– Gentler vacuum pressure seems to reduce the risk of paradoxical adipose hyperplasia after cryolipolysis, according to Suzanne Kilmer, MD, director of the Laser and Skin Surgery Center of Northern California, Sacramento.

She and her colleagues have noticed a reduction with the newer CoolAdvantage applicators from Zeltiq Aesthetics, the manufacturer of CoolSculpting equipment. CoolAdvantage runs colder and with less suction than earlier applicators. “It seems to work equally as well,” but with shorter treatment times, less bruising, and less discomfort. Although paradoxical adipose hyperplasia (PAH) “is incredibly rare, it is something we want to reduce, and we do see decreased incidence with these new applicators,” Dr. Kilmer said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Dr. Suzanne Kilmer M. Alexander Otto/Frontline Medical News

Dr. Suzanne Kilmer

No one knows exactly what causes PAH; men seem to be more at risk, especially if the target is firm, fibrous belly fat. Given the experience with CoolAdvantage, “we think it’s related to the actual suction,” she said, noting that if it does occur, liposuction fixes the problem.

Typically, one CoolSculpting session will get rid of about 20%-25% of the fat sucked up into the cryolipolysis cup. There can be some discomfort, for instance, when ice crystals are massaged afterward. To ensure patient satisfaction, “you really need to be realistic about what they can expect. It’s likely to be more than one session,” she said.


Another newer option from the manufacturer is the CoolMini applicator for submental fat. Dr. Kilmer generally does two overlapping applications with the CoolMini in the same session, in order to cover as much chin fat as possible. There will be what looks like a stick of butter under the chin when the applicators are removed; it goes away after a few minutes of massage. Patient satisfaction is high, but there can be unveiling of the platysmal bands, which is “something you want to talk to patients about ahead of time,” she said.

She sometimes uses the CoolMini first, followed by the other recently available option for submental fat, deoxycholic acid (Kybella). “We shrink down everything we can with CoolSculpting, and then come back with Kybella to clean up whatever’s left.” Using this approach, patients are injected with less deoxycholic acid, with less inflammation, she said.

“I think you get more fat loss out of a given CoolSculpting treatment than you do with Kybella,” said Dr. Kilmer, who noted that deoxycholic acid is also an option for PAH.

As for going off label with CoolSculpting for jowls, “we’ve done it, and I tell everybody there’s a chance of a 2-3 month palsy. All you are really doing is demyelinating the nerve, not injuring it. If you do liposuction, you actually have a little bit of risk of actually injuring it. You can use a nerve stimulator to map out the nerves beforehand,” she said.

Dr. Kilmer is a consultant for Zeltiq Aesthetics, and an investigator on many of the company’s development trials. She’s also a consultant for Allergan, manufacturer of Kybella, which recently acquired Zeltiq. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.