When Fat Fights Back… PAH After Cryolipolysis
As technology continues to soar, so does the number of noninvasive machines for cosmetic treatments. In the last decade, we have seen the emergence of lasers and tasers, wands and wires, paddles and probes. While they have very different modes of action, they all promise the same thing: nonsurgical contouring with excellent results and no down time.
As a consummate surgeon, I tend to favor definitive operations over most of these tools to achieve predictable and satisfying results. Many of these machines are extraordinarily expensive and only moderately effective, and this is just not good enough for what I am trying to offer my patients. Many patients do not mind having to undergo multiple procedures, or even spending the same amount as they would on surgery in the end, as long as they can have some success without an actual operation. But when the treatment itself literally backfires on you, this becomes a real problem.
Paroxysmal adipose hypertrophy (PAH) literally means that the fat is supposed to shrink, and instead it gets larger. This it not a common complication (estimates range from 1 in 4000 cycles to 1 in 1000 cycles), but it does translate into a big problem. To make matters more complicated, it is unclear exactly why or how this happens, and we do not have a way of predicting any one patient’s risk profile for the phenomenon.
The typical presentation of PAH is a patient who undergoes cryolipolysis (an example of this is Coolsculpting), with the intention of having the fat in their target areas frozen until it dies. Dead fat cells then open and release their contents, and the body cleans up the debris and breaks it all down. It stands to reason that there is usually some scar tissue or other evidence of the process left in place of the fat, but this material is usually smaller in size than the fat itself, so it leads to a modest overall shrinking of the area in questions. Because there is no surgery involved, and no incision, the fat is never actually removed from the body.
PAH occurs when some of the fat that did not die begins to overgrow in response to the assault, becoming large and inflamed, and making the target area bigger than it was before. Obviously, this is exactly the opposite of what was planned, making it a true complication- one that ironically then becomes a surgical problem. Affected areas are usually hard, tender, and uncomfortable; and it can take a while for the process to stop, with no way of stopping it from getting worse. Eventually, it does stabilize, and the area will usually soften, but then you are left with the new problem of even more fat where there was supposed to be none left.
Because you have to wait for the fat to soften, in most cases, the recommendation is to wait at least 6 months after PAH occurs before intervening. While there is some evidence that other nonsurgical treatments may help, I do not recommend them. Whatever made the fat in that particular patient revolt has likely not been remedied, and it would be highly problematic to provoke it again. In general, the accepted treatment for PAH is actually good old-fashioned liposuction. Tiny incisions are made, a cannula inserted, and the fat suctioned right out. This is the tried-and-true method of fat contouring that has been around for ages, and exactly the thing that these patients were trying to avoid- but why?
Somehow, as technology has evolved, the plastic surgery world has begun to believe that they can achieve surgical results without surgery. This has never been my impression. Yes, there are many small preventative moves you can make against aging. Yes, there are noninvasive tools that help with resurfacing and scar therapy. But I have never seen any instrument to date that can achieve what surgery can achieve in cases where it is indicated. If you need a facelift, nothing else will give you the result.
For liposuction in particular, I find it odd that there is such a new resistance. The procedure is generally quick, safe, and leaves very little evidence behind. Yes, the first few postop days are intense; but the results can be precisely guided, the outcomes are usually very consistent, you only need one treatment, and it almost never backfires. Liposuction can be performed under general or local anesthesia (in many cases), and it can have a beneficial effect on the skin itself as well. In my experience, this is to date the only definitive way to get to target contour, and it only takes one treatment.
Cryolipolysis, on the other hand, has varying levels of success. In some patients, results can mimic small volume liposuction, although a true result is almost never attainable. The procedure also claims to be able to “sculpt” tissue, but the flat paddle delivers the cold randomly, and there really is no way to fine-tune a shape at all. It is also often painful, multiple procedures means additive cost (which gets higher than people realize when they start out), and by the time you’re done, you may have spent years trying to chase a result that could have happened in one day of treatment and a few months of recovery.
For patients with PAH, the ricochet effect is very distressing. Having to wait to even get the therapeutic liposuction adds insult to injury, as well as cost and unexpected surgical coordination. But the good news is that there is a solution, and it is generally well tolerated and successful in its mission. It’s just very frustrating when the path to the simple solution is so complicated, when you could have just started there in the first place.
