ORIGINAL ARTICLE
Botulinum Toxin A for Aesthetic Contouring of Enlarged
Medial Gastrocnemius Muscle
H YUN -J EONG L EE , MD, D ONG -W ON L EE , MD, Y EON -H O PARK , MD,
M I -K YUNG C HA , MD, H ONG -S IK K IM , MD, AND S EOG -J UN H A , MD
BACKGROUND. Oversized, muscular calves can cause psycholo-
gical 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 gastrocne-
mius 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.
HYUN-JEONG LEE, MD, DONG-WON LEE, MD, YEON-HO PARK, MD, MI-KYUNG CHA, MD, HONG-SIK KIM, MD,
AND SEOG-JUN HA, MD HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.
IN ORIENTAL women, shapeless legs with thick calf
muscles are a common aesthetic problem. Muscle
hypertrophy of the lower extremities is rarely reported
in conditions with peripheral nerve lesions,1 chronic
spinal atrophy,2 chronic recurrent polyneuropathy,3
and poliomyelitis,4 but in most cases, the causes of
aesthetic hypertrophy of the gastrocnemius muscle are
unknown.
Invasive, surgical treatments have been performed
for the aesthetic reduction of hypertrophic calf
muscles. Liposuction has not been recommended as a
suitable method for the muscular legs, because the
gastrocnemius muscle rather than subcutaneous fat is a
major factor determining the shape and size of
muscular legs.5 Surgical resection of partial gastro-
cnemius muscle has been successfully performed to
reduce hypertrophic calves. No functional instability
in walking or running has been reported in a long-term
follow-up.5–8
Recently, botulinum toxin A was used to treat
benign masseteric hypertrophy with the relief of pain
and the correction of a squared facial appearance.9–11
Address correspondence and reprint requests to: Hyun-Jeong Lee, MD,
Jeonghyun B/D 8th floor, 250-3, Seohyun-dong, Bundang-ku, Seongnam-
city, Kyunngido, 463-050 Korea, or e-mail: cnpskin9@hanmail.net.
r 2004 by the American Society for Dermatologic Surgery, Inc.  Published by Blackwell Publishing, Inc.
ISSN: 1076-0512/04/$15.00/0  Dermatol Surg 2004;30:867–871
RESULTS. All of the enrolled subjects showed a reduction in the
medial gastrocnemius muscle after the botulinum toxin injec-
tion. 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.
The therapeutic effect was resulted from the botuli-
num toxin A-induced inactivity atrophy of the
masseter muscle. It is possible that botulinum toxin
A can be effective in reducing enlarged calf muscles.
Therefore, this study examined the effect of botulinum
toxin A injections in volunteers with muscular legs. In
this preliminary study, botulinum toxin A was injected
in the medial head of the gastrocnemius muscle, which
is the most prominent muscle of the calf and is
functionally redundant.
Materials and Methods
Botulinum toxin A was injected in six female
volunteers (age range 24–30 years, mean age
28.7  4.84 years) with moderate aesthetic hypertro-
phy of the medial gastrocnemius muscle after obtain-
ing written informed consent. The subjects had no
diseases or occupations known to be associated with
the calf muscle hypertrophy. Each vial of botulinum
toxin A contained 100 U of Clostridium botulinum
toxin type A with human serum albumin and sodium
chloride in a sterile, vacuum-dried form without
preservatives (Botox, purified neurotoxin complex,
Allergan, Inc., Irvine, CA). All the injections were
prepared by reconstituting a 100-U vial of botulinum
868 LEE ET AL: BOTULINUM TOXIN FOR ENLARGED CALF Dermatol Surg 30:6:June 2004

