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[[File:CoolSculpting device.jpg|right|thumb|250px|The commercial CoolSculpting® device.]] {{DISPLAYTITLE: CoolSculpting and DIY CoolSculpting (Cryolipolysis)}} __NOTOC__
CoolSculpting uses cold to reduce fat and it can be effective as long as you know the limitations; a similar effect can be achieved cheaply at home. This approach is marketed as CoolSculpting® ; or Cryolipolysis®. It works by chilling the skin, causing the underlying fat cells to naturally die off. This reduces the thickness of fat in the area treated, though the actual reduction is quite small. Typically, a single treatment will result in the loss of about 1.4oz/40g of fat and 7mm of thickness two months after treatment. While commercial CoolSculpting requires expensive equipment, I've found that a similar effect can be produced at home for almost no cost. See [[#DIY CoolSculpting| the section on DIY CoolSculpting]] for details.
=What is CoolSculpting?=
CoolSculpting uses an FDA approved device to chill the skin for up to an hour<ref name="Avram-2009"/>, with a session lasting one to three hours<ref name="CSFaq"/>, producing a reduction in the fat thickness in the treated area. Animal and human studies have shown a reduction in fat thickness between 20% and 80% over 3 months following treatment<ref name="ClNelson"/>. The device sucks the skin and underlying fat into a cup<ref name="Coleman-2009"/>. More than one treatment can be used, but the results of the second treatment are not as dramatic as the first<ref name="Shek-2012"/>. CoolSculpting is considered an alternative to liposuction<ref name="StevensPietrzak2013"/>, which is the one of the most common types of plastic surgery<ref name="PlasticSurgry2013"/>. There are some initial indications that CoolSculpting may improve skin texture and laxity, with a tightening of the lose skin<ref name="CarruthersStevens2014"/>. While promising, more studies are needed.
The cost seems to vary quite a bit, and I couldn't find any recommended prices. However, self-reported costs seem to be generally between $1,500 and $4,000.
=How does CoolSculpting work?=
The device removes heat from the skin at a constant rate, rather than chilling to a particular temperature. (I suspect that simple icing is not used to ensure the technique is patentable.) While the underlying mechanism is unclear<ref name="ClNelson"/>, the current theory is that chilling fat tissues to just below freezing triggers inflammation of the fat cells ([http://en.wikipedia.org/wiki/Panniculitis Panniculitis]) and then triggers natural cell death in the fat cells ([http://en.wikipedia.org/wiki/Apoptosis apoptosis]). The inflammation starts 3 days after treatment, peaking at 30 days, with some residual inflammation seen after 90 days and the number of fat cells declining over the 90 day period<ref name="Zelickson-2009"/>. ==Is CoolSculpting Just Thermogenesis? ==Because the time frame of CoolSculpting is months, it seems extremely unlikely that the fat loss is due to the localized metabolism of fat to produce heat. The early research into CoolSculpting used Yucatan Pigs that are incapable of non-shivering thermogenesis<ref name="Kruglikov-2014"/>. While there is a recent study showing that as little as 30 minutes of icing can change the gene expression of fat cells to improve their fat burning capability<ref name="Kern-2014"/>., this is not what is typically meant by "Thermogenesis". Rather this is an increased thermogenic capability, and it could contribute to the fat reduction of CoolSculpting. (The study also showed that in lean subjects, similar changes naturally occurred in winter, but far less change occurred in obese subjects.){| class="wikitable" |- valign="top"|[[File:CoolSculpting-Kern-2014-Icing.jpg|none|thumb|x300px|Changes in fat burning capabilities due to 30 minutes of icing<ref name="Kern-2014"/>. The markers represent each of the seven subjects. ]]|[[File:CoolSculpting-Kern-2014-Winter.jpg|none|thumb|x300px|Changes in seasonal fat burning capabilities of lean and obese subjects<ref name="Kern-2014"/>. (A BMI of 30 was used to divide subjects.)]]|}==How Cold is CoolSculpting? ==
A study looked at the temperature of the skin surface and the fat at a point 1.5cm below the surface during a 60 minute CoolSculpting application<ref name="Sasaki-2014"/>. The skin surface dropped in temperature steadily during the 60 minutes until it was at an average of 12.3c/54f (+/-2.6c). The underlying fat temperature dropped for the first 30 minutes to around 13c/55f then cooled more slowly for the final 30 minutes to around 10c/50f. It's interesting to note that the skin temperature was warmer than the underlying fat.
