Body Contouring

Paradoxical Adipose Hyperplasia: A Complication of Coolsculpting Fat Freezing

30 September 2021


Have you heard of paradoxical adipose hyperplasia? This condition is now one of the most searched for terms on search engines after supermodel Linda Evangelista filed a lawsuit against the makers of Coolsculpt, a fat freezing treatment after suffering this complication.


In a heartfelt post on instagram, Linda Evangelista addressed the reason why she left the limelight for the last five years. As a result of a non-surgical face and body sculpting treatment called Coolsculpting, she suffered a complication known as paradoxical adipose hyperplasia. Instead of having her fat cells removed; paradoxically, as its name suggests, the fat cells grew.


Linda Evangelista’s statement on her Instagram page.


According to Linda Evangelista, this complication from Coolsculpt fat freezing has resulted in her looking “brutally disformed” and sent her into a “deep cycle of depression, profound sadness and the lowest depths of self loathing”. In court documents, Linda Evangelista stated that she is now “unemployable and unable to earn an income as a model” due to paradoxical adipose hyperplasia. She is seeking $50 million in damages from Zeltiq Aesthetics, the manufacturer of Coolsculpt.


The complaint and legal documents of lawsuit between Linda Evangelista and Zeltiq Aesthetics can be read here.


In this review, you can learn about fat freezing (cryolipolysis) and paradoxical adipose hyperplasia (PAH).


What is Coolsculpting?


Coolsculpting is a brand of cryolipolysis treatment. Cryolipolysis is a non-surgical and non-invasive treatment that removes fats in the face, neck and body by freezing the fat cells (i.e. fat freezing). The frozen fat cells die and are removed by the body. Coolsculpting is US FDA approved for reducing fat in the abdomen, flanks, thighs, bra fat, back fat, banana roll, and most recently the upper arms.


The idea of using cold temperatures to freeze off or kill fat cells was an observation in children eating popsicles. In 2008, two scientists from Harvard Medical School, Dr Rox Anderson and Dr Dieter Manstein noticed that some children sucking on popsicles developed a condition called cold panniculitis or popsicle panniculitis. These children developed permanent dimples in the cheeks. The coldness of the popsicles damaged fat cells in the cheeks of these children, causing depressions in their cheeks.





What does Coolsculpting Fat Freezing do?


Cryolipolysis with Coolsculpting is a treatment for patients to lose unwanted fats in their face, neck and body. However, cryolipolysis or fat freezing is not intended for large amounts of fat loss; especially in overweight patients. Instead Coolsculpting cryolipolysis is better used for body contouring or removing stubborn pockets of fat that have not responded to dietary changes and exercise in patients at ideal body weights.


How does Coolsculpting Fat Freezing/ Cryolipolysis work?


In Singapore, Coolsculpting fat freezing is a treatment that is performed by doctors. A gel is first applied to the skin over the intended area of fat freezing to protect the skin. Coolsculpting applicators then cool the skin and the underlying fat tissues to about zero degrees celsius. The treatment time ranges from 30 minutes to two hours, depending on the body part treated.



Bringing the fat cells to freezing point causes inflammation, shrinking and eventual death of the fat cells. Over time, the thickness of fat in the treated area reduces in the patient. These changes happen over one to six months.

What is Paradoxical Adipose Hyperplasia (PAH)?


In some patients who have undergone Coolsculpting Fat Freezing, instead of finding their fat cells decreasing, the fat cells instead increase in size. This is known as Paradoxical Adipose Hyperplasia (PAH). A simple way of explaining it: the patient looks fatter rather than thinner with PAH.


the areas of their body affected by PAH, patients develop visible fat lumps. These lumps are well outlined and are classically described as “sticks of butter”. This is because PAH looks like a long stick of butter under the skin; matching the shape of the Coolsculpt applicator.


PAH typically occurs 2-3 months after Coolsculpting fat freezing treatment. Paradoxical adipose hyperplasia does not go away on its own; so this complication of cryolipolysis is understandably distressing for affected patients.


 Paradoxical Adipose Hyperplasia in a patient after fat freezing. Image credit: Singh et al.


Why does paradoxical adipose hyperplasia occur after Coolsculpting fat freezing?


The exact mechanisms causing the development of paradoxical adipose hyperplasia after Coolsculpting fat freezing remain unclear.


Some of the hypothesised mechanisms include hypertrophy of pre-existing fat cells, migration of fat cells and/or stem cells into the affected areas, changes in metabolism of fat cells and signalling mechanisms.


What is the risk of Paradoxical Adipose Hyperplasia from Coolsculpting Fat Freezing?


The risk of developing PAH after Coolsculpting varies across different studies. According to the manufacturer of Coolsculpting, Allergan, the risk of PAH is 1 in 4000 cycles or 0.025%. One recent study demonstrated a risk of 1 in 138 Coolsculpting cycles or 0.72%.


A more recent review of the incidences of PAH after Coolsculpting in eight clinics in Canada over four year was recently published in 2021. This study involving than eight thousand patients found that the risk of PAH after Coolsculpting to be less than 1 in 2000- which is almost double than the risk quoted by the manufacturer of Coolsculpting.


How can Paradoxical Adipose Hyperplasia from Coolsculpting Cryolipolysis be Treated?


PAH from Coolsculpting fat freezing does not go away by itself. Surgical correction such as excision, liposuction and abdominoplasty are required to remove the PAH.


Even then, the surgery to treat PAH is not a straightforward one. Fat that has been forzen is denatured, inflammed and scarred down. Some patients may require more than one surgery to treat their PAH.


For patients who have a confirmed diagnosis of paradoxical adipose hyperplasia after Coolsculpting, Zeltiq will reportedly pay for surgical treatment of the PAH. But on one condition- that the patient signs a confidentiality agreement and release. With this, the patients are not to publicise their experience and release the company of all claims.



1. Paradoxical Adipose Hyperplasia After Cryolipolysis. Jalian et al. JAMA Dermatol. 2014 Mar; 150(3): 317–319.

2. Complication of ‘fat freezing’ procedure may be more common than thought. Kelly et al. Plast Reconstr Surg. 2018 Jul;142(1):17e-22e.

3. A Multicenter Evaluation of Paradoxical Adipose Hyperplasia Following Cryolipolysis for Fat Reduction and Body Contouring: A Review of 8658 Cycles in 2114 Patients. Nikolis and Enright. Aesthet Surg J. 2021 Jul 14;41(8):932-941.



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