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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, though this DIY approach entails some risks. A safer approach is to use an authorized CoolScultping facility, and I'd recommend ensuring you're going to [http://find.coolsculpting.com/find-a-center/ an authorized provider]. (There are lots of cheap clones of the official CoolScultping machines on ebay.com, so check the machine is by ZELTIQ.)
=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 on skin laxity are needed.
=How Much Does CoolSculpting Cost?=
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 Does CoolSculpting workWork?=
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 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"/>.
=How Cold is CoolSculpting? =
CoolSculpting uses an approach of removing heat from the body at a constant rate, something they call Cooling Intensity Factor (CIF) <ref name="Bernstein2016"/><ref name="Zelickson-2009"/>. This makes it tricky to understand the actual temperatures involved, though studies often quote figures of around -5c to -10c for the temperature of the paddles that are in contact with the patient's skin. * 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 set to -7c/19f<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, and that even though the CoolSculpting device was set to well below freezing point, the skin never got close to that cold. The CoolSculpting setting was a "Cooling Intensity Factor" of 42, and it's unclear to me how that relates to the actual temperaturewhich has units of mW/cm<sup>2</sup>. * An animal study of two different machines that cooled showed a final skin temperature of 8.6c/47f and 5.8c/42f<ref name="JeongKwon2017"/>, which is similar to the human study. * Another study in 2017 evaluated two newer versions of the CoolSculpting device designed to go colder for a shorter period showed skin temperatures of -1.6c/29f and -7.1c/19f<ref name="Kilmer2017"/>. * Further research by ZELTIQ looked at how isolated pig fat cells responded to chilling for an hour and then rewarming<ref name="PreciadoAllison2008"/>. They found that chilling the fat cells to -2c, 0c or 2c caused the cells to die off (necrosis), while chilling them to 7f7c/45f caused some necrosis and some apoptosis (programmed cell death). Chilling the cells to 14c/57f, 21c/70f, or 28c/82f resulted in no necrotic injury and approximately the same apoptosis. Mouse * An early use of CoolSculpting used CIF of 42 mW/cm<sup>2</sup> and produced -10c, or CIF of 34 mW/cm<sup>2</sup> and produced -5c (both after 60 minutes.)<ref name="Bernstein2016"/>. * Isolated mouse fat cells exposed to 8c/46f for 10 minutes showed some crystallization, with more crystallization seen after 25 minutes<ref name="Pinto-"/>. The crystal structures were still visible after 2 hours at 22c/72f. * Colder temperatures have been investigated. Most studies compare to the standard CoolSculpting as -10c/14f for an hour. One small study of 15 subjects used -12c for 45 minutes and -15c for 30 minutes, deployed under the chin area<ref name="Leal SilvaCarmona Hernandez2017"/> (the fat reduction was less than 2mm). There's an abstract of a test using of 45 subjects using CIF of 50 mW/cm<sup>2</sup> (-15c/5f) for 45 minutes on the flanks, resulting in 4.2mm (+/-2.6mm, range 10.7mm to 0mm) <ref name="Kilmer-2015"/>.* According to the FDA fillings, a version of CoolSculpting branded as "CoolAdvanatage" uses -11c/12f for 45 or 35 minutes<ref name="FDA-CoolAdvantage-2017"/>.* Most images of patients after CoolSculpting show the fat has become semi-solid, which is sometimes referred to as the "butter stick". (Google for "CoolSculpting butter stick" for examples.) Some research from 1946 found that fat from 15 cadavers melted at various temperatures<ref name="Schmidt-Nielsen1946"/>. There was variation between individuals and between locations in the body. Subcutaneous abdominal fat melted around 31c-35c//88f-95f. * As another reference point, the most common fats in adipose (body fat) <ref name="Kunešová-2012"/> are Oleic acid (~45%) with a melting point of 13-14c/55-57f, Palmitic acid (~22%) with a melting point of 63c/145f, and Linoleic acid (~12%) with a melting point claimed to be from -16c/12f to -5c/23f (sources differ.) This means that Palmitic acid is always going to be solid and Linoleic acid is always going to be liquid, so the "butter stick" effect seems to come from Oleic acid. Any solidification would suggest the fat has been chilled below 13-14c/55-57f.All this research suggests that while relatively modest temperatures can result in the loss of fat cells, with CoolSculpting may use lower temperatures having and may have more impact.