=How Much Fat Is Lost?=
A 2014 study showed an average of 7mm reduction in fat thickness two months after a single treatment (about 1.4oz/40g)<ref name="GaribyanSipprell2014"/>. A 2012 study of CoolSculpting showed an average reduction of about 4mm after two months<ref name="Shek-2012"/>. A second treatment had a lower reduction of an additional 1-2mm. Another study conducted between 2009 and 2012 of 518 patients showed an average of 23% reduction in fat thickness measured by calipers<ref name="DierickxMazer2013"/>. One patient showed a localized reduction of 2.2cm (nearly 1 inch) in fat thickness in spite of an increase of 0.1 Kg in overall weight.
=What About frostbite?=
A common concern is frostbite, or other damage to the skin. This is should not be a problemif correctly performed, as you need far colder temperatures (-10c/14f) to cause that type of damage<ref name="Gage-1982"/><ref name="Gage-1979"/>. CoolSculpting uses temperatures that do not immediately kill off the fat cells, but rather trigger the natural process of cell death ([http://en.wikipedia.org/wiki/Apoptosis apoptosis]). That's why CoolSculpting takes weeks or months for the full effect to be seen. =Risks and Side Effects of CoolSculpting Compared With Cryosurgery=A 2015 analysis of the available research concluded that CoolSculpting is quite different "presents a compelling alternative to Cryosurgeryliposuction", which uses cold "appears to kill off tissuebe safe in the short term", such as tumors. Typically cryosurgery uses far lower temperatures (-20c/-4f to -40c/-40f) and immediately kills off the living cells ([http://en.wikipedia.org/wiki/Necrosis necrosis]) <ref name="CryosurgeryTempresults in significant fat reduction"/>. Cell damage is caused by temperatures below -10c/14f<ref name="Gage-1982IngargiolaMotakef2015"/><ref name="Gage-1979"/> and CoolSculpting does not go that cold. =Side Effects However, there are a number of risks to CoolSculpting=.There have been no serious * A common side effects reported so far<ref name="ClNelson"/>. The effect is that the skin being treated goes red, with some bruising and numbness<ref name="ClNelson"/>. I suspect that the bruising may be because the CoolSculpting device sucks<ref name="Coleman-2009"/> the fat against the cooling device. These problems normally resolve within a week. The numbness is not associated with nerve damage<ref name="Coleman-2009"/>.* Studies have shown no changes in blood lipid levels or liver function<ref name="Avram-2009"/>. The numbness is not associated with nerve damage<ref name="Coleman-2009"/>. * A study of 528 patients that underwent a total of 2,729 cycles showed only three cases of mild or moderate pain, which resolved within 4 days<ref name="StevensPietrzak2013"/>. * Another study of 518 patients showed 4% experienced severe pain during the first 5 minutes of treatment, with the remainder reporting mild to tolerable pain<ref name="DierickxMazer2013"/>. * While "CoolSculpting" is a registered trademark of ZELTIQ, there are a variety of relatively cheap machines that claim to perform Cryolipolysis. Many even claim to be "ZELTIQ" even though they look nothing like the machines made by ZELTIQ and cost a tiny fraction of the cost of a genuine machine. * There is one report of frostbite from Cryolipolysis received at a beauty salon<ref name="ChoongWohlgemut2017"/>. It's unclear if this was from an official ZELTIQ CoolSculpting treatment or not. The subject had two painful blisters arise within a few hours of treatment, but was advised against seeking medical help by the salon owner. The blisters deteriorated over the next few days until the subject went to the doctor. At that point there were two nasty 2" by 3" wounds (5x7cm) which were treated as frostbite. * The manufactures report that there have been a small number of patients (about 1 in 20,000 treatments) that report of a paradoxical increase in fat thickness<ref name="JalianAvram2014"/>. A 2015 analysis of the available research concluded However, another report suggests that CoolSculpting "presents a compelling alternative to liposuction", "appears to be safe in the short term", and "results rate is much higher at 1 in significant fat reduction"120 patients<ref name="IngargiolaMotakef2015KellyRodriguez-Feliz2016"/>.{| class="wikitable" style="margin-left: auto; margin-right: auto; border: none;"|- valign="top"|[[File:Paradoxical Adipose Hyperplasia After Cryolipolysis-1.png|none|thumb|300px|An example of a subject that had an increase in fat thickness due to Cryolipolysis. While rare (1:20,000), you can see this is a fairly dramatic increase in fat thickness.]]|[[File:Paradoxical Adipose Hyperplasia After Cryolipolysis-2.png|none|thumb|300px|An MRI shows that the increase in fat thickness is greatest on the edges of the treatment zone.]]|}
=Weight Loss or Spot Reduction?=
CoolSculpting reduces the fat thickness in the limited area that is treated rather than producing overall [[Weight Loss]]<ref name="ClNelson"/>. CoolSculpting does not seem to be effective in obese people, though it may simply be harder to observe the effects<ref name="ClNelson"/>. It's worth noting that CoolSculpting reduces the fat thickness in people who have a stable weight; in other words, you don't need to be on a diet for it to work.
