Coolsculpting is the answer to fat in the plastic surgery world. Visible body fat is one of the many issues that body-conscious individuals are facing today. This is the kind of fat that sits in your stomach, thighs, arms, etc. that no amount of exercise can burn, not even any type of diet can get rid of. In fact, there is no literature available which can prove that abdominal fat in particular, can be reduced as a direct result of weight loss from exercise. 1
But most of us don’t want to undergo cosmetic surgery such as liposuction for its removal, whether it’s the persistent pooch or back fat. For one, liposuction surgery is expensive. While studies have shown that liposuction is still the safest fat reduction method for as long as it is performed by certified surgeons and under local anesthesia, 2 there are those that continue to think of it as high-risk, just like other major surgeries. 3 Notwithstanding, the operation still does not guarantee a permanent fat loss in the area due to fat compensatory mechanisms of the human body. 4
In recent times, we have seen the proliferation of non-surgical, so-called lunchtime procedures that promise to obliterate stubborn and unwanted fat in specific areas, without the need to stitch one up. These treatment modalities include radio frequency, low laser, ultrasound, to name a few. 5 According to the Plastic Surgery Report from the American Society of Plastic Surgeons (ASPS), more than 15 million non-surgical cosmetic procedures were performed in the US alone in 2017, with cryolipolysis treatments having a 7 percent increase during that year. 6
While surgical liposuction remains a viable option to this day, most especially if you’re looking at a highly significant fat reduction, 7 the massive appeal of these minimally invasive options is undeniable. One does not have to skip work or activity for such treatments as they come with little to zero downtime. Moreover, the results can be life-changing for many individuals.
In this article, one of the fast-rising fat removal treatments called CoolSculpting will be discussed.
What is CoolSculpting
CoolSculpting is an innovative cosmetic procedure that removes body fat found in regions such as the abdomen, hips, arms, thighs, back, among others. More accurately, it is a product name of a device created by the company Zeltiq that uses a revolutionary method called cryolipolysis as a fat reduction treatment.
The CoolSculpting system consists of a portable thermoelectric device that can either be used to apply controlled cooling, or heating of the target area. 8 Cryolipolysis is an FDA-approved procedure of freezing fat in order to break it down and remove it without damaging the skin and other vital tissues surrounding it. The use of this treatment via CoolSculpting is also compliant with Health Canada and European Union regulations. 9
Founded in 2005 by Mitch Levinson, Zeltiq used to be a health care division of a wireless tech company during its inception. CoolSculpting was developed by dermatologists Dr. Dieter Manstein and Dr. Rox Anderson by using the cryolipolysis methodology. Inspired by the hollow cheeks on children caused by frequent popsicle-sucking, the idea that ultracold temperatures can destroy fat cells seemed very compelling. This was bolstered by a successful cryolipolysis experimentation performed on Yucatan pigs, which yielded favorable results of significant fat reduction. 10 This, along with clinical trials on humans thereafter, prompted a prototype device which we now know as the CoolSculpting system.
The Zeltiq company was then awarded the license for its proprietary cold technology platform, and exclusive commercial rights to market cryolipolysis. Coolsculpting was its first product that employs a targeted solution for fat that is otherwise difficult to remove even with strict food intake and exercise. With this treatment, you can reshape your body by blasting away many forms of unwanted fat, such as the muffin top, double chin, thunder thighs, banana rolls, among other creative names.
Evolution from Cold Panniculitis to CoolSculpting
Long before CoolSculpting has been first released back in late 2000s, many dermatologists have already employed cryotherapy, or freezing-cold treatments in a number of applications. Cryotherapy is the use of extremely cold temperatures for medical purpose. Ranging from dry ice to liquid nitrogen, these doctors have subscribed to cold-based therapies one way or another. It was commonly used to address superficial skin problems such as warts and the like. It must be noted that such treatments were not yet targeted and did not discriminate particular tissues. Instead, the use of the opposite warm temperatures was introduced as a fat-blasting solution at the time. 11
The first ever sign of a correlation between cold sensitivity and fatty tissues was observed by Austrian physician Dr. Carl Hochsinger as early as 1902. Dr. Hochsinger noticed these firm nodules found on the chin of children as an adverse freezing reaction. In 1941, Dr. Haxthausen published the clinical cases of 4 children on which he noticed winter lesions, and termed them as “adiponecrosis e frigore” or cold panniculitis. 11 Many cases of cold injury to adipose tissue have been discovered since not only among children, but also on a number of adults as well.