=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. Note that the FDA clearance for CoolScuplting specifies a BMI of <=30 kg/m<sup>2</sup><ref name="FDA-CoolSculpting-2017"/>.
=What About frostbite?=
A common concern is frostbite, or other damage to the skin. This should not be a problem if correctly performed, as you need far colder temperatures (-10c/14f) to cause that type of damage<ref name="Gage-1982"/><ref name="Gage-1979"/>. A study of mice showed the minimum time and temperature for cell damage is -4c/25f for 3 min<ref name="BournePiepkorn1986"/>, but this is actual cell temperature, not exposure to that temperature. 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. (* There is one case report of frostbite from commercial Cryolipolysis received at a beauty salon<ref name="ChoongWohlgemut2017"/>, but it's not clear if this was an official ZELTIQ CoolSculpting treatment or not.* There are reports of occasional frostbite in patients using a machine to pump ice/water to improve post-operative recovery<ref name="McGuireHendricks2006"/>. These incidents are rare, with only 4 patients out of thousands having an issue, and the site of the frostbite is over the patella (kneecap)where blood supply may be a little more limited. * While there are reports of frostbite from gel packs<ref name="RivlinKing2014"/>, this appears to be surprisingly rare given the sales of gel packs. * A comparison of ice and gel packs showed that after 20 minutes ice reduced skin temperature to 10c/50f and gel packs to 13.6c/56f<ref name="Kanlayanaphotporn-2005"/>. Another study using different amounts of ice showed that larger quantities of ice produced colder skin temperatures, with 0.6Kg/1lb producing an average of 6c/43f and a minimum of 4.4c/40f<ref name="Janwantanakul2009"/>.
=Risks and Side Effects of CoolSculpting=
A 2015 analysis of the available research concluded that CoolSculpting "presents a compelling alternative to liposuction", "appears to be safe in the short term", and "results in significant fat reduction"<ref name="IngargiolaMotakef2015"/>. However, there are a number of risks to CoolSculpting.
* A common side 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 sucksthe fat against the cooling device<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"/>.* While most patients find CoolSculpting uncomfortable, some suffer from "delayed onset pain." A study of 125 patients who underwent 554 treatments found 19 (15%) suffered from this problem<ref name="KeaneyGudas2015"/>. The criteria for defining delayed onset pain was two of stabbing/shooting/burning pain, pain that disrupted sleep, or pain unresponsive to pain medication. The pain lasts 3-11 days, with no permanent symptoms.
* Studies have shown no changes in blood lipid levels or liver function<ref name="Avram-2009"/><ref name="KleinBachelor2017"/>.
* 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"/>.
=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.
=How long does it take Long Does It Take to workWork?=
The effects of CoolSculpting should start within a few weeks, but the full effect may take 3-4 months<ref name="Zelickson-2009"/>. Tests indicate that the changes are noticeable after 2-7 weeks (average 4 weeks)<ref name="Shek-2012"/>.
=How Long Does It Last?=
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.)
* Making a mistake can cause serious injury. Even performed correctly, if you have circulatory issues or a susceptibility to frostbite<ref name="Daanen-2005"/>, DIY CoolSculpting can be dangerous.
* Using anything other than ice water can result in temperatures low enough to result in serious frostbite requiring hospitalization<ref name="LeonardKahn2016"/>.
* Never use any type of gel pack. These start too cold and can easily cause frostbite<ref name="Stevens-1978"/>, and they warm up too quickly<ref name="ChestertonFoster2002"/><ref name="Kanlayanaphotporn-2005"/>.
