A Multicenter Evaluation of Paradoxical Adipose Hyperplasia Following Cryolipolysis for Fat Reduction and Body Contouring: A Review of 8658 Cycles in 2114 Patients

Sociocultural pressures and engagement with cosmetic products and procedures in adult women

Previous studies have shown that cosmetic procedures and products that perpetuate Western hegemonic beauty standards among women have become increasingly popular, and pressures from sociocultural agents to utilize them are significant. However, little work has documented the relationship between perceived sociocultural pressures and use of cosmetic procedures and products among a larger age range of adult women. A community sample of 308 women aged 18-66, mean (SD) age of 35.7 (9.7), reported on the cosmetic procedures they had considered or used, as well as perceived pressures from the media, peers, romantic partners, and health and beauty professionals. Findings revealed that, among those investigated, the most frequently utilized products and procedures were supplements and hair removal. However, a significant minority reported considering more invasive procedures, including cosmetic surgery. Media was the predominant source of pressure, while partners were the least frequently endorsed. While pressure from professionals and peers had small-to-moderate associations with utilization of cosmetic products and procedures, pressure from partners had the largest association with their use. This work frames important future directions for examining the impact of sociocultural pressures on women's willingness to utilize cosmetic products and procedures that are sometimes underregulated and risky for physical and mental health.

Non-invasive Body Contouring Technologies: An Updated Narrative Review

INTRODUCTION

Nowadays, a lot of body contouring devices and methods are introduced all over the world. The object of the present narrative review was to update and classify existing evidence on these methods and devices.

METHODS

We searched databases including PubMed, Cochrane, and Google Scholar for 11 essential keywords, including cryolipolysis, high-intensity focused ultrasound (HIFU), shock wave, low-level laser therapy (LLLT), radiofrequency (RF), capacitive resistive electrical transfer (TECAR), high-intensity focused electromagnetic (HIFEM), electromyostimulation (EMS), carboxytherapy, mesotherapy, and acupuncture and their abbreviations, in addition to obesity, overweight, cellulite, subcutaneous fat, and body contouring.

RESULTS

Totally 193 references were used in 11 main topics.

CONCLUSION

In order to help physicians with finding the best evidence in different methods, the data were summarised in 11 topics. Furthermore, FDA-approved devices, side effects and common protocols were described in each section.

LEVEL OF EVIDENCE I

This journal requires that authors 39 assign a level of evidence to each article. For a full 40 description of these Evidence-Based Medicine ratings, 41 please refer to the Table of Contents or the online 42 Instructions to Authors www.springer.com/00266 .

Cryolipolysis for fat reduction using Cooltech® Define technology: A large-sample retrospective clinical study

BACKGROUND

Cryolipolysis is a noninvasive technique for localized fat reduction, which induces selective apoptosis of the adipocytes using controlled exposure to intense cold. During the past 10 years, this technique has been shown to be safe and effective and its application has significantly increased. In this context, Cooltech® devices have been widely used around the world.

AIMS

The purpose of this retrospective study was to evaluate the efficacy and safety of the removal of localized fatty tissue in different body areas using the new Cooltech® Define controlled cooling system.

METHODS

This single-center study was carried out on 287 patients, both female and male, treated with Cooltech® Define on different body areas for a total of 1118 procedures. Follow-up evaluations were conducted to estimate efficacy and safety. Efficacy was evaluated through plicometry and photographs. Side effects were also reported.

RESULTS

Fold thickness showed a significant reduction (-69.91 ± 12.55%) after cryolipolysis treatment (fold thickness before: 35.33 ± 8.41 mm; fold thickness after: 10.69 ± 5.27 mm). Few side effects were reported, they included posttreatment pain (1.70%) and one case of paradoxical adipose hyperplasia (0.09%).

CONCLUSION

The Cooltech® Define cryolipolysis device is a safe, effective, and well-tolerated nonsurgical procedure for reducing localized fat.