In 1970, Dr. Ervin Epstein and Dr. Mark Oren coined the offshoot term popsicle panniculitis, which is the resulting red nodules on the cheeks of infants after sucking popsicles. It was found that same lesions occur when ice cubes are pressed on the infant’s buttocks. As such, they have come up with an idea that fatty tissues are injured by extreme cold more than the tissues that hold water. Interestingly, this was common in young children, which can be best explained using the butter and olive oil analogy. When you store both these fat forms at room temperature, butter remains in its solid state while the olive oil will still be in liquid form. Comparing a child, particularly a baby, and butter, both have high levels of saturated fat in their adipose tissue. As such, young children are more susceptible to cold panniculitis. 11
In 2007, CoolSculpting inventors Dr. Manstein and Dr. Anderson came out with the novelty idea of cryolipolysis. Having observed the notable indentations on the pig subjects used during a pilot clinical study after being exposed to -7-degree Celsius copper plate, they have measured a fat reduction of 30 percent in the treatment spot. 10 The same findings have been reproduced in other subsequent studies that seem to suggest that cold-induced fat apoptosis was the clinical effect, yet leaving no adipocyte damage.
Coolsculpting prototype was designed as an applicator with the shape of a cup that draws from a specific fat area using a vacuum mechanism between 2 cold plates. This present cooling can be adjusted, which reduces blood flow to the targeted spot, allowing the applicator to perform its contouring much better. The procedure takes about an hour, followed by a massage for faster homogeneous nucleation.
Since then, several clinical testings have been performed and pretty much confirms the high efficacy of cryolipolysis in reducing localized fat. One remarkable study included 50 human subjects which focused on fat reduction on the flanks or love handles. About 82 percents showed marked improvement between their “before” and “after” images. As such, the FDA greenlighted its use to reduce side fat in 2010, abdominal fat in 2012, 12 followed by its clearance as a treatment for subcutaneous fat in the thighs and submental area in 2014. 13 The CoolSculpting device was also approved in 2015 as cold therapy for post-trauma and post-surgery patients to relieve pain and reduce cellulite appearance. 8
How effective is CoolSculpting?
In a sea of non-surgical fat removal devices that use different scientific principles, how does CoolSculpting fare? While all these treatments available in the market have a common goal, that is to kill fat cells in the body, CoolSculpting appears to have a better edge with a high patient satisfaction rate of 73 percent based on one study. 14 It also has a high success rate as far as removing excess fat in problem areas such as the abdomen, flanks, thighs, arms, and under the chin are concerned.
Controlled clinical trials have been conducted on humans, which have yielded satisfactory results. From these experiments, it has been established that fat cells are vulnerable to cold temperatures. 13 This sensitivity results in sooner cell death of fat. The use of precise cooling on adipocytes will trigger their inflammation, which would then lead to slow digestion of surrounding stationary cells.
The majority of the research done on cryolipolysis have indicated that it is a fairly safe and effective procedure for removing fat from the body. Excess abdominal fat is one of the most common complaints of people, which surrounds vital organs and can lead to different types of heart diseases among other health issues. Cryolipolysis can be utilized to selectively target fat cells found in the abdominal region by subjecting them to below zero temperatures 15.
In one study, cryolipolysis procedure was performed on 20 subjects with subcutaneous fat in the abdomen using a non-vacuum applicator. 8 After 1st treatment, around 77 percent showed significant improvement. Afterward, six subjects opted for a second treatment. This was proven to be more effective as 100 percent were satisfied with their fat reduction on their abdomen.
Using a new contoured applicator, 12 Korean subjects were tested by treating the left lower abdomen for 35 minutes and was immediately followed through with another treatment. 16 Results are apparent when compared to the untreated right abdomen immediately after. These improved further after 8 weeks as measured using high-resolution ultrasound.
On the other hand, there has been a case of cold panniculitis resulting from cryolipolysis performed on the abdomen of a 69-year old woman. 17 Cold panniculitis is the traumatic injury in the adipose tissue which is incurred from exposure to extreme coldness. Using the CoolSculpting device, her abdomen was treated for an hour on each side. Three days later, she developed nodules on the treatment site which was found to have experienced adipocyte necrosis where cold panniculitis occurred. After prescribing an oral medication, the patient recovered after 6 weeks. However, she did not repeat the CoolSculpting procedure and instead, she was treated using radio frequency with considerable results.
