CoolSculpting Remains Most Popular Procedure for Noninvasive Fat Removal, Expert Says

Doug Brunk

September 07, 2023

SAN DIEGO — After fashion model Linda Evangelista filed and ultimately settled a lawsuit against Zeltiq Aesthetics in 2022 subsequent to developing paradoxical adipose hyperplasia she claimed was caused by several sessions of CoolSculpting, some aesthetic experts wondered how consumers would embrace the fat reduction procedure going forward.

The negative publicity surrounding this case "is thought to have detracted from some of the volume of it [in terms of demand], but it looks like it's coming back again," Omar A. Ibrahimi, MD, PhD, medical director of the Connecticut Skin Institute, Stamford, said during a presentation on noninvasive fat removal treatment options at the annual Masters of Aesthetics Symposium.

Dr Omar Ibrahmi

In fact, he said, CoolSculpting accounts for an estimated 72% of noninvasive fat removal treatments performed in the United States. "By and large, there is high satisfaction with this procedure," said Dr. Ibrahimi. "There have been about 17 million procedures done worldwide. Paradoxical adipose hyperplasia is a very rare side effect. As newer iterations of this technology have come out, I think there is an even lower incidence."

CoolSculpting, or cryolipolysis, freezes excess fat to remove it from stubborn areas via panniculitis. The technology was developed by Dieter Manstein MD, PhD, and R. Rox Anderson, MD, at Massachusetts General Hospital and Harvard Medical School, both in Boston, and cleared by the U.S. Food and Drug Administration for noninvasive fat removal in 2010.

"If you kill a fat cell in an adult, it can't come back," Dr. Ibrahimi said. "When this technology first came out it was very simple. We treated an area once and were done. Now we know to treat the area multiple times, and you can treat a much larger volume in a patient during one session safely. You can bring about dramatic results, but it often takes a series of 35-minute treatment cycles and about 3 months to see clinical results. There are published studies showing that results are persisting even 10 years after treatment. This is nice, because I tell my patients, ‘if you keep up with your diet and exercise, we don't expect the fat to come back.' "

Other noninvasive options for fat removal include the following:

  • Ultrasound. Options include high-intensity focused ultrasound (Liposonix) and pulsed focused ultrasound (UltraShape). Dr. Ibrahimi described these devices as "very painful, and the results were very difficult to reproduce from the initial clinical studies."

  • Low-level light therapy. Early devices on the market include Zerona and UltraSlim. "Oftentimes these lacked any sort of histological analysis," he said. "There was no obvious mechanism of action, and questionable efficacy."

  • Laser. Powered by a 1060-nm laser, SculpSure can reduce fat cells safely in 25-minute treatment sessions, Dr. Ibrahimi said. Each session is delivered with one of four available applicators and involves 4 minutes of heating and the next 21 minutes alternating between heating and cooling. "You're trying to reach a target temperature that kills fat cells," he explained. "The beauty of having these applicators is that you can kind of customize to the individual patient; it uses contact cooling, and it's safe for all Fitzpatrick skin types. This device results in a 10%-12% reduction in fat, so it's clinically significant but very modest."

A robotic version of the technology, known as the Robotic Fat Killer, is also available. So is the EON, a touchless 1064-nm laser FDA cleared for abdominal, flank, thigh, and back fat reduction. "It adapts to the body shape of the area and individual to deliver a customized treatment," Dr. Ibrahimi said.

  • Radiofrequency. Most devices on the market, such as truSculpt and Vanquish, are powered by monopolar radiofrequency (RF) energy. "Similar to the 1060-nm laser, you can customize these treatments," he said. "You're treating to a target temperature. It involves 15-minute cycles, and there are clinical, histology, and ultrasound data supporting this technology."

Dr. Ibrahimi uses truSculpt and CoolSculpting in his practice, "but sometimes you have patients who are ‘too fit' for CoolSculpting; they don't fit the handpiece perfectly," he said. "That's where having a monopolar RF or a 1060-nm laser is useful, to help you hone in on those stubborn pockets of fat."

  • Deoxycholic acid. While not a device, deoxycholic acid (Kybella), administered subcutaneously, is approved by the FDA for improving "the appearance of moderate to severe convexity or fullness associated with submental fat" in adults. "A lot of people use it off-label on the abdomen and other stubborn areas," Dr. Ibrahimi said. "It often requires a series of treatments. That's the biggest limiting issue with using this technology. It works well, but compared to CoolSculpting, there is a lot of swelling and bruising, which you would expect with an injectable. Managing that down time and hand holding is difficult. But if you can get patients to buy into the downtime, [it yields] pretty impressive results."

Dr. Ibrahimi also discussed the promise of electrical muscle stimulation for strengthening, firming, and toning muscles. The technology applies an electrical current through electrodes placed on the skin, which stimulates muscles, or through an electromagnetic field.

In a published study of 45 men and women, Dr. Ibrahimi, Anne Chapas, MD, medical director of UnionDerm in New York, and colleagues evaluated the safety and efficacy of an electrical muscle stimulation system for improving muscle strength and toning of the upper extremities.

For the treatments, they used disposable contact pads to place pairs of electrodes on the biceps and on the triceps. All patients (median age 42) received 30-minute treatments twice weekly for 2 or 3 weeks, corresponding to four or six total sessions respectively, depending on the study site. Follow-ups were conducted 30 and 90 days after treatment. They used a validated dynamometer device to measure strength at baseline, at the final treatment session, and at the post-treatment 30- and 90-day visits.

"We saw about a 40% increase in strength in the biceps and about a 30% increase in strength in the triceps," Dr. Ibrahimi said. "Interestingly, the effect got greater at 30 and 90 days, so this is something that lingers on for quite a while." In addition to the increase in strength, the researchers and patients noted an improvement in the appearance of the arms. He predicted that this technology "is going to play a role in functional medicine and getting injured athletes back to their sports faster."

Dr. Ibrahimi disclosed that he is a member of the Advisory Board for Accure Acne, AbbVie, Cutera (manufacturer of truSculpt), Lutronic, Blueberry Therapeutics, Cytrellis, and Quthero. He also holds stock in many device and pharmaceutical companies (none are relevant to the treatments mentioned in this story).

This article originally appeared on, part of the Medscape Professional Network.


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