* A mixture of ice and water will be about freezing point, but solid ice can be much colder, so don't use a solid block of ice. Make sure the ice is starting to melt slightly so that you have a mixture of ice and water. I've found that crushed ice in a Ziploc bag works well as it conforms to the shape of your body and starts melting quickly.
* It's critical that you monitor your skin temperature closely (See below).
* A [[Thermal Camera]] is great as it allows you to see not only the temperature at one spot, but the pattern of temperature changes. The downsides are that you have to take the ice off to check the temperature, and the cameras are expensive. I'd use this with the above temperature sensor rather than instead of it. Of the two consumer-grade thermal cameras on the market, I prefer the FLIR, but it's discontinued and the new model hasn't been released yet. If you don't want to wait for the update, I'd recommend looking at the Seek <jfs id="B00NYWABAA" noreferb="true"/>, but check out [[Thermal Camera]] for more details. <br/>[[File:Cryolipolysis Thermal Camera.jpg|center|thumb|300px|An example image from my [[Thermal Camera]] showing the skin temperature.]]
==Typical Skin Temperatures==
I've made a number of tests, monitoring my skin temperature for up to three hours. The graph below shows three tests where I took temperature readings every 15 minutes, and it's fairly typical of what I see. The skin temperature initially drops fairly quickly, dropping to around 5-15c/40-60f within five minutes, and stabilizing around 5-10c/40-50f within 15-20 minutes. After that, the temperature tends to be reasonably stable, and most of the variation is down to how much the ice water is moved. If the bag of ice water is kept very still, the skin temperature will rise somewhat, but if it's actively agitated, then the skin temperature can drop. It takes some effort for me to get the skin temperature below 2c/36f, and obviously, the skin temperature never drops below freezing, as the ice water isn't that cold. This is broadly similar to research studies<ref name="Kanlayanaphotporn-2005"/><ref name="BelitskyOdam1987"/><ref name="Janwantanakul2009"/>.
[[File:Skin Temp Graph.jpg|center|thumb|400px|Skin temperature against time while icing.]]
Here are some other tests I performed, showing the variation you might experience, with temperatures rising and falling. Some of this variation is due to the body's natural responses, but quite a bit is due to how much I move the ice water around.
<ref name="PreciadoAllison2008">Jessica A. Preciado, John W. Allison, 59. The effect of cold exposure on adipocytes: Examining a novel method for the non-invasive removal of fat, Cryobiology, volume 57, issue 3, 2008, pages 327, ISSN [http://www.worldcat.org/issn/00112240 00112240], doi [http://dx.doi.org/10.1016/j.cryobiol.2008.10.060 10.1016/j.cryobiol.2008.10.060]</ref>
<ref name="Pinto-">H. Pinto, E. Arredondo, D. Ricart-Jane, Evaluation of adipocytic changes after a simil-lipocryolysis stimulus., Cryo Letters, volume 34, issue 1, pages 100-5, PMID [http://www.ncbi.nlm.nih.gov/pubmed/23435706 23435706]</ref>
<ref name="Kunešová-2012">M. Kunešová, P. Hlavatý, E. Tvrzická, B. Staňková, P. Kalousková, N. Viguerie, TM. Larsen, MA. van Baak, SA. Jebb, Fatty acid composition of adipose tissue triglycerides after weight loss and weight maintenance: the DIOGENES study., Physiol Res, volume 61, issue 6, pages 597-607, 2012, PMID [http://www.ncbi.nlm.nih.gov/pubmed/23098653 23098653]</ref>