Another test was conducted on 2 female pigs, this time using a conventional cryolipolysis device and its newer 4D version. 18 The new cooling device produced a better fat reduction of 81.63 percent compared to the 75.25 percent improvement with the use of the conventional model.
CoolSculpting was first approved for treatment in the flank region in 2010. In one case study using Contrast cryolipolysis, which is another device that can reduce localized fat using a “heating to cooling to heating” method, two volunteer subjects were exposed to both Contrasts cryolipolysis and conventional cryolipolysis. It was revealed that the Contrast cryolipolysis showed a better reduction of fat on the flanks than the conventional method.
In another blind experiment that aims to evaluate the safety and efficacy of cryolipolysis using a contoured vacuum applicator, 10 subjects were treated on their flanks. 19 Their before and after pictures were evaluated 12 weeks post-treatment by 4 physicians in terms of their visible improvement. From a score of zero to ten, the overall rating is 4.3 which meant a 43 percent improvement. The correct “before and after” photos were identified by the reviewers 94 percent of the time. Side effects that occurred in some of the individuals such as bruising, edema, numbness, etc. disappeared naturally after several weeks.
Another type of fat that is difficult to lose is the one on either the inner thighs or the outer thighs or both. Twenty females with excess fat in their arms and inner thighs were given one CoolSculpting cryolipolysis treatment using the flat cup vacuum applicator. 20 While there was no significant weight change on the subjects, the circumference on the treated areas has diminished after the third and sixth months from initial treatment.
There was an average reduction of 0.41cm on the third month and 0.72cm on the 6th month. However, there was a much lower satisfaction rate among the subjects who have rated their improvement on the sixth month, but most of them have gained weight at this point which might have affected their opinion on the subject.
It was observed during one study that fibrous (non-pinchable) fat in the thigh region can be a challenge to work on using a vacuum applicator. Nonetheless, cryolipolysis was still found to significantly reduce the fat thickness and “saddle bag” appearance during a number of studies 21. However, Dr. David Rapaport, a New York Plastic Surgeon, adds that outer thighs are not ideal for fat reduction using CoolSculpting because of its tight collection of fat which cannot be pulled with one’s fingers.
Submental fat is the excess fat under one’s chin, causing fullness in this region, which is commonly referred to as double chin.
One cadaveric study has proven that there is one superficial fat compartment in the submental area. 22 As such, corresponding fat removal and rejuvenation techniques have become popular, having associated this double chin condition with aging as well.
Four clinical trials and one case study with a total of 101 subjects were conducted on the use of cryolipolysis to reduce submental fat. 23 It was concluded that there was a visible fat reduction on the under chin area which resulted in the high satisfaction rate of patients. There are neither reports of any nerve injury nor fat increase after treatment. The same results came out from another study involving 10 Koreans where a CoolMini applicator from Zeltiq was used as a contact device. 24
A comparative study using 2 low temperatures of the CoolSculpting system was performed 10 weeks apart on 15 subjects. 25 It was found that the small volume applicator with the lower temperature at -15 degrees Celsius produced a significant reduction of submental fat with less treatment time of 30 minutes as opposed to -12 degrees Celsius for 45 minutes.
An in-house study by Zeltiq was also done to evaluate the efficacy of CoolSculpting on double chins. Results thereof show that no adverse effect was considered serious from the use of the device on the 60 subjects who participated. Any side effect which includes erythema, hyperpigmentation, and fullness sensation resolved after 12 weeks. Patients manifested a reduction in fat layer thickness of 0.20 centimeters after three months of treatment. 13
How is CoolSculpting performed
Each CoolSculpting procedure can last up to an hour depending on the treatment site. Some sessions may stretch up to 4 hours if multiple fat regions are being treated. A doctor or licensed therapist will perform this non-surgical procedure which is 100 percent safe and FDA approved. During pre-treatment, the skin surface of the targeted fat will be cleansed and assessed based on the appropriate size and curvature of the applicator to be used.
