Skin Necrosis of the Thigh After a Cryolipolysis Session: A Case Report

Skin Necrosis of the Thigh After a Cryolipolysis Session: A Case Report Abstract Cryolipolysis is a noninvasive technique for reducing localized subcutaneous fat that is based on adipocyte’s high sensitivity to cold. We report a case of a lateral thigh skin necrosis postcryolipolysis, performed by a dermatologist, on a 42-year-old woman without any significant medical history. The treatment of these lesions required a surgical procedure (necrosectomy associated to direct suture), performed in the operating room. Complete wound healing was obtained in 2 weeks, with a satisfying aesthetic result at 6 months. Level of Evidence: 5 Cryolipolysis is a noninvasive technique used to reduce localized subcutaneous fat. Its principle was described by Rox Anderson and Dieter Manstein in 2008.1 It is based on adipocyte’s higher sensitivity to cooling injury compared to other skin cells. The application of localized cold triggers an inflammatory phenomenon known as panniculitis. This phenomenon was reported in both children2 and adults.3 It induces apoptosis of adipocytes which will be engulfed and digested by macrophages 15 to 30 days after the cold exposure.4 Cryolipolysis is considered a noninvasive technique. Commonly reported transient side effects are erythema, bruising, edema, pain, and dysesthesia of the treatment site.5-7 One case of motor neuropathy was described after a cryolipolysis of the arm and fully recovered at 6 months.8 Also, some cases of paradoxical adipose hyperplasia have been reported.9 To date, only one case of skin necrosis after a “do-it-yourself” version of cryolipolysis has been described.10 In fact, no permanent skin injuries have been reported in the literature when cryolipolysis is performed under medical guidance. We report a case of skin necrosis after a cryolipolysis procedure of the thigh that required surgical management. CASE REPORT A 42-year-old female fitness trainer, with no significant medical history, presented to our practice for necrosis of the skin and the subcutaneous tissue of the lateral side of the left thigh following a cryolipolysis session. The device used was the Freeze Sculptor 2 slimming system S80B (SUS advancing Technology Co., Guangzhou, China). The sessions were performed in August 2015 in France by an experienced dermatologist (B.R.) who previously performed more than 250 procedures without any complications. During the first 60 minutes the patient had an abdominal session at −5°C without any issue. The second treatment session was planned with the same device for 60 minutes at −2°C on the trochanteric area. The procedure had to be stopped after 25 minutes due to the important pain felt by the patient. When the hand piece was removed, a lack of gel was noted, exposing the skin directly to the cooling plates. The evolution of this skin injury led to the formation of two skin necrosis areas of 1 × 6 cm and 15 × 4 cm (Figure 1). These areas matched with the hand piece’s cooling plates. Twenty-six days after the cryolipolysis treatment, the patient presented to our plastic surgery department for the treatment of her skin lesions. At day 36, a necrosectomy was done under general anesthesia and the resulting defect was closed primarily. The patient was followed up to 6 months without any complications and with satisfying aesthetic results (Figure 2). The patient satisfaction was evaluated through the postoperative interviews conducted personally by the plastic surgeon (L.L.). Written informed consent was obtained from the patient. Figure 1. View largeDownload slide Photographs of this 42-year-old woman (A) 5 days and (B) 26 days post-cryolipolysis. Figure 1. View largeDownload slide Photographs of this 42-year-old woman (A) 5 days and (B) 26 days post-cryolipolysis. Figure 2. View largeDownload slide Photograph of this 42-year-old woman taken 6 months after undergoing a necrosectomy to close the lesions. Figure 2. View largeDownload slide Photograph of this 42-year-old woman taken 6 months after undergoing a necrosectomy to close the lesions. Further investigations, done by an internal medicine consultant (independent of this study), showed no cold induced pathologies (such as Raynaud’s syndrome or cold urticarial) and biological investigations were negative for cryoglobulinemia and cryofibrinogen, and positive for antinuclear antibodies. DISCUSSION Over the past few years, cryolipolysis has been shown to be a procedure without irreversible or major side effects.11 It seems to be an effective