toxin A with 2.5 mL of sterile preservative-free saline

to achieve a concentration of 4 U/0.1 mL in the
botulinum toxin A vials.
The subjects received doses of 32 U (Subjects 1 and
2), 48 U (Subjects 3 and 4), or 72 U (Subjects 5 and 6)
in each side of the leg at the initial visit. The botulinum
toxin A dose was selected according to the gross size of
the contracted medial gastrocnemius muscle in the
tiptoe position. The gross size of the contracted
gastrocnemius muscle did not correlate with the leg
circumference. The injections were performed under
sterile conditions using 1-in.-long, 23-gauge needles.
Three to six intramuscular injections with 1.5- to 2-cm
intervals were performed along the most prominent Figure 1. Clinical pictures of the posterior calf in Subject 1 on the
tiptoe position before the injection of 32 U of botulinum toxin A in
part of the medial gastrocnemius muscle in each leg in
each medial gastrocnemius muscle (A) and 1 (B) and 6 (C) months after
the prone position. the treatment. The size of the medial gastrocnemius muscle was
Subjects were evaluated at the baseline and 1 and 6 decreased in volume with a change in the contour of the medial calf.
months after the injection. Clinical photography was
taken in the standing position on a flat floor (relaxed
muscle) and on the tiptoe (contracted muscle). The leg
circumferences were measured at the superior, middle,
and inferior levels6 in the tiptoe position. Length of the
leg was measured from the lateral malleolar protuber-
ance to the lateral end of the popliteal skin crease. The
total length was divided to four equal parts, and the
leg circumference was measured at three levels. The leg
circumference measurements were made by the same
investigator (H.J.L.) at each visit. Functional evalua-
tions were performed by examining range of joint
motion and motor and sensory examination.

Results Figure 2. Clinical pictures of the posterior calf in Subject 4 on the

All of the enrolled subjects showed clinical improve-
ment with a reduction in the medial gastrocnemius
muscle after the botulinum toxin A injection (Figures
1–4). The reduction in the medial calf was noticed even
after 1 week, and the improvement was clearly seen at
1 month. A volume reduction in the medial calf was
apparent in the tiptoe position with the contracted
muscle (Figures 1–3), but this was also observed in the
normal standing position on a flat floor (Figure 4). The
effect of the botulinum toxin A injection was well
maintained for 6 months after the injection. In Subject
5, clinical picture could be taken at 12 months after the
treatment (Figure 5). The medial gastrocnemius muscle
became enlarged, but the clinical improvement was still
maintained in comparison with the baseline picture.
Besides the reduction in the medial gastrocnemius
muscle, leg contouring was also obtained as a result of
the botulinum toxin A treatment. The clinical pictures
revealed that the most prominent point in the contour
of the medial calf moved upward to approximately the
three-fourths level of the calf (Figures 2 and 3).
tiptoe position before the injection of 48 U of botulinum toxin A in
each medial gastrocnemius muscle (A) and 1 (B) and 6 (C) months after
the treatment. Angulated masculine bulging of the medial gastro-
cnemius muscle had disappeared after the botulinum toxin A
treatment with an upward movement of the most prominent point
(indicated by the pointer) of the leg contour.
The change in the leg circumference was most
remarkable in the middle leg circumference, which
reflects the volume reduction of the medial gastro-
cnemius muscle (Table 1, Figure 6). The middle leg
circumference was decreased in all subjects except for
Subject 4. These five subjects also showed a slight
decrease in the superior or low leg circumferences. In
Subjects 2, 5, and 6, the decrease in the middle leg
circumference was most prominent, which consistently
decreased during the follow-up visits. In Subject 4,
despite the clinical improvement, there was a slight