The actual procedure will begin by applying gel on the site’s skin surface without anesthesia. Using an initial temperature of 4 degrees Celsius, the applicator will be placed on the spot as it freezes and destroys the fat cells permanently without posing any hazard to other cells and tissues. The proprietary vacuum applicator draws the tissue into its corresponding cup and holds it between two cooling plates, extracting heat in the process.
The sensors in the applicator are tracked for a consistent treatment, which is linked to the console to provide feedback to the physician. Although CoolSculpting is considered a comfortable treatment, some individuals may experience the pulling sensation as the applicator works on the target area.
The patient may experience mild pinching and tugging of the skin as a suction effect of the vacuum applicator. The freezing action may also cause numbness on the treatment site, which can be relieved by a medicated balm after the session. A post-treatment manual massage for at least two minutes is often recommended to enhance clinical results. 8 26
There may or may not be a visible reduction immediately after the treatment as it can take at least 2 weeks to see any change. During this process, cell death will occur in the treated adipose, which will be eliminated naturally by the human body through its own lymphatic system. Dramatic results are expected on the 8th week and onwards. 8
Who is eligible for CoolSculpting?
According to the indications of use by its manufacturing company Zeltiq, it is intended for those individuals who are looking at a localized fat reduction on the abdomen, flank, thigh, and submental area, who have a Body Mass Index (BMI) of 30 or less. 13 As loosely put by Dr. Rapaport, a rule of thumb for eligibility to the treatment is that if you can pinch enough skin between your fingers, you can qualify for CoolSculpting.
It must be noted that CoolSculpting is not a weight loss program, but a body contouring procedure. As such, it will not solve one’s obesity and related morbidities. 27 Dr. Will Kirby, a licensed dermatologist who performs CoolSculpting, many patients who he has treated are considered relatively fit, but are unable to get rid of their specific fat bulges from diet and exercise. As such, individuals who require small to moderate amounts of fat and cellulite removal stand to benefit the most from the treatment. 28
Patients with discrete fat are better candidates for the procedure than obese individuals who will not experience the same efficacy as the former. 28. However, there is no age limit for CoolSculpting. 29. Based on one clinical study involving subjects between the ages of 13 and 16 years old, cryolipolysis was performed in comparison with laser lipolysis. This yielded satisfactory outcomes given significant fat reduction and improved hip to waist ratio. 30
In any case, an individual, male or female, who will undergo cryolipolysis must be in good health, has a normal renal functioning, and no medical history pertaining to neurological and orthopedic problems. 29. Patients suffering from cold-induced conditions which include cryoglobulinemia, cold urticaria, paroxysmal cold hemoglobinuria should also skip this type of treatment. 5 Cryolipolysis should also be avoided on skin surfaces with dermatitis, varicose veins, and other lesions. 31
Meanwhile, patients with cardiovascular disorders, high cholesterol levels, and hepatic steatosis-related diseases might be discouraged from taking this type of procedure. It should be noted though, that multiple studies have shown no significant change in terms of worsening the condition after cryolipolysis. 29
In any case, patients should be forthright with their chosen doctor regarding their medical history to avoid serious complications.
CoolSculpting’s cooling technology may also be used to minimize pain and thermal injury during laser and dermatological treatments. The device can act as a local anesthetic for procedures that induce minor local discomfort.
The hot and cold settings of the CoolSculpting System are also indicated for use to provide localized thermal therapy, which can minimize pain from post-trauma and post-surgery, and for temporary relief of minor aches, and muscle spasms. Its optional massage function can also be utilized to address minor muscle aches, pains, and spasms. This feature may improve local circulation and reduce the appearance of cellulite. 13
How safe is CoolSculpting
The safety and effectiveness of CoolSculpting have been proven by a number of clinical studies. 27. Based on one study about abdominal fat on adolescents, cryolipolysis is considered a safe procedure and may be applied to all skin types without any risk, even with recurrent applications. 30. Another study involving over 500 subjects found no serious side effects after three months from the treatment of fat on the abdomen, flank and back areas using cryolipolysis. 32. No skin damage has been observed in the sixth month following the procedure as revealed in another study. 33
Risks and side effects
CoolSculpting is a medical procedure that can benefit the individual by having as much as a 25 percent fat reduction in target areas. 8 At the same time, it can also cause a number of side effects which resolve after 3 months for most patients. It is also important to note that this treatment is not for everyone.
