Considering Coolsculpting? Paradoxical Adipose Hyperplasia (PAH) is a “Growing” Concern

Written by Dr. Jonathan Zelken

Coolsculpting remains the world’s #1 nonsurgical fat reduction procedure. Formally called cryolipolysis (CLL), this technology literally freezes fat cells and the surrounding tissues which leads to selective fat cell death. The fat cells are ultimately metabolized by the body and a subsequent reduction of the fat is seen. Seems too good to be true, does it not? It is my understanding that in most cases, the satisfaction of patients undergoing this procedure is very high. Although it seems impossible to determine the actual satisfaction rate, this procedure has been- and remains incredibly popular. Entire clinics are founded on cryolipolysis. Because the procedure is nonsurgical and noninvasive, all the risks associated with surgery, including downtime, pain, wounding, and other issues are mitigated. Because the doctor is not needed to perform the procedure, it is an omnipresent technology and easily accessed by the public.

But an emerging complication of this technology is starting to surface. Technically, the first case report was in 2014. More and more people and communities are discussing a strange phenomenon among online forums and media platforms. You may know someone, or even have personally experienced something called paradoxical adipose hyperplasia (PAH). In fewer instances, this phenomenon is also known as paradoxical adipose hypertrophy. Truth is, we do not know whether the fat cells that grow abnormally become hyperplastic, meaning increase in number, or just bigger, meaning that they increase in size. After puberty, humans typically have a finite and fixed amount of fat cells. It is unusual to expect fat cells to increase in number. However, the term paradoxical adipose hyperplasia has seemed to stick. It is by far the most widely reported term in the medical literature and in the lay community. Interestingly, this term was simply suggested in one of the first case series of this condition but may not be accurate. It is somewhat bothersome that we have named a disease after a process that we do not fully understand.

Moving forward, I will refer to PAH as paradoxical adipose remodeling (PAR). I believe this is a more accurate term to describe what is happening after fat in the surrounding stromal cells are irreversibly altered by cryolipolysis. This is not the only inconsistency and source of confusion based on a lacking literature. I also keep reading that the most common patients who seem to be targeted by this condition are middle aged male Hispanic patients. This is because the one or two case series on the topic report only Hispanic patients affected. However, it is seldom reported that these papers come from centers in Latin America and Miami, where the population is largely if not entirely Hispanic. In fact, in my own practice I see a representative cross-section of America’s ethnicities affected by this condition. I have treated patients of Pakistani descent, Caucasians, Asians, and African Americans. Interestingly, I have only seen one Hispanic man with PAH among the 18 patients I have treated. Most recently, I treated an Indonesian woman who did not even know she had the condition.

Treatment strategies for paradoxical adipose remodeling are also questionable based on a literature review. A lot of people talk about liposuction or power assisted liposuction to treat this condition. Other reports say that abdominoplasty may be warranted if there is an excess of skin that can be treated by liposuction alone. These papers do little to describe treatment of the underlying problem. While liposuction and power assisted liposuction are effective ways of reducing fat pockets, it seems that little is being done to address the stromal disruption and “bulge-like” remodeling that occurs after cryolipolysis in these rare cases. In my own practice, and I have treated 18 patients this way, I believe radiofrequency assisted lipolysis (RFAL, BodyTite) is the treatment of choice for paradoxical adipose remodeling. Here is why: 1) tightening of the outstretched and weakened stromal network allows a bulging infrastructure to be tightened again. 2) Radiofrequency tightening of the overlying skin envelope allows the tissue expander effect of paradoxical adipose remodeling to correct itself. 3) Radiofrequency skin tightening, prior to liposuction, increases the collateral injury to fat cells allowing more fat loss than with liposuction alone.

Also, in my own practice, I have seen at the fat that is removed in patients with paradoxical adipose hyperplasia, AKA paradoxical adipose remodeling (PAR), tends to appear grossly different than other fat. Suctioned fat typically is yellow in nature, and perhaps slightly lighter in color after radiofrequency assisted lipolysis, but it can sometimes appear gray in paradoxical adipose remodeling patients! Also, I literally must work twice as hard to remove the same volume of fat in patients with this condition. This is my favorite way of determining whether patients have paradoxical adipose hyperplasia AKA paradoxical adipose remodeling. Clinically, the fat pockets typically are well defined, well demarcated, firm, sometimes tender, and unsightly. The literature states that PAR is most often seen in upper and lower abdomen, however in my practice, it seems to be equally present in the bra roll and flank region. And when patients lie down, unaffected soft tissue typically will evenly distribute itself, with PAR, the fat pocket seems to hold its position and stand up, almost as though there is an underlying implant.

The most important thing to know is this: you are not alone. Paradoxical adipose remodeling is an unfortunate complication that ironically affects patients who intended to avoid the risks of surgery. Moreover, it affects patients who are trying to reduce fat, not gain it. I suspect that this condition is far more prevalent then reported, possibly because some patients do not even know they have it. Other times, patients may be too busy or too embarrassed to address the issue. My advice?

1) do not treat PAH (PAR) with more Coolsculpting.

2) wait 6-9 months before losing hope and addressing this with surgery.

3) in most cases, this is a treatable, if not curable condition. In my practice, I prefer radiofrequency assisted lipolysis and power assisted liposuction to do this.

If you or a loved one has or wonders if they have PAH/PAR/Paradoxical Adipose Hyperplasia, call (949) 432-4730 to schedule a consultation online or in person with Dr. Zelken.