Cryolipolysis for the Removal of Fat A Review and Clinical Update

he removal of unwanted fat is one of the most talked about procedures in cosmetic and Taesthetic surgical circles. Many different modalities have come into play as researchers and clinicians try to find the Holy Grail to successfully remove fat from our patients in a comfortable and non-invasive manner. The Zeltiq CoolSculpting device may be the closest modality yet developed to achieve non-invasive fat removal for those seeking treatment for unwanted areas of localized fat. This device, to be summarized in this review, does have US FDA approval for the non-invasive removal of fat. Liposuction and abdominoplasty are the two main surgical modalities to remove fat. Abdominoplasty is a true invasive procedure and comes with it all of the associated surgical complications including the potential for excessive scarring, something many patients receiving abdominoplasty are not wanting to encounter in the post-operative period. (1) Liposuction, also a truly invasive procedure, has become safer and more acceptable in recent years with the advent of tumescent anesthesia and smaller and less traumatic cannulas to remove the excess fat. (2) Figure 1: Evidence of fat layer reduction in animal model. Photos courtesy of Zeltiq Aesthetics. As well, laser lipolysis has in our everyday practice of modulating the cold exposure, the gained favor amongst many, dermatology. Cold air cooling has goal is to “melt” fat without although this procedure is also become a common part of most damaging the overlying epidermis limited, as is liposuction, to those lasers and pulsed light or and dermis. If successful, a nontruly skilled in both laser use and radiofrequency procedures. This invasive localized treatment for liposuction use. The potential for cold air is not used for any excessive areas of fat could be adverse events, including infection, therapeutic effect but for the achieved. perforation, non-uniform fat comfort of our patients during these removal, sepsis, and death, remain procedures. Liquid nitrogen is a The first animal studies important considerations for those mainstay of dermatology, and is performed with this concept performing and those receiving used for a treatment for many of the involved experiments on four liposuction, either alone or in common dermatologic entities we Yucatan pigs. Manstein et al (5) combination with lasers. (3, 4) see on a daily basis in our practices, described three different clinical whether it be for the treatment of approaches in their first report on The trend in aesthetic and actinic keratoses or for the cryolipolysis. This included their cosmetic surgery has been towards treatment of verrucae. Irreversible initial exploratory study, a less invasive procedures with cell damage by the liquid nitrogen is dosimetry study, and a study on numerous modalities being used for the mechanism of action in which by serum lipid levels. The initial the treatment of cellulite and for liquid nitrogen works. However, exploratory study used a cold body contouring which have entered this does not affect cells lower than copper applicator device which was into the aesthetic “space” in recent the dermis, and thereby has no chilled with a circulating anti-freeze years. Whether they are based on direct impact on fat. solution. This solution was massage rollers, low level laser maintained at a constant energy incorporated into the Manstein et al (5) proposed temperature of -7 degrees Celsius, massage effects, pulsed light, or that fat cells may be preferentially and was applied to the skin of the even radiofrequency, many of these sensitive to cold injury. Using their pigs for various time ranges, have no direct impact on the fat knowledge of fat necrosis in infants, varying from 5 to 21 minutes. In cells themselves. These devices are known as popsicle panniculitis, and the buttock regions of the pigs, it acceptable for the temporary the concept of equestrian was found that 80% of the improvement in the appearance of panniculitis, in which there is superficial fat layer was able to be cellulite or for the circumferential selective injury to fat cells in removed which was equivalent to reduction of certain body areas or response to exposure to cold, they 40% of the total fat layer. This for tissue tightening – all from a were able to design an elaborate effect was noted at 3 and one half dermal point of view, again not preclinical animal study looking at months after the application of the impacting directly on the fat cells the use of cold in the selective treatment. An example of this is themselves. Several focused destruction of fat cells. (6, 7) The shown in Figure 1. ultrasound devices, using large term “cryolipolysis” has been transducers to target deeper layers introduced as the including the fat, have been mechanism of introduced outside of the United localized fat States, and have shown some destruction via the promise in removing unwanted use of cold. The areas of fat in clinical studies; concept is to cause a however, experience with these localized panniculitis devices in the US is lacking, as the within the skin using two current available machines are controlled fat cooling, not yet cleared by the US FDA. or energy extraction, which will result in The use of cold is not a new fat reduction. In concept in dermatology. Many of us doing this controlled are very aware, or perhaps not that fat cooling concept aware, of how often we use “cold” and through Cryolipolysis for the Removal of Fat