A review of research for a cryolipolysis technology

BACKGROUND

Obesity and excess body fat are known health issues and a major aesthetic concern. Numerous modalities have been developed to address unwanted deposits of adiposity, including the development of various noninvasive methods overcoming the limitations and risks of invasive alternatives. Cryoadipolysis, also known commonly as cryolipolysis, involves the harnessing of selective cryolysis, the selective cold-based damaging of subcutaneous fat cells which die via apoptosis, and are removed naturally by the body over time.

AIMS

To provide a brief but comprehensive summary of the literature supporting two related cryoadipolysis devices that are only available outside of North America, Cooltech and Cooltech Define (Sinclair).

RESULTS/DISCUSSION

Review of 10 available clinical studies evaluating the two devices, specifically, showed both devices to be safe, with side effects profiles comparable to those of similar platforms in the armamentarium. Both operate by non-invasively lowering the temperature of localized subcutaneous fat and maintaining it at or below a threshold that causes disruption of adipocytes via crystallization, inducing apoptosis (programmed cell death). Over time, clinically significant reductions in fat thickness and circumference of the treated area were noted. Patient satisfaction is high. The literature also highlights the necessity of adherence to patient selection and device use guidelines to minimize potential for rare paradoxical adipose hyperplasia and maximize patient satisfaction.

Literature review of adverse events associated with cryolipolysis

BACKGROUND

Cryolipolysis is a noninvasive procedure for localized fat reduction and body contouring. This technique utilizes controlled cooling to induce adipocyte apoptosis without damage to overlying skin and other tissue. Although the procedure was once thought to be relatively harmless, recent studies have shed light on the risks of adverse effects (AEs).

AIMS

The aim of this article was to review AEs in cryolipolysis as published in clinical data.

METHODS

A comprehensive search was performed in PubMed, using relevant keywords such as "cryolipolysis," "CoolSculpting," "adverse effects," "complications," and "side effects" with no set data range. The search was limited to studies published in English. The selected studies encompassed a variety of study designs, including randomized controlled trials, prospective cohort studies, case series, case reports, and reviews.

CONCLUSIONS

Since its FDA approval in 2010, our understanding of the potential risks and complications associated with cryolipolysis has grown significantly, and shown that the procedure may not be as harmless as once thought. Continued post-market surveillance of cryolipolysis devices combined with documenting of AE cases help providers better understand the true risks associated with this procedure. As "cryolipolysis" and "CoolSculpting" are often used interchangeably, further research is needed to understand if AEs such as paradoxical adipose hyperplasia (PAH) that occur both inside and outside the United States are CoolSculpting cases or linked to other devices. Additionally, further studies are needed to understand the pathophysiology of such sequelae as PAH, and to better recognize the risks and potential complications associated with cryolipolysis so that we can more accurately inform patients.

Cryolipolysis: The future of cryolipolysis

BACKGROUND

Cryolipolysis has revolutionized the field of cosmetic dermatology as a nonsurgical procedure, utilizing controlled cooling to selectively destroy fat cells.

AIMS AND METHODS

This review article will focus on the future prospects of cryolipolysis, considering advancements in current technology as well as innovations that hold promise for the future. We will explore emerging trends in cryolipolysis, considering novel applicator designs, combination therapies, an innovative injectable treatment approach, and the evolving role of this technology in the field of cosmetic dermatology.

CONCLUSION

The future holds promise for advances in cryolipolysis using both the noninvasive topical cooling approach and the novel injectable ice-slurry technology.

Cryolipolysis in the United States-Review of the clinical data

BACKGROUND

Noninvasive body contouring is becoming more popular in the United States as an alternative to liposuction. The most popular of these methods, cryolipolysis, uses precisely controlled cooling to reduce focal adiposities. The number of cryolipolysis procedures performed annually has experienced rampant growth in United States markets, and the indications have likewise diversified. In light of this change, it is imperative to perform an updated review of available US safety and efficacy data on cryolipolysis.

AIMS

To examine the safety and efficacy of cryolipolysis treatments in the United States using data extracted from research performed exclusively at US-based sites.

