Treating Cankles

By Dr Sanjay Gheyi / 06 Apr 2017

Laser surgeon Dr Sanjay Gheyi examines the treatments available for lipodystrophy of the calf-ankle area

 A ‘cankle’ is defined as an obese or otherwise swollen ankle that blends into the calf without clear demarcation.1 Lipodystrophy, or abnormal fat distribution, can mean that there is little definition between the calf and ankle, which can be a frustrating aesthetic concern for some patients.

The appearance of cankles is not necessarily dependent on body weight and can be exacerbated by genetic conditioning and special resistance to diet.2 Calf and ankle lipodystrophy is usually present from early adolescence3 and the most common cause of cankles in patients seen in an aesthetic clinic is excess of fatty tissue without a systemic condition.

Clinical assessment

Most of us see medically fit and well patients for body contouring. However we must still take a thorough medical history and perform a clinical examination to make the correct diagnosis and eliminate conditions that our treatments can’t address or may make worse. It is imperative to rule out other causes of lower extremity swelling,8 which includes:

  • Lymphoedema – a chronic condition that causes swelling in the body’s tissues – it can affect any part of the body9 
  • Venous disease – a chronic venous insufficiency, deep vein thrombosis
  • Systemic disease – congestive heart failure, renal disease, hypoalbuminemia
  • Cellulitis
  • Cyclical and idiopathic oedema
  • Myxoedema

Clinical history should include onset and duration of symptoms, symptom progression, symptom exacerbation, and any prior attempts at treatment. Practitioners should consider if there is any prior history of lymph node biopsy, lymph node surgery or radiation as this may point towards lymphoedema. A history of previous varicose veins, venous surgery, fractures, soft tissue injuries or deep vein thrombosis (DVT) may indicate a vascular etiology.8 In these cases a practitioner should refer a patient to a GP or an appropriate specialist. Cardiovascular and renal history may indicate that fluid is a cause of ankle swelling.8

Figure 1: Ankle fat pad located at the lateral aspect of the ankle

Recognising lipoedema

It is also important to distinguish and to rule out lipoedema during a physical examination, which is a rare and long-term chronic condition that typically involves the abnormal build-up of fat cells in the legs, thighs and buttocks, where legs usually become enlarged from the ankles up to the hips.7 Increased awareness of lipoedema and its presentation may enable practitioners to diagnose and treat patients more efficiently.8 Diagnosis and treatment should be made as early as possible to prevent complications associated with increased functional and cosmetic morbidity.8

Lipoedema is a condition that can be treated through the use of surgical options such as liposuction and/or excisional lipectomy in patients who are resistant to non-surgical treatment such as exercise, compression therapy and massage. Liposuction appears to be one of the most effective and long-lasting treatments to date, although many patients often require ongoing non-surgical treatment postoperatively to maintain results.8

The fatty hypertrophy seen in patients typically starts at the hips and extends throughout the legs, one of the major distinguishing features of lipoedema is the sparing of the feet, which can create a distinct ‘step-off’ at the ankle.11,12 A helpful diagnostic tool during a physical examination to distinguish lipoedema from lymphoedema is to pinch the skin over the dorsum of the base of the second toe. If the skin appears thickened and is difficult to lift off of the underlying tissue, then this could be an indication of Stemmer’s sign, which is considered a diagnostic tool for lymphoedema.13 To avoid patients raising complaints that treatment has caused neurovascular conditions, I would advise performing a neurovascular evaluation prior to treatment. Review of family history may also be useful as patients with lipoedema often have other female family members with similar symptoms.10

Physical examination 

A typical patient presenting for treatment will have subcutaneous fat around the ankle region. Typically, fat distribution, in my experience, is anterolateral and posteromedial in mild cases, while circumferential in patients with a larger amount of fat. It may be the only area of concern or may be associated with excess fat around the knee, medial and lateral thighs or involve the whole lower extremities. The pinch test will reveal areas amenable to treatment.

