LAUSR

In the recent article, “Paradoxical Adipose Hypertrophy (PAH) After Cryolipolysis” by Strouzma et al, the incidence of PAH is estimated to be approximately 1/100 based on their reporting on 4 cases in 398 patients.1 The authors state that this incidence is still most likely under-reported, and our experience with this technique is completely in agreement with this impression. We started performing CoolSculpting in 2014, and the enthusiasm we generated with this technique quickly generated about 150 patients over an 18-month period. During that short time, we experienced 2 patients with fulminant PAH. By personal recollection, at least 10 other patients had what we considered unchanged or even worsened “girth,” which in retrospect may represent a new classification of PAH considered to be mild to moderate. The 2 patients that had fulminant PAH (Figures 1 and 2), both required follow-up liposuction. In one case, the skin retraction following liposuction was so poor that a second surgical procedure involving skin excision was necessary to produce a smoother abdominal contour. In both cases, the most significant area of PAH was seen in the central abdomen, and both patients were male. In one patient, the love handles were also affected. Both patients who underwent surgery following CoolSculpting were exceedingly upset because a nonsurgical approach was the method they initially requested, but they had to pursue a surgical method instead. It is sobering to review the reported incidence of this complication rise from the manufacturer’s initial quoted rate of 0.0032% in 2013 to a 1% incidence as just reported by Strouzma et al.1 A literature review by Ho and Jagdeo reported only 16 cases in the world literature in 2017.2 The fact that we experienced (unpublished) 2 cases out of approximately 150 treated patients in my solo practice alone speaks volumes about the under-reporting and likely true incidence of PAH. The cited article is likely to be a landmark publication opening the door to more frequent reporting of PAH—and hopefully research into its etiology, treatment, and avoidance. In the meantime, our loss of enthusiasm for this technology persists.