<ref name="McGuireHendricks2006">David A. McGuire, Stephen D. Hendricks, Incidences of Frostbite in Arthroscopic Knee Surgery Postoperative Cryotherapy Rehabilitation, Arthroscopy: The Journal of Arthroscopic & Related Surgery, volume 22, issue 10, 2006, pages 1141.e1–1141.e6, ISSN [http://www.worldcat.org/issn/07498063 07498063], doi [http://dx.doi.org/10.1016/j.arthro.2005.06.027 10.1016/j.arthro.2005.06.027]</ref>
<ref name="RivlinKing2014">Michael Rivlin, Marnie King, Richard Kruse, Asif M. Ilyas, Frostbite in an Adolescent Football Player: A Case Report, Journal of Athletic Training, volume 49, issue 1, 2014, pages 97–101, ISSN [http://www.worldcat.org/issn/1062-6050 1062-6050], doi [http://dx.doi.org/10.4085/1062-6050-48.6.19 10.4085/1062-6050-48.6.19]</ref>
<ref name="Schmidt-Nielsen1946">Knut Schmidt-Nielsen, Melting Points of Human Fats as Related to their Location in the Body, Acta Physiologica Scandinavica, volume 12, issue 2-3, 1946, pages 123–129, ISSN [http://www.worldcat.org/issn/00016772 00016772], doi [http://dx.doi.org/10.1111/j.1748-1716.1946.tb00372.x 10.1111/j.1748-1716.1946.tb00372.x]</ref>
<ref name="Kanlayanaphotporn-2005">R. Kanlayanaphotporn, P. Janwantanakul, Comparison of skin surface temperature during the application of various cryotherapy modalities., Arch Phys Med Rehabil, volume 86, issue 7, pages 1411-5, Jul 2005, PMID [http://www.ncbi.nlm.nih.gov/pubmed/16003673 16003673]</ref>
<ref name="BelitskyOdam1987">Rosalind B. Belitsky, Stella J. Odam, Cheryl Hubley-Kozey, Evaluation of the Effectiveness of Wet Ice, Dry Ice, and Cryogen Packs in Reducing Skin Temperature, Physical Therapy, volume 67, issue 7, 1987, pages 1080–1084, ISSN [http://www.worldcat.org/issn/0031-9023 0031-9023], doi [http://dx.doi.org/10.1093/ptj/67.7.1080 10.1093/ptj/67.7.1080]</ref>
<ref name="Janwantanakul2009">Prawit Janwantanakul, The effect of quantity of ice and size of contact area on ice pack/skin interface temperature, Physiotherapy, volume 95, issue 2, 2009, pages 120–125, ISSN [http://www.worldcat.org/issn/00319406 00319406], doi [http://dx.doi.org/10.1016/j.physio.2009.01.004 10.1016/j.physio.2009.01.004]</ref>
<ref name="KeaneyGudas2015">Terrence C. Keaney, Amber Tario Gudas, Tina S. Alster, Delayed Onset Pain Associated With Cryolipolysis Treatment, Dermatologic Surgery, volume 41, issue 11, 2015, pages 1296–1299, ISSN [http://www.worldcat.org/issn/1076-0512 1076-0512], doi [http://dx.doi.org/10.1097/DSS.0000000000000502 10.1097/DSS.0000000000000502]</ref>
<ref name="Leal SilvaCarmona Hernandez2017">Hector Leal Silva, Esther Carmona Hernandez, Mariana Grijalva Vazquez, Sebastian Leal Delgado, Angel Perez Blanco, Noninvasive submental fat reduction using colder cryolipolysis, Journal of Cosmetic Dermatology, volume 16, issue 4, 2017, pages 460–465, ISSN [http://www.worldcat.org/issn/14732130 14732130], doi [http://dx.doi.org/10.1111/jocd.12383 10.1111/jocd.12383]</ref>
<ref name="FDA-CoolSculpting-2017">https://www.accessdata.fda.gov/cdrh_docs/pdf17/K172144.pdf, www.accessdata.fda.gov</ref>
<ref name="FDA-CoolAdvantage-2017">https://www.accessdata.fda.gov/cdrh_docs/pdf17/k171069.pdf, www.accessdata.fda.gov</ref>
<ref name="Kilmer-2015">Kilmer S, Boey G, Burns AJ. Safety and efficacy of colder temperature, shorter duration cryolipolysis treatments. Lasers Surg Med 2015; 47(S26):28. https://docksci.com/american-society-for-laser-medicine-and-surgery-abstracts-american-society-for-l_5a58568dd64ab2e895a5257c.html </ref>
</references>