increase in the posttreatment leg circumferences
compared to the pretreatment value.
Subjective degree of improvement was mild in
Subjects 3 and 5 and moderate in the other four
Dermatol Surg 30:6:June 2004
Figure 3. Clinical pictures of the posterior calf in Subject 5 on the
tiptoe position before the injection of 72 U of botulinum toxin A in
each medial gastrocnemius muscle (A) and 1 (B) and 6 (C) months after
treatment. The angulated masculine bulging of the medial gastro-
cnemius muscle had disappeared after the botulinum toxin A
treatment with an upward movement of the most prominent point
(indicated by the pointer) of the leg contour.
Figure 4. Clinical pictures of the posterior calf in Subject 5 in the
normal standing position on a flat floor before the injection of 72 U of
botulinum toxin A in each medial gastrocnemius muscle (A) and 1 (B)
and 6 (C) months after the treatment. The bulging contour of the
medial gastrocnemius muscle had disappeared after the botulinum
toxin A treatment with the atrophy of medial gastrocnemius muscle
after the botulinum toxin A treatment.
subjects. The subjects felt some softening of the medial
part of their calf after the injections.
The subjects complained of mild tenderness lasting
a few days owing to the intramuscular injections.
Bruising was noticed at the injection sites in a few
subjects. Functional evaluations were normal in all
subjects with no discomfort in the gait and running.
Discussion
Botulinum toxin A has been widely used in the
management of a variety of disorders involving muscle
overactivity.12–15 Botulinum toxin A has been success-
fully used to treat masseteric hypertrophy, which
corrected the squared facial appearance along with
LEE ET AL: BOTULINUM TOXIN FOR ENLARGED CALF 869
Figure 5. Clinical pictures in Subject 5 at 12 months after the
treatment on the tiptoe position (A) and in the normal standing
position (B). The size of medial gastrocnemius became enlarged, but
the improvement in the angulated bulging contour is still maintained
along with the slight decrease in the volume of the muscle.
the elimination of the associated pain in this condi-
tion.9–11 Botulinum toxin A caused marked inactivity
atrophy and the atrophy was maintained for more than
1 year in most cases.9–11 In this study, botulinum toxin
A was used to treat a hypertrophic medial head of the
gatrocnemius muscle. The contour of the posterior side
of the legs is determined by the gastrocnemius and
soleus muscles. The surface contours of the legs are
more closely related to the superficially located
gastrocnemius muscle.5 Commonly, the medial head
of the gastrocnemius muscle forms a prominent
contour medially in the posterior aspects of the legs
in Korean women. The purpose of this preliminary
study was to investigate the effect of a botulinum toxin
A injection in contouring the medial parts of the legs
and to assess the duration of the clinical effects as well
as proper dosage of botulinum toxin A in Korean
women with enlarged gastrocnemius muscles.
A partial excision of the gastrocnemius muscle has
been successfully performed with few functional
disabilities.5–8 Selective neurectomy of the nerve to
the medial head of the gastrocnemius muscle can also
reduce the volume of the muscle.5 These methods are
invasive, surgical treatments for a calf reduction. The
greatest advantage of botulinum toxin A treatment is
that the aesthetic problem of thick, muscular legs can
be solved using a simple, noninvasive technique.
In this study, botulinum toxin A was effective in
contouring the medial side of the legs with a slight
volume reduction. The thick, angulated bulging con-
tour of the medial gastrocnemius was smoothened
with the upward location of the most prominent part
of the leg. The criteria for an aesthetically pleasing leg
includes maximum circumference being three-fourths
of the leg length, which is often located on or below
the superior level of the four equal parts of the leg.16
870 LEE ET AL: BOTULINUM TOXIN FOR ENLARGED CALF Dermatol Surg 30:6:June 2004