METHODS

In order to identify relevant studies, a literature search was conducted on PubMed using the terms "CoolSculpting" OR "cryolipolysis" OR "lipocryolysis." Articles were manually reviewed to exclude literature reviews, research not performed on humans, studies on experimental combinations of techniques, and any studies not performed in the United States.

RESULTS

The initial literature search returned 246 results. Following manual review, a total of 18 studies were selected for data extraction. Mean reduction in fat thickness by ultrasound was 2.0-5.1 mm or 19.6%-32.3%; mean reduction by body caliper was 2.3-7 mm or 14.9%-21.5%. Side effects were mild and transient. Four instances of PAH were documented in 3453 treatment cycles.

CONCLUSIONS

Cryolipolysis is a safe, modestly effective method for reducing focal adiposity. Complications are rare and treatable. However, US-based studies are few in number and often of low power and/or quality. More high-quality research is needed for all aspects of cryolipolysis.

Noninvasive lipolysis modalities in aesthetic medicine

BACKGROUND

Adipose tissue is a vital metabolic organ that takes part in body homeostasis. However, an increase in fat tissue can be detrimental for one's health and lead to undesirable changes in body shape. Noninvasive lipolysis is becoming an increasingly popular method to destroy and remove excess body fat and improve one's satisfaction with their body appearance.

AIM

The aim of this study was to perform an evidence-based review of the clinical efficacy and safety of noninvasive lipolysis modalities in fat reduction.

MATERIALS AND METHODS

An evidence-based review was performed to evaluate the scientific evidence available on the subject. Three electronic databases (PubMed, Scopus, and Embase) were searched between February and May 2022 for randomized controlled trials and observational studies performed on adult population in the last 20 years investigating the clinical outcomes of noninvasive lipolysis modalities. The selected studies were divided by modality type (cryolipolysis, ultrasound therapy, radiofrequency, and laser therapy), and the data on the efficacy and safety were extracted.

RESULTS

In total, the search identified 55 papers which met the inclusion criteria. All four energy-based modalities, including cryolipolysis, ultrasound therapy, radiofrequency, and laser therapy, were shown to be clinically effective in terms of both objective body measurements, such as fat layer thickness or circumference reduction, and subjective patient satisfaction. Furthermore, the abovementioned methods were proven to have a low side effect profile.

CONCLUSION

In conclusion, although evidence supports safety and efficacy, further well-designed trials are needed to strengthen confidence in long-term effectiveness and safety of noninvasive lipolysis.

Use of a microwave device for the treatment of cellulite and localized fat adiposity: a 1-year follow-up study

BACKGROUND

The body contour market has grown steadily over the last years, due to the persistent demand for non-invasive treatments for localized fat adiposities, cellulite, and skin laxity.

MATERIALS AND METHODS

The purpose of this observational study was to evaluate the efficacy and safety of a new device delivering microwaves (MWs) energy for unwanted fat and cellulite reduction after a full cycle of treatments and 1 year later. A total of 45 patients with localized adiposity and/or cellulite in different body areas (inner thigh, upper arm, abdomen, culotte de cheval, buttocks), received four treatment sessions, 4 weeks apart. Photographic records and global aesthetic improvement scale (GAIS) score were performed.

RESULTS

For the treatment of cellulite the average GAIS score passed from 3.65 ± 0.49 at 1-month follow-up (1MFU) to 2.7 ± 0.66 at 1-year follow-up (1YFU). For the treatment of localized adiposity, the average GAIS score passed from 3.52 ± 0.51 at 1MFU to 2.82 ± 0.88 at 1YFU. No particular red area was detected either during or after the treatment. There was no mention of assessment of pain or side effects.

CONCLUSIONS

The study findings showed that MWs allow for the treatment of cellulite and localized fat adiposity in a safe and effective way, with results lasting over time up to 1 year after the end of the treatment.