method used to reduce the subcutaneous fat layer, with an average reduction of 25% at 6 months.4 To date, no cases of severe skin lesions after cryolipolysis have been reported in the literature.9 Cold temperatures can cause skin burns known as frostbites and such complications should have been expected with this type of procedure. Freezing induces the formation of intra and extra cellular crystals leading to vasoconstriction, tissue hypoxia and arterio-venous thrombosis. This process may induce first, second, or third degree skin burns. In our case, skin necrosis was probably due to either a lack of gel on the interface or to the sliding of the hand piece during the procedure. In fact, the fibrous lateral thigh fat cannot be easily drawn into the 2 cooling plates by the hand piece’s vacuum. Stevens and Bachelor12 worked on a nonvacuum conformable surface applicator specific of the trochanteric area to improve the results of cryolipolysis. Our decision to conduct a necrosectomy with primary closure was motivated by the patients’ profession who requested a rapid wound healing with minimal scarring. Healing by secondary intention or skin graft are also potential treatments. However, these techniques, require long healing periods and result in inferior aesthetic outcome. Cryolipolysis has become a very popular alternative to liposuction with more than 450,000 procedures performed around the world.6 Thus, this isolated case (on one device, with one practitioner) does not allow us to draw final conclusions about this technique’s safety. This case highlights cryolipolysis potential risks and shows that caution is needed to avoid this kind of complications. Having standardized and high quality devices with conformable hand pieces seems paramount to obtain satisfying results while minimizing adverse events. CONCLUSION The occurrence of a single isolated case of skin necrosis postcryolipolysis arises questions about the safety of this technique. The use of certified material (ie, noncounterfeit devices) with hand pieces adapted to the treated area is important to ensure the patient’s safety. These procedures should be performed with extreme caution in order to minimize this type of adverse events. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERECNES 1. Manstein D Laubach H Watanabe K Farinelli W Zurakowski D Anderson RR. Selective cryolysis: a novel method of non-invasive fat removal. Lasers Surg Med . 2008; 40( 9): 595- 604. Google Scholar CrossRef Search ADS PubMed  2. Rotman H. Cold panniculitis in children. Adiponecrosis E frigore of Haxthausen. Arch Dermatol . 1966; 94( 6): 720- 721. Google Scholar CrossRef Search ADS PubMed  3. Beacham BE Cooper PH Buchanan CS Weary PE. Equestrian cold panniculitis in women. Arch Dermatol . 1980; 116( 9): 1025- 1027. Google Scholar CrossRef Search ADS PubMed  4. Krueger N Mai SV Luebberding S Sadick NS. Cryolipolysis for noninvasive body contouring: clinical efficacy and patient satisfaction. Clin Cosmet Investig Dermatol . 2014; 7: 201- 205. Google Scholar PubMed  5. Dierickx CC Mazer JM Sand M Koenig S Arigon V. Safety, tolerance, and patient satisfaction with noninvasive cryolipolysis. Dermatol Surg . 2013; 39( 8): 1209- 1216. Google Scholar CrossRef Search ADS PubMed  6. Ingargiola MJ Motakef S Chung MT Vasconez HC Sasaki GH. Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment paradigms. Plast Reconstr Surg . 2015; 135( 6): 1581- 1590. Google Scholar CrossRef Search ADS PubMed  7. Derrick CD Shridharani SM Broyles JM. The safety and efficacy of cryolipolysis: a systematic review of available literature. Aesthet Surg J . 2015; 35( 7): 830- 836. Google Scholar CrossRef Search ADS PubMed  8. Lee SJ Kim YJ Park JB Suh DH Kwon DY Ryu HJ. A case of motor neuropathy after cryolipolysis of the arm. J Cosmet Laser Ther . 2016; 18( 7): 403- 404. Google Scholar CrossRef Search ADS PubMed  9. Jalian HR Avram MM Garibyan L Mihm MC Anderson RR. Paradoxical adipose hyperplasia after cryolipolysis. JAMA Dermatol . 2014; 150( 3): 317- 319. Google Scholar CrossRef Search ADS PubMed  10. Leonard CD Kahn SA Summitt JB. Full-thickness wounds resulting from ‘do-it-yourself’ cryolipolysis: a case study. J Wound Care . 2016; 25( 4): S30- S32. Google Scholar CrossRef Search ADS PubMed  11. Ferraro GA De Francesco F Cataldo C Rossano F Nicoletti G D’Andrea F. Synergistic effects of cryolipolysis and shock waves for noninvasive body contouring. Aesthetic Plast Surg . 2012; 36( 3): 666- 679. Google Scholar CrossRef Search ADS PubMed  12. Stevens WG Bachelor EP. Cryolipolysis conformable-surface applicator for nonsurgical fat reduction in lateral thighs. Aesthet Surg J . 2015; 35( 1): 66- 71. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