Anatomy

For practical purposes it is important to note that the two danger areas are the popliteal fossa (the shallow depression located at the back of the knee joint)4 and the area around the malleoli (the bony projection on either side of the ankles)5 as important nerves and vessels reside in this area superficially. In the superior aspect we have skin, superficial fascia and subcutaneous fat, followed by a deep fascia envelope around the anterior, posterior and lateral muscular compartments.5 

Figure 2: Patient A has excess fat distribution along calves, ankles, knees, inner and outer thighs. Topographic markings for areas to be suctioned. 

Figure 3: Patient A 12 weeks after the liposuction procedure. (Photos taken without flash to highlight contour abnormalities). 












The posterior compartment has three layers of calf muscles, mainly gastrocnemius soleus and tibialis posterior. The anterior compartment has the tibialis anterior and extensor muscles and the lateral compartment has the peroneal muscles. Tendons of these muscles are located in the lower part, along with nerves and blood vessels, which are located superficially in this area.

It is of course important to take note of the nerves and blood vessels as any oedema here can cause compartment syndrome, which is a painful condition that occurs when pressure within the fascial envelope builds. Compartment syndrome is likely to cause neurovascular complications if it is not recognised and treated effectively.5 

A fat pad called the lateral inframalleolar fat pad (LIMFP), located at the lateral aspect of the ankle, has been described in a clinical article by D. Brémond-Gignac and H. Copin et al; they claim it is not often referred to in anatomical texts so it is imperative to be aware of.6 They outline how the LIMFP is oval and made up of an unilocular fatty tissue that is distinct from the subcutaneous plane. The sural nerve is a sensory nerve in the calf region that runs over the surface of the fat pad and supplies cutaneous sensation to part of the fifth toe. This is accompanied by the short saphenous vein, which gives off a medial perforator that traverses the LIMFP. It is necessary to recognise the location of this fat pad before any procedure on the lower limbs, in order to prevent over correction or under corrections during treatment.6

Treatments

Figure 4: Pre-op image in a slender patient with small amount of localised cankle fat highlighting area of maximum fat.

Figure 5: Post-op image, a small area of hyperpigmentation from cannula entry point is noticeable, treatment of laser liposuction.

Liposuction

Liposuction is one of the most evidence-based and preferred ways to remove fat.14 The two key principals for successful liposuction procedures are good patient selection and realistic expectations. Many liposuction procedures can be performed under local anesthesia in an office surgical suite. A conservative approach is always appropriate as overcorrection can be difficult to treat.14




Current technology for liposuction includes suction-assisted, ultrasound-assisted, power-assisted, laser-assisted, and radiofrequency-assisted liposuction. The choice of technology and technique often depends on patient characteristics and surgeon preference.15 My preferred approach is laser lipolysis2 and micro-cannula liposuction, administered under local anaesthesia.16 Sometimes a circumferential liposuction of knees, calves, and ankles is the best option to create more slender looking legs.17 This procedure can also be combined with fat injections into the calf area to achieve further reshaping and contrast between the calves and ankles. 

Other procedures to augment calves include silicone calf implants.15 Calf contouring with endoscopic fascial release, calf implant, and structural fat grafting have also been described.18 In patients with minimal fat many practitioners opt not to aspirate, further limiting direct tissue trauma.19 As a result, patients can quickly return to daily activities within three to five days.19 

Patient selection and a thorough pre-procedure discussion are necessary to minimise any difference between the patients’ expectations and treatment results

A variety of laser wavelengths have been used to try and correct excess fat. My preferred approach is laser lipolysis2 and micro-cannula liposuction under pure local anaesthesia20 due to the following advantages; fast patient recovery, diminished post-operative pain, ecchymosis and oedema.21,19 The coagulation of blood vessels may explain these advantages.9 I use tumescent anaesthesia followed by a 1470 nm diode laser lipolysis. The laser energy is delivered by a 600 micron laser fibre. Following this I use a 14G micro-cannula to suction the liquefied fat. I then provide patients with a compression bandage that is changed to Class 2 compression stockings at the post-op check up. Compression stockings are used day and night for at least one week. I encourage patients to use these during the daytime for as long as possible.