FDA MAUDE database reported adverse events on noninvasive body contouring, cellulite treatment, and muscle stimulation from 2015 to 2021

OBJECTIVE

Noninvasive cosmetic procedures have continued to gain popularity, owing to their short, in-office treatments combined with little to no downtime. These procedures are also highly accessible, even offered at medical spas by nonphysician operators. The coronavirus disease 2019 (COVID-19) pandemic also saw heightened interest in all cosmetic procedures, presumably as social distancing and stay-at-home orders allotted time and space for postop recovery. As the market for these procedures expand, a thorough understanding of potential adverse events is critical for providers to better counsel their patients on risks and expectations when obtaining informed consent.

MATERIALS AND METHODS

We employed the Food and Drug Administration (FDA's) Manufacturer and User Facility Device Experience (MAUDE) database (http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm), which compiles medical device reports (MDRs) for suspected injuries from device use or malfunction, submitted by manufactures and operators. We focused our query on three main categories: noninvasive body contouring, cellulite treatments, and muscle stimulation therapies that utilize electromagnetic energy. The query was performed in February 2022 using a comprehensive list of product names and manufacturers.

RESULTS

The initial search yielded 827 MDRs, which were individually reviewed for duplicate reports or insufficient data. Ultimately, 723 MDRs were analyzed (660 for noninvasive body contouring, 55 for cellulite treatment, and 8 for muscle stimulation). Paradoxical hyperplasia accounted for the majority of MDRs for noninvasive body contouring, while burns and scars were most common for muscle stimulation and cellulite treatments, respectively. Of the 7-year span we surveyed, 2021 accounted for 515 of the 723 total assessed MDRs (71.2%), the majority of which were from cryolipolysis procedures.

CONCLUSION

The MAUDE database remains an essential tool to monitor potential adverse events of medical devices, including those utilized for noninvasive, cosmetic procedures. Insight from the MAUDE database can be clinically translated when discussing treatment options with patients, helping to optimize patient safety and satisfaction.

Characteristics and Treatment of Patients Diagnosed With Paradoxical Adipose Hyperplasia After Cryolipolysis: A Case Series and Scoping Review

BACKGROUND

Paradoxical adipose hyperplasia (PAH), a rare side effect of CoolSculpting (cryolipolysis), is characterized by fatty enlargement of the treatment area occurring months after the procedure.

OBJECTIVES

The purpose of this study was to report a retrospective case series of patients diagnosed with PAH at the authors' institution, increase the collective understanding of this complication and subsequent management, and raise the question of who should ethically perform cryolipolysis.

METHODS

All participants diagnosed with PAH by a plastic surgeon at a large academic medical center were identified. Demographic information, medical history, procedure details, time to PAH diagnosis, and corrective surgical intervention details were collected. Mean duration of time from cryolipolysis treatment to diagnosis of PAH was calculated, along with other descriptive statistics. A scoping review of all PAH literature published in PubMed, Embase, and Web of Science was also conducted.

RESULTS

Four patients diagnosed with PAH after cryolipolysis were identified for inclusion in this study. The calculated incidence of PAH at our center was 0.67%. All patients requested therapy for PAH and subsequently underwent either liposuction, abdominoplasty, or both. The mean duration of in-person follow-up time after final surgical treatment of PAH was 13.8 + 19.8 months (range, 2.8-43.5). Fortunately, no patients showed signs of PAH recurrence, and 3 out of 4 patients did not show signs of residual deformity.

CONCLUSIONS

Findings from this patient cohort and scoping review provide evidence that although revisions may be required, conventional body contouring methods, not in the armamentarium of non-plastic surgeon practitioners, effectively alleviated PAH.

LEVEL OF EVIDENCE: 4

Adverse Events of Non-Invasive Body Contouring: Analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience Database

BACKGROUND

Multiple non-invasive modalities have become popular alternatives to surgical procedures for body contouring.

OBJECTIVE

To analyze adverse events (AEs) associated with non-invasive body contouring devices reported through the Manufacturer and User Facility Device Experience (MAUDE) database.

METHODS AND MATERIALS

The MAUDE database were queried for AEs associated with non-invasive body contouring devices between January 2011 and June 2021. An extensive list of keywords and brand and manufacturer names was used.