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© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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Abstract

Abstract Cryolipolysis is a noninvasive technique for reducing localized subcutaneous fat that is based on adipocyte’s high sensitivity to cold. We report a case of a lateral thigh skin necrosis postcryolipolysis, performed by a dermatologist, on a 42-year-old woman without any significant medical history. The treatment of these lesions required a surgical procedure (necrosectomy associated to direct suture), performed in the operating room. Complete wound healing was obtained in 2 weeks, with a satisfying aesthetic result at 6 months. Level of Evidence: 5 Cryolipolysis is a noninvasive technique used to reduce localized subcutaneous fat. Its principle was described by Rox Anderson and Dieter Manstein in 2008.1 It is based on adipocyte’s higher sensitivity to cooling injury compared to other skin cells. The application of localized cold triggers an inflammatory phenomenon known as panniculitis. This phenomenon was reported in both children2 and adults.3 It induces apoptosis of adipocytes which will be engulfed and digested by macrophages 15 to 30 days after the cold exposure.4 Cryolipolysis is considered a noninvasive technique. Commonly reported transient side effects are erythema, bruising, edema, pain, and dysesthesia of the treatment site.5-7 One case of motor neuropathy was described after a cryolipolysis of the arm and fully recovered at 6 months.8 Also, some cases of paradoxical adipose hyperplasia have been reported.9 To date, only one case of skin necrosis after a “do-it-yourself” version of cryolipolysis has been described.10 In fact, no permanent skin injuries have been reported in the literature when cryolipolysis is performed under medical guidance. We report a case of skin necrosis after a cryolipolysis procedure of the thigh that required surgical management. CASE REPORT A 42-year-old female fitness trainer, with no significant medical history, presented to our practice for necrosis of the skin and the subcutaneous tissue of the lateral side of the left thigh following a cryolipolysis session. The device used was the Freeze Sculptor 2 slimming system S80B (SUS advancing Technology Co., Guangzhou, China). The sessions were performed in August 2015 in France by an experienced dermatologist (B.R.) who previously performed more than 250 procedures without any complications. During the first 60 minutes the patient had an abdominal session at −5°C without any issue. The second treatment session was planned with the same device for 60 minutes at −2°C on the trochanteric area. The procedure had to be stopped after 25 minutes due to the important pain felt by the patient. When the hand piece was removed, a lack of gel was noted, exposing the skin directly to the cooling plates. The evolution of this skin injury led to the formation of two skin necrosis areas of 1 × 6 cm and 15 × 4 cm (Figure 1). These areas matched with the hand piece’s cooling plates. Twenty-six days after the cryolipolysis treatment, the patient presented to our plastic surgery department for the treatment of her skin lesions. At day 36, a necrosectomy was done under general anesthesia and the resulting defect was closed primarily. The patient was followed up to 6 months without any complications and with satisfying aesthetic results (Figure 2). The patient satisfaction was evaluated through the postoperative interviews conducted personally by the plastic surgeon (L.L.). Written informed consent was obtained from the patient. Figure 1. View largeDownload slide Photographs of this 42-year-old woman (A) 5 days and (B) 26 days post-cryolipolysis. Figure 1. View largeDownload slide Photographs of this 42-year-old woman (A) 5 days and (B) 26 days post-cryolipolysis. Figure 2. View largeDownload slide Photograph of this 42-year-old woman taken 6 months after undergoing a necrosectomy to close the lesions. Figure 2. View largeDownload slide Photograph of this 42-year-old woman taken 6 months after undergoing a necrosectomy to close the lesions. Further investigations, done by an internal medicine consultant (independent of this study), showed no cold induced pathologies (such as Raynaud’s syndrome or cold urticarial) and biological investigations were negative for cryoglobulinemia and cryofibrinogen, and