An alternative approach: botulinum toxin

Although not directly related to the appearance of cankles, enlarged medial gastrocnemius muscles in the calves can also cause psychological distress in some women.22 In 2004, Lee et al described the use of botulinum toxin injections for the reduction of calf muscle size.22 Botulinum toxin A injections of 32, 48 or 72 units were injected into each medial head of the gastrocnemius muscle in six women. In all of the participants there was a reduction in the medial gastrocnemius muscle after the injection. According to the study authors, the reduction in the medial calf was noticed even after one week and the effect was well maintained for six months. Leg contouring was obtained by the botulinum toxin treatment. The middle leg circumference indicated a slight decrease in five subjects. No functional disabilities were observed.23

Complications

As with any aesthetic treatment, complications can occur. Patient selection and a thorough pre-procedure discussion are necessary to minimise any difference between the patients’ expectations and treatment results. It is critical to avoid aggressive superficial liposuction, which could cause lipotrops and liponots. These indicate uneven areas where either too much or not enough fat has been removed, respectively. I advise that practitioners administering this procedure remain above the deep fascia and wait 30 minutes after the injection of tumescent fluid to allow for detumescence to be able to grasp the fat, before cannula introduction. Liposuction complications can include injury to adjacent structures, transient numbness, and temporary hyperpigmentation at cannula entry sites, but specific to this area is prolonged oedema.24 Due to their dependent position, legs and ankles are prone to oedema, which can last between six and 12 months. For this reason, I encourage the use of a small cannula of 14G or smaller, gentle technique and compression stockings.

Conclusion

Laser-assisted liposuction in the remodeling of the calf and ankle area is a safe and reproducible technique that is particularly appreciated by the patient. The procedure allows for homogeneous reduction of fatty tissue together with skin tightening.2