Table 1. Data of the Middle Leg Circumference in Six Women after a Botulinum Toxin A Injection into the Medial
Gastrocnemius Muscle

Middle Leg Circumference (cm)

32 U of Botulinum 48 U of Botulinum 72 U of Botulinum

Toxin A per Each Side Toxin A per Each Side Toxin A per Each Side

Subject 1 Subject 2 Subject 3 Subject 4 Subject 5 Subject 6

Baseline 34.8 34.0 33.0 30.4 34.2 33.3
1 month 33.2 33.3 31.5 30.5 32.4 31.8
6 months 34.2 32.8 31.9 30.9 32.3 31.7

after the injection, and this effect was well maintained

Figure 6. Leg circumferences measured before the botulinum toxin A
treatment (labeled as visit 1) and 1 (visit 2) and 6 (visit 3) months after
the treatment in Subjects 1 (A), 2 (B), 3 (C), 4 (D), 5 (E), and 6 (F).
From this aspect, the botulinum toxin A treatment
resulted in a better aesthetic appearance.
The botulinum toxin A-induced atrophy of medial
gastrocnemius muscle was observed within 1 month
for 6 months. In one subject, the botulinum toxin A-
induced clinical improvement still remained at 12
months after the treatment. The hypertrophic masseter
muscle treated with botulinum toxin A showed a
decrease in the muscle mass over the course of 2 to 8
weeks, and the atrophy was maintained for over 1
year.9–11 This clinical course appears to be similar in
the medial gastrocnemius muscle treated with botuli-
num toxin A.
Only the medial head of the gastrocnemius muscle
was injected in this study. A reduction of the medial
calf could result in an accentuation of the bow
appearance of the leg, although this was not the case
in our subjects. In an additional trial, both the medial
and the lateral gastrocnemius muscle could be injected
for the best response.
The botulinum toxin A dose used in this study was
chosen by considering the amount of botulinum toxin A
used in the masseteric hypertrophy, where the masseter
muscles were treated with 100 to 300 U of C. botulinum
toxin type A-hemagglutinin complex. Three different
doses of botulinum toxin A were used according to the
gross size of the medial gastrocnemius muscle in this
study. Botulinum toxin A doses of 32, 48, or 72 U were
all effective in contouring the medial calf. The minimal
optimum dosage for reducing the size of the calf muscles
needs to be confirmed in a further study.
Leg circumference measurements were used in this
study to evaluate the volume reduction of the calf. The
volume reduction resulting from the botulinum toxin
A injection in the medial gastrocnemius muscle was
noted clinically, but it resulted in only a small change
in the leg circumference measurement. The posttreat-
ment leg circumference was reduced in five of six
subjects. The decrease in the leg circumference was
most prominent in the middle circumference, which is
related to upward movement of the most prominent
point of the medial calf. The decrease in the middle leg
circumference was in a range of 5 to 20 mm, which
reflects only minimal degree of volume reduction.
These subtle improvements in leg circumference could
Dermatol Surg 30:6:June 2004
easily be masked by the leg edema associated with
daily physical activity. Subject 3 complained of
frequent leg swelling, and pitting edema was observed
at the follow-up visit at 2 months. In this context, the
leg circumference measurements are not a good
measure for assessing the botulinum toxin A treatment
for the medial gastrocnemius muscle.
In contrast, clinical photography has the greatest
importance in the assessment. A limitation in this study
is that we did not uniformly define the assessment at
the tiptoe position. The volunteers were asked to raise
their heels as much as possible on the tiptoe position,
but this position was not uniformly defined and was
rather subjective. Nevertheless, clinical photography
could reflect the clinical improvement despite the slight
differences in the level of their heel in the tiptoe
position. This different position could also have
influenced on the leg circumference measurement.
The subjective degree of satisfaction was rather low
in the botulinum toxin A calf reduction because it was
difficult to perceive the improvements. One cannot
observe one’s posterior side of the leg, and the
botulinum toxin A-induced volume reduction was
not so prominent to be easily recognized. This fact
should be clearly communicated to the patients before
the botulinum toxin A treatment of the calf, and cost-
effectiveness should be considered.
In conclusion, botulinum toxin A can be used to
contour aesthetic hypertrophy of the medial gastro-
cnemius muscle with a slight volume reduction of the
enlarged calf. The botulinum toxin A-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.
Commentary
Enlarged calves caused by hypertrophy of the gastrocnemius
muscle is prevalent in Asian women. This condition is
commonly referred to as ‘‘radish calf’’ in Chinese society.
Making women’s lower legs slimmer is one of the most
challenging aesthetic surgeries in Oriental patients. Lee and
colleagues conducted an interesting study by injection of
botulinum toxin A to reduce volume of medial gastrocnemius
muscle. Although the clinical result was not completely
satisfactory, the authors have shown that injection of botulinum
toxin A with a dosage of up to 72 U is safe without major
complications. This preliminary study may encourage more
researchers in this field. Before this new indication becomes
acceptable, more scientific and meticulous studies must be
performed including location and technique of injection, dosage
adjustment, objective evaluation methods (ultrasound and
MRI, etc.) and long-term effects and safety.
REN-YEU TSAI, MD
Taipei, Taiwan
LEE ET AL: BOTULINUM TOXIN FOR ENLARGED CALF 871
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Commentary
Botulinum toxin A injection is probably one of the fastest
growing cosmetic procedures in Asia and this article is certainly
interesting because it examines its role in improving the calf
contour, a common concern among Asian persons. Nevertheless,
there are several pitfalls in this study that should be mentioned. The
sample size was small and the observer was not blinded.
Furthermore, there was no accurate objective assessment such as
the use of radiologic imaging to measure the muscle bulk.
Radiologic assessment including ultrasound was commonly used
in previous studies to assess the effectiveness of botulinum toxin A
for the treatment of masseteric hypertrophy. These limitations
imply that findings in this study should be considered to be
preliminary in nature. Given the issue of cost-effectiveness, further
studies are necessary before one can justify such use of botulinum
toxin A.
HENRY H. L. CHAN, MD (LOND), FRCP
University of Hong Kong