Definitive Treatment of PAH Paradoxical Adipose Hyperplasia

What the definitive treatment of PAH paradoxical adipose hyperplasia has to explain

Paradoxical adipose hyperplasia (PAH) is localized fat growth in areas previously treated with Coolsculpting cryotherapy. Patients present with paradoxical overgrowth of fat and a bulge in the area that was treated with cryotherapy.

The excised tissue is described as showing hyperproliferation of fat in the localized cryotherapy area when compared with adjacent fat layers.

Patients with paradoxical adipose hyperplasia often admit to moderate weight gain. That history is the basis for a hypothesis on the mechanism of PAH and for a treatment plan published in the Journal of American Cosmetic Surgery in 2020. The article is not quoted. No dose, gram target, or tumescent recipe is stated.

Cryotherapy, cryolipolysis, and weight

Cryotherapy is a cosmetic procedure that eliminates fat by freezing the superficial fat layer exposed to external cooling pads. The pads act from outside the skin, on the superficial layer they touch. Cryolipolysis is the superficial fat death that follows, and the body later resorbs that fat. The contour that improves is the contour under the cryo pad.

A 20 % improvement in contour lines has been described as an alternative to a liposuction procedure. The figure is a contour-line claim, not a weight change. Patients must maintain their weight after this treatment. If they do not, the risk named is PAH.

Pressure apoptosis

With moderate weight gain, the treated area is prone to enlargement. Its deep fat overgrows the deep fat in adjacent areas that were not treated. The hypothesis names the reason pressure apoptosis. Pressure apoptosis stops a cell from overgrowing and from suffocating neighboring cells.

When a cell feels pressure, it stops growing. Cryotherapy removes the superficial fat that had supplied that external compression. Without it, deep fat cells in the treated area preferentially start growing, while the adjacent deep fat is still compared against them. That preferential growth is termed paradoxical hyperplasia.

Why both fat layers are removed

Treatment options are described as limited by two different fat patterns. Treated areas have a great amount of deep fat and minimal superficial fat. Adjacent areas have moderate superficial fat and moderate deep fat. The only option named for that mismatch is to remove both layers of fat from both areas. That removal is the definitive treatment of PAH paradoxical adipose hyperplasia on this account.

Repeat cryo lipolysis is described as compounding the problem, because it removes more of the protective superficial fat. Traditional liposuction is described as able to remove little deep fat and as unable to remove superficial fat.

VASER removal of deep and superficial fat

The definitive treatment of PAH paradoxical adipose hyperplasia is the use of VASER ultrasound-assisted liposuction. It is described as able to remove both the deep and superficial fat from the cryo-treated areas and the non-cryo-treated areas. The fat in both layers is cavitated, or melted, and then siphoned with conventional cannulas.

Conventional cannulas cannot remove the most superficial fat, because that fat is compartmentalized. VASER is the step that melts both layers before those cannulas siphon the fat. Used alone, the cannulas leave that superficial compartment. After the fat is gone, skin over the bulging area needs tightening. The bulge is attributed to overgrowth of the deep fat, so the skin that had covered that overgrowth is the slack that remains.

Renuvion for the slack skin

Once the fat has been removed with VASER, slack skin is observed and needs attention. Renuvion is described as contracting that redundant skin with helium activated plasma and radiofrequency. The contraction is called subdermal coagulation. Those energies are said to contract collagen molecules and then the overlying skin, without cutting. Renuvion is the skin step in the definitive treatment of PAH paradoxical adipose hyperplasia.

How the treated site differs from the site beside it

The treated site and the adjacent site do not hold the same fat. Cryotherapy was aimed at superficial fat, so the treated site keeps a great amount of deep fat and only minimal superficial fat. The adjacent site was not under the pad, so it still has moderate superficial fat and moderate deep fat. The bulge is the treated site, where deep fat has overgrown the deep fat next to it. The excised specimen shows hyperproliferation in the cryotherapy area compared with those adjacent layers.

Taking fat from one layer, or from one site only, leaves that step in place. The only option named is to remove both layers from both areas. Repeat cryo lipolysis would remove more of the protective superficial fat and compound the step. Traditional liposuction removes little deep fat and cannot remove superficial fat, including the compartmentalized superficial fat conventional cannulas do not take.

Order from the cooling pad to the slack skin

External cooling pads freeze superficial fat. That fat dies and is resorbed. A 20 % improvement in contour lines is the benefit described, as an alternative to liposuction, and it depends on weight being maintained. Moderate weight gain is the history patients often admit. A cell that feels pressure stops growing, which is also described as keeping a cell from suffocating its neighbors. After the superficial fat is gone, that pressure on the deep fat is gone, and the deep cells in the treated area preferentially grow. The name for that growth is paradoxical hyperplasia.

VASER ultrasound-assisted liposuction then melts deep and superficial fat in the cryo-treated areas and the non-cryo-treated areas, and conventional cannulas siphon what was melted. Slack skin over the bulge is contracted with helium activated plasma and radiofrequency. That pairing is called subdermal coagulation. Collagen contracts, and the overlying skin contracts with it, without a cut. The caption still names a modified abdominal skin resection as the specialized tummy tuck on this 51-year-old. That resection is not given another technique here, and it stays beside the photo line that names Renuvion skin tightening.

The American Society of Plastic Surgeons describes liposuction, sometimes referred to as lipo by patients, as a surgical procedure that involves the removal of excess fat from specific areas of the body. That sentence matches fat removal. It does not describe Coolsculpting cryotherapy, the 20 % contour figure, pressure apoptosis, the layer rules, VASER cavitation, the cannula limit, Renuvion, or the 51-year-old caption.

Approaches set aside before VASER

Repeat cryolipolysis is the first approach set aside. Cryolipolysis removes superficial fat. In a treated area that superficial fat is already the layer that was lost, and that loss is what removed the compression on the deep fat. Freezing the area again removes more of the protective superficial layer. The deep fat, which is the fat that overgrew, is not the layer cryolipolysis is described as treating. The mismatch grows: still less superficial fat, and the same great amount of deep fat.

Traditional liposuction is the second approach set aside. It can remove little of the deep fat, and it cannot remove superficial fat. The adjacent site still has a moderate superficial layer and a moderate deep layer to reduce, and the treated site has a great deep layer plus whatever superficial fat remains. A method that takes little deep fat and no superficial fat does not clear either site. Conventional cannulas add a further limit: the most superficial fat is compartmentalized, and those cannulas do not remove it. VASER is distinguished by melting both layers first, so the cannulas can siphon fat they otherwise leave.

The skin step is separate from the fat step. After VASER, slack skin is observed. That slack is redundant skin over the area that bulged from deep-fat overgrowth. Renuvion uses helium activated plasma together with radiofrequency. The pairing is called subdermal coagulation. Collagen molecules contract, and the overlying skin contracts with them. No cut is required for that contraction. The caption still separately names a modified abdominal skin resection, a specialized tummy tuck, for this 51-year-old. That resection is not redescribed as the Renuvion contraction.