References
  1. English Oxford Dictionary, ‘Cankle definition’, 2017. <https://en.oxforddictionaries.com/definition/cankle>
  2. Leclère FM & Moreno-Moraga J et al., ‘Laser-assisted lipolysis for cankle remodeling: a prospective study in 30 patients’, Laser in Medical Science, 2014, 1, pp.131-6. <https://www.ncbi.nlm.nih.gov/ pubmed/23471498>
  3. Patrick J. Lillis, ‘Liposuction of the knees, calves and ankles’ Dermatologic Clinics, 1999, 4, pp.865-879. <http://www.derm. theclinics.com/article/S0733-8635(05)70134-0/abstract>
  4. Dagur G & Gandhi J, ‘Anatomical Approach to Clinical Problems of Popliteal Fossa’, Current Rheumatology Reviews, (2017). <https://www.ncbi.nlm.nih.gov/pubmed/27894238>
  5. Susan Stranding, ‘Gray’s Anatomy: The Anatomical Basis of Clinical Practice, Expert Consult’, 2008.
  6. Brémond-Gignac D & Copin H et al., ‘The lateral inframalleolar fat pad: a poorly recognized anatomical structure’ Surgical and Radiological Anatomy, 2001, 5, pp.325-9. <https:// www.researchgate.net/publication/11536366_The_lateral_ inframalleolar_fat_pad_Apoorly_recognized_anatomical_ structure>
  7. NHS, ‘Lipoedema definition’ 2014. <http://www.nhs.uk/conditions/lipoedema/Pages/Introduction.aspx>
  8. Warren Peled A & Kappos EA et al., ‘Lipedema: diagnostic and management challenges’ International Journal of Women’s Health, 2016, 8, pp.389-95. <https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4986968/>
  9. NHS, ‘Lymphoedema definition’ 2014. <http://www.nhs.uk/ conditions/lipoedema/Pages/Introduction.aspx>
  10. Wold LE & Hines EA et al., ‘Lipedema of the legs; a syndrome characterized by fat legs and edema’ Annals of Internal Medicine, 1951, 34:5, pp.1243-50. <https://www.ncbi.nlm.nih.gov/ pubmed/14830102>
  11. C.A Harwood & R.H. Bull et al., ‘Lymphatic and venous function in lipoedema’ British Journal of Dermatology, 1996, 134:1 pp.1-6. <https://www.ncbi.nlm.nih.gov/pubmed/8745878>
  12. BeninsonJ & Edelglass JW, ‘Lipedema–the non-lymphatic masquerader’ Angiology, 1984, 35:8, pp.506-510. <https://www. ncbi.nlm.nih.gov/pubmed/6476475>
  13. Stemmer R, ‘A clinical symptom for the early and differential diagnosis of lymphedema’ Vasa, 1976, 5:3, pp.261-262. <https:// www.ncbi.nlm.nih.gov/pubmed/969857>
  14. Arthur J. Sumrall, ‘A review of Liposuction as a Cosmetic Surgical Procedure’ Journal of the National Medical Association, 1987, 79:12, pp.1275-1279. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2625655/>
  15. Shridharani SM & Broyles JM, ‘Liposuction devices: technology update’ Medical Devices: Evidence and Research, 2014, 21:7, pp.241-51.<https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4114741/>
  16. Jeffrey A. Klein, ‘Tumescent Technique: Tumescent Anaesthesia and Microcannular Liposuction’, Ophthalmic Plastic and Reconstructive Surgery, 2000. <http://journals.lww.com/oprs/ Citation/2001/11000/Tumescent_Technique__Tumescent_ Anesthesia_and.20.aspx>
  17. Ersek RA & Salisbury AV, ‘Circumferential liposuction of knees, calves, and ankles’, Plastic and Reconstructive Surgery, 1996, 98, pp.880-883. <http://journals.lww.com/plasreconsurg/ Citation/1996/10000/Circumferential_Liposuction_of_Knees,_ Calves,_and.24.aspx>
  18. Karacaiglu E & Zienowicz RJ, ‘Calf contouring with endoscopic fascial release, calf implant and structural fat grafting’, Plastic and Reconstructive Surgery, 2013, 1:5, pp.35. <https://www.ncbi.nlm. nih.gov/pmc/articles/PMC4174200/>
  19. Goldman A & Gotkin RH, ‘Laser-assisted liposuction’, Clinics in Plastic Surgery, 2009, 36:2, pp.241-53. <http://www. plasticsurgery.theclinics.com/article/S0094-1298(08)00136-3/ abstract>
  20. Jeffrey A. Klein, ‘Tumescent Technique: Tumescent Anaesthesia and Microcannular Liposuction’, Ophthalmic Plastic and Reconstructive Surgery, 2000. <http://journals.lww.com/oprs/ Citation/2001/11000/Tumescent_Technique__Tumescent_ Anesthesia_and.20.aspx>
  21. Palm MD & Goldman MP, ‘Laser lipolysis: current practices’, Seminars in Cutaneous Medicine and Surgery, 2009, 28:4, pp.212-9. <https://www.ncbi.nlm.nih.gov/pubmed/20123419>
  22. Han KH & Joo YH et al., ‘Botulinum toxin A treatment for contouring of the lower leg’, Journal of Dermatological Treatment, 2006, 17:4, pp.250-4. <https://www.ncbi.nlm.nih.gov/ pubmed/16971324>
  23. Lee H J & Lee D W et al., ‘ Botulinum toxin a for aesthetics contouring of enlarged medial gastrocnemius muscle’, Dermatologic Surgery, 2004,6, pp.967-71. <https://www.ncbi.nlm. nih.gov/pubmed/15171764>
  24. Varun V. Dixit & Milind S. Wagh, ‘ Unfavourable outcomes of liposuction and their management’, Indian Journal of Plastic Surgery, 2013, 46, pp. 377-392. <https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3901919/>

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