One of the most common effects of CoolSculpting is the patient experiencing a tugging sensation at the treatment area which involves placing the fat bulge between two cooling plates. This may cause discomfort which can last as long as the duration of the procedure. For most individuals, studies indicate that this effect is tolerable and most patients have found themselves in a comfortable position throughout the procedure by reading, sleeping, or simply relaxing. 33
Bruising is also exhibited by a number of patients who have undergone cryolipolysis treatment. Erythema, or redness of the skin caused by increased blood flow has also been seen in individuals, but usually goes away after a few days. 14 You will find the treated area temporarily firm and cold within 5 minutes of post-treatment massage and reverts to normal after about an hour. 33
Another possible side effect which occurred in three subjects during a cryolipolysis study is dysesthesia. This is when a person has an abnormal sense of touch, which often presents itself as pain and inappropriate sensation. This resolved after three weeks of treatment. 33
On a very rare occasion, with an incidence of 0.0051 percent, paradoxical adipose hyperplasia (PAH) can occur after a cryolipolysis procedure. 34. It would seem that this previously unreported adverse event would be more common with male individuals. Further research is required given this isolated case.
Other FAQs on CoolSculpting
How soon can you see the results?
You can expect a reduction on fat layer thickness within 7 days from treatment which may amount to about 1.08 centimeters in the abdomen region. 15 At this time, there will still be some mild inflammation and fibrosis for some. Fat reduction takes place after 15 days that becomes more dramatic with a smaller circumference measurement on the 4th month after treatment during which it allows the skin to adhere to its new body contours. When side fat is treated using cryolipolysis, you can notice visible reduction 3 months post-treatment, while saddlebags are mitigated substantially after 4 months from baseline. 21
Will CoolSculpting results last?
Technically, yes. The destroyed adipose cells as a result of the CoolSculpting procedure will not come back because these are disposed of naturally by your body over the course of 6 to 12 weeks. While larger longitudinal research should be done to quantify the duration of results, it appears that the results are maintained based on a study on the long-term efficacy of cryolipolysis which monitored the treated area after 6 and 9 years from treatment. 35
In addition, there is no evidence to suggest that fat loss from cold exposure could even regenerate. 8 But if one asks if he can be fat again after the treatment, in that same area, the answer is yes. And it has nothing to do with CoolSculpting but everything to do with one’s diet and lifestyle. As there are a few fat cells left in the treated site, they will not increase their number.
Instead, these remaining cells may expand due to poor food choices, which may cause an increase in overall size. Therefore, to enjoy the long-term benefits of this procedure, the quintessential healthy living must be observed by the patient thereafter.
How much does each CoolSculpting session cost? Can health insurance cover it?
The price of CoolSculpting treatment differs among providers and will be based on the body area being treated, the length of time it would take to treat it during the session, and where you live. The average CoolSculpting price is $2500 in total, or about $750 an hour for small applicators. Normally, prices can start from $500 and more. As such, if you are looking at multiple fat bulges: expect a higher cost for CoolSculpting. CoolSculpting’s price range is usually from $2,000 dollars to $6,000 per treatment. 39
Note that there are instances that you will need more than one session for the target area, which typically happens when you work with abdominal fat. There are occasions when the price would vary depending on the type of applicator used. A session that entails the use of a small applicator can cost you 750 dollars an hour. Treating a tummy bulge may cost up to 1,500 dollars at a time. For both arms, you can expect to pay 1,300 dollars while the procedure on both thighs can run you up as much 4,000 dollars.
As CoolSculpting is a cosmetic procedure, it is not covered by health insurance, therefore, this will be a personal expenditure. You can always inquire from your provider for any payment plans available or discounts applicable to you.
How does cryolipolysis compare to other treatment modalities for spot reduction?
While cryolipolysis will provide permanent results just like a conventional liposuction surgery would, it will not be as dramatic as the latter. But if one has a low pain tolerance and prefer less risk and recovery time that are linked with surgical procedures, the CoolSculpting treatment proves to be a good alternative.
Comparing it to other non-invasive treatments such as the use of radio frequency, CoolSculpting results may not be instant, but when these results manifest, they will stay permanently, unlike RF treatments that require frequent sessions every month. According to a scientific assessment on fat removal procedures, cryolipolysis achieved the most significant reduction in the tummy area compared to other non-invasive and invasive treatments like Exilis, lipolysis, and even liposuction. 36
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