RESULTS

A total of 1,325 reports with 1,590 AEs were identified among 6 modalities. More than 70% were reported in the past 5 years. Cryolipolysis made up 38.3% reports, which mostly pertained to paradoxical hyperplasia and hernias. Radiofrequency had the most reports (41.9%). Like laser devices, most of their reports described burns. Focused ultrasound was commonly associated with unintentional fat loss and surface irregularities. Focused electromagnetic field resulted in only 7 reports.

CONCLUSION

The analysis of present study supports previous studies concerning common local symptoms caused by these devices, but it also reveals complications not reported in previous device studies. This study highlights the importance of proper technique and adherence to device guidelines. Practitioners should be knowledgeable of potential complications from each device to both prevent and manage them accordingly.

Safety, Efficacy, and Tolerability of Simultaneous Bilateral Cryolipolysis Using a Rapid Cycling Contoured Cup Applicator for Noninvasive Fat Reduction in the Enlarged Male Breast: A Pilot Study

BACKGROUND

A previous study using a parallel cooling plate cryolipolysis applicator demonstrated the efficacy of cryolipolysis for pseudogynecomastia. Although the procedure was safe and effective, treatment times were prolonged and anesthetic was needed to reduce treatment discomfort.

OBJECTIVE

To evaluate the safety, efficacy, and tolerability of a short cycle, reduced vacuum contoured cup cryolipolysis applicator for the treatment of pseudogynecomastia.

MATERIALS AND METHODS

Twelve male subjects received simultaneous bilateral treatment consisting of a 35-minute cryolipolysis cycle, followed by a short manual massage, and a second 35-minute cycle with 50% treatment area overlap in a single treatment visit. At the 6-week follow-up, a second treatment was performed with up to 2 overlapping cycles per side. Efficacy was assessed after the second treatment using transcutaneous ultrasound, standardized clinical photography, and subject surveys.

RESULTS

Ultrasound analysis showed a mean fat layer reduction of 5.1 ± 2.3 mm (p < .001). Blinded, independent reviewers correctly identified 97% of baseline/treatment photography results. Surveys revealed 100% subject satisfaction with 91% reporting visible fat reduction and 100% stating they would recommend treatment. Transient side effects included mild intratreatment discomfort, paresthesia, and tenderness.

CONCLUSION

A rapid cycling, reduced vacuum cryolipolysis applicator provides rapid, safe, effective, and tolerable treatment of pseudogynecomastia.

Global Expert Opinion on Cryolipolysis Treatment Recommendations and Considerations: A Modified Delphi Study

Background

Cryolipolysis is an increasingly popular nonsurgical fat-reduction procedure. Published treatment guidance and adverse event (AE) management protocols are limited.

Objective

A modified Delphi study aimed to establish global expert consensus on the use of CoolSculpting (Allergan Aesthetics, an AbbVie Company, Irvine, CA), a noninvasive cryolipolysis treatment system.

Methods

A literature search informed survey topics for an 11-expert Delphi panel. Panelists completed an online 39-question survey. An interim panel discussion, with open-ended questions and yes/no voting, informed a second survey containing 61 statements, for which panelists rated agreement using a 5-point Likert scale. Topics included treatment outcome and responder definitions, patient evaluation and selection, treatment protocols, patient satisfaction, and AEs.

Results

Panelists achieved consensus on 38 final guidelines and recommendations. They reached moderate to complete consensus on 4 statements on defining responders (ie, patients with a range of visible improvement) and 6 statements on patient factors contributing to treatment outcomes (eg, how well the applicator conforms to patient body region). Panelists defined minimum numbers of treatment cycles to achieve visible clinical outcomes for 12 body regions, with moderate to complete consensus on 31 statements. They achieved a strong to complete consensus on 7 statements about patient satisfaction (eg, importance of patient expectations, visible improvement, and before-and-after photographs). Panelists defined management strategies for AEs, with moderate to complete consensus on 15 statements.

Conclusions

A modified Delphi process yielded multiple guideline recommendations for cryolipolysis, providing a needed resource for the broad range of clinicians who perform this noninvasive fat-reduction procedure.

Level of Evidence 5