=CoolSculpting and Massage=
A 2014 study looked at CoolSculpting followed immediately by 2 minutes of massage, and compared the results with CoolSculpting alone<ref name="Boey-2014"/>. Subjects received the CoolSculpting on both sides of their body, but massage only on one side, the other acting as a control. The study found that the addition of massage improved fat reduction by 68% after two months and 44% after four months. Samples of the fat tissue showed increasing inflammation, peaking at 30 days post treatment, with no signs of necrosis or fibrosis at any time (0-120 days). The massage and non-massage groups were similar, but quite small. The massage was described as "1 minute using a vigorous kneading motion followed by 1 minute of circular massage using the pads of the fingers."
=CoolSculpting Compared With Cryosurgery=
CoolSculpting is quite different to Cryosurgery, which uses cold to kill off tissue, such as tumors. Typically cryosurgery uses far lower temperatures (-20c/-4f to -40c/-40f) and immediately kills off the living cells ([http://en.wikipedia.org/wiki/Necrosis necrosis]) <ref name="CryosurgeryTemp"/>. Cell damage is caused by temperatures below -10c/14f<ref name="Gage-1982"/><ref name="Gage-1979"/> and CoolSculpting does not go that cold.
=Is CoolSculpting Just Thermogenesis? =
Because the time frame of CoolSculpting is months, it seems extremely unlikely that the fat loss is due to the localized metabolism of fat to produce heat. The early research into CoolSculpting used Yucatan Pigs that are incapable of non-shivering thermogenesis<ref name="Kruglikov-2014"/>. While there is a recent study showing that as little as 30 minutes of icing can change the gene expression of fat cells to improve their fat burning capability<ref name="Kern-2014"/>, this is not what is typically meant by "Thermogenesis". Rather this is an increased thermogenic capability, and it could contribute to the fat reduction of CoolSculpting. (The study also showed that in lean subjects, similar changes naturally occurred in winter, but far less change occurred in obese subjects.)
{| class="wikitable" style="margin-left: auto; margin-right: auto; border: none;"
|- valign="top"
|[[File:CoolSculpting-Kern-2014-Icing.jpg|none|thumb|x300px|Changes in fat burning capabilities due to 30 minutes of icing<ref name="Kern-2014"/>. The markers represent each of the seven subjects. ]]
|[[File:CoolSculpting-Kern-2014-Winter.jpg|none|thumb|x300px|Changes in seasonal fat burning capabilities of lean and obese subjects<ref name="Kern-2014"/>. (A BMI of 30 was used to divide subjects.)]]
|}
=DIY CoolSculpting=
Having reviewed the evidence for the commercial CoolSculpting, I wondered if it would be possible to replicate the effects by simply applying ice to the skin. An early animal study of CoolSculpting Cryolipolysis showed a reduction in the fat levels from 10 minutes' exposure to temperatures of -1c/31f, though not as great a loss as colder temperatures<ref name="Manstein-2008"/>. The levels A more recent study of fat on my legs are noticeably lower than other parts of my body, which might be humans using commercial CoolSculpting showed the skin surface temperature dropped steadily during the result 60-minute treatment until it was at an average of regular icing12c/54f<ref name="Sasaki-2014"/>. There is evidence that applying ice to the skin produces an inflammation response in just a few minutes<ref name="Avram-2009"/>, so this approach seems viable. There are clearly risks to Cryolipolysis, but for me I decided they were acceptable.
