +/- 22.9) in the relative response of peak-to-peak potentials when compared with group I (46.6% +/- 19) and group II (51.8% +/- 14.0). Muscle flap stimulation was most prominent at 6 weeks in sensory-to-motor reinvervated flaps (group III 133.1% +/- 25.4; group I 84.9% +/- 20.2). In this study, sensory-to-motor nerve repair significantly improved the sensibility of skin flaps at 6 weeks. Denervated flaps presented with 3 months of sensory recovery delay.     

Aesthetic Resection of the Gastrocnemius Muscle in Postpoliomyelitis Calf Hypertrophy: An Uncommon Case Report

Muscle hypertrophy is a rare finding in neurologic lesions. Infiltration, stretching, and exercise of the muscle are causative factors of enlargement and hypertrophy. We report a case of unilateral calf hypertrophy postpoliomyelitis. The resection of the total medial and partial lateral gastrocnemius muscle was performed to achieve left calf reduction and a symmetrical contour of both legs. The patient is satisfied with the results and has not complained of any instability in walking or running after 2 years of follow-up.     

Effects of nerve growth factor on the neurotization of denervated muscles

Studies on surgical repair techniques of the peripheral nerve are still trying to improve the outcome. There are many studies on the effects of various neurotrophic factors on the transected peripheral nerve. Muscular neurotization, which is the direct implantation of the nerve to the target denervated skeletal muscle, is one of the techniques used when the primary repair of the peripheral nerves is not possible. The effects of nerve growth factor (NGF), which is one of the primary neurotrophic factors, on the reinnervation of denervated muscles by neurotization is investigated in this experimental study. The denervated soleus muscle was neurotized via peroneal nerve implantation (group 1), and NGF was administered to the neurotized muscle (group 2). All animals were evaluated at weeks 8, 10, and 12 using electromyography. Muscle contractility, muscle weight, and histological morphometric tests were performed at week 12. The experimental groups were compared with each other and normal control values. Electromyographically, group 2 (direct nerve implantation + NGF) demonstrated better reinnervation in all evaluations. The study of muscle weight showed that the muscle mass was 75% of the normal soleus muscle in group 1 and was 85% of the normal side in group 2 at the end of week 12. In group 1, the twitch force was 56% of the normal soleus muscle and was 71% in group 2. Tetanic force was 53% of the normal soleus muscle in group 1 and 68% in group 2. Histological morphometric studies revealed that there was a decrease in the density of the motor end plates in group 1, but there was no statistically significant difference between the normal soleus muscles and the NGF applied to group 2. The positive effects of NGF on the neurotization of denervated muscles seen in this study suggest that it may be useful for treating some difficult reconstructions caused by denervation.     

Physiological cross-sectional area of human leg muscles based on magnetic resonance imaging.

Magnetic resonance imaging techniques were used to determine the physiological cross-sectional areas (PCSAs) of the major muscles or muscle groups of the lower leg. For 12 healthy subjects, the boundaries of each muscle or muscle group were digitized from images taken at 1-cm intervals along the length of the leg. Muscle volumes were calculated from the summation of each anatomical CSA (ACSA) and the distance between each section. Muscle length was determined as the distance between the most proximal and distal images in which the muscle was visible. The PCSA of each muscle was calculated as muscle volume times the cosine of the angle of fiber pinnation divided by fiber length, where published fiber length:muscle length ratios were used to estimate fiber lengths. The mean volumes of the major plantarflexors were 489, 245, and 140 cm3 for the soleus and medial (MG) and lateral (LG) heads of the gastrocnemius. The mean PCSA of the soleus was 230 cm2, about three and eight times larger than the MG (68 cm2) and LG (28 cm2), respectively. These PCSA values were eight (soleus), four (MG), and three (LG) times larger than their respective maximum ACSA. The major dorsiflexor, the tibialis anterior (TA), had a muscle volume of 143 cm2, a PCSA of 19 cm2, and an ACSA of 9 cm2. With the exception of the soleus, the mean fiber length of all subjects was closely related to muscle volume across muscles. The soleus fibers were unusually short relative to the muscle volume, thus potentiating its force potential.(ABSTRACT TRUNCATED AT 250 WORDS)     

Changes in muscle of a muscle flap after severance of its innervating nerve. A preliminary study]

The purpose of this study is to observe changes in muscle after severance of its main innervation, especially the changes in its volume and weight. In ten rabbits, it was found that the reduction of the volume of gastrocnemius muscle flap was 47.8%, and that of gastrocnemius and soleus muscles was 50.5% one month after the severance of the tibial nerve, while their weights were decreased 47.6%, 51.3% and 46.9% respectively. After three months the respective reduction in volume was 40.3%, 32.3% and 38.8%, while the weight was reduced to 44.0%, 34.0 and 40.3%, respectively. Histological examination revealed capillary dilatation and congestion, decrease myofibrils and increase of adipose tissue. Evidence of diminution of muscular metabolism and energy consumption was found by histochemical study, including ATPase, phosphorylase, and succinic dehydrogenase staining. The result of electromyogram examination confirms the presence of muscle denervation.     

Determination of Normal Calf and Ankle Values Among Medical Students

The current study was undertaken to determine the mean values of surface measurements from right and left calves and ankles. These measurements were taken from 150 second-year medical students (75 women and 75 men, ages 18 to 23 years) from Cukurova University in Turkey using a flexible standard measuring tape. The mean values for calf circumference, length of the medial head of the gastrocnemius muscle, distance between the inferior border of the medial head of the gastrocnemius muscle and the medial malleolus of tibia, and ankle circumference were analyzed. The observations presented in the report have defined anatomic parameters that need to be taken into consideration when cosmetic surgical procedures are performed in the calf and ankle area for this population.