==Frostbite Risks==
==Testing 'DIY CoolSculpting'==
So I undertook a simple experiment and applied a bag of ice to the left side of my abdomen for 1-3 hours a day for two weeks. I generally did this in the evenings, applying the ice while watching TV or reading. While the ice is initially uncomfortable and cold, this sensation disappears in a couple of minutes. It also seems that after the first few times the ice is applied, the discomfort is far less.
==Results of DIY CoolSculpting==
At the end of the two weeks the fat thickness on the left side was noticeably thinner than the right side. The difference seemed to increase in the week following termination of the icing. It's hard to evaluate exactly how much change occurred in a few weeks, and I'm already quite thin (<10% body fat), so small differences are more noticeable than would be the case on someone larger. I used [[Skinfold Calipers]] to check my abdominal skinfold thickness and found a 2mm difference (measured 2 inches to the side of my navel). This is enough to be obvious to me, but not to show up well on photographs. Below are a couple of pictures that attempt to capture the resulting asymmetry.
[[File:CoolSculpting asym1.jpg|nonecenter|thumb|400px|The asymmetry resulting from icing the left side of abdomen using an oblique light to highlight the differences. The larger shadow on the right of the picture highlights the reduction in fat thickness in this area. You can also see larger bulges on the left side of the photo.]][[File:CoolSculpting asym2.jpg|nonecenter |thumb|400px|The asymmetry highlighted by taking the image from an oblique angle.]]
==The Duration of DIY CoolSculpting Changes==
The research into CoolSculpting suggests that it takes 3-4 months for the full effect. Because I applied the CoolSculpting more to the left side of my abs, it is possible to see how long the effects last. I used DIY CoolSculpting in May 2012 for a period of a few weeks. In the following two years my weight fluctuated by around 15 pounds. I performed no more DIY CoolSculpting or icing of my abs during that time. Regardless of these fluctuations the slight difference in the two sides remained constant. This difference is slight, amounting to around 1-2mm, but is noticeable on inspection. This suggests that the effects of DIY CoolSculpting last for at least two years and probably much longer. Obviously DIY CoolSculpting does not prevent overall weight gain, but it's unclear if it will limit this gain in any way.
<ref name="Boey-2014">GE. Boey, JL. Wasilenchuk, Enhanced clinical outcome with manual massage following cryolipolysis treatment: a 4-month study of safety and efficacy., Lasers Surg Med, volume 46, issue 1, pages 20-6, Jan 2014, doi [http://dx.doi.org/10.1002/lsm.22209 10.1002/lsm.22209], PMID [http://www.ncbi.nlm.nih.gov/pubmed/24338439 24338439]</ref>
<ref name="IngargiolaMotakef2015">Michael J. Ingargiola, Saba Motakef, Michael T. Chung, Henry C. Vasconez, Gordon H. Sasaki, Cryolipolysis for Fat Reduction and Body Contouring, Plastic and Reconstructive Surgery, volume 135, issue 6, 2015, pages 1581–1590, ISSN [http://www.worldcat.org/issn/0032-1052 0032-1052], doi [http://dx.doi.org/10.1097/PRS.0000000000001236 10.1097/PRS.0000000000001236]</ref>
<ref name="KellyRodriguez-Feliz2016">Emma Kelly, Jose Rodriguez-Feliz, Michael E. Kelly, Paradoxical Adipose Hyperplasia after Cryolipolysis, Plastic and Reconstructive Surgery, volume 137, issue 3, 2016, pages 639e–640e, ISSN [http://www.worldcat.org/issn/0032-1052 0032-1052], doi [http://dx.doi.org/10.1097/01.prs.0000480023.35573.b7 10.1097/01.prs.0000480023.35573.b7]</ref>
<ref name="ChoongWohlgemut2017">W.L. Choong, H.S. Wohlgemut, M.J. Hallam, Frostbite following cryolipolysis treatment in a beauty salon: a case study, Journal of Wound Care, volume 26, issue 4, 2017, pages 188–190, ISSN [http://www.worldcat.org/issn/0969-0700 0969-0700], doi [http://dx.doi.org/10.12968/jowc.2017.26.4.188 10.12968/jowc.2017.26.4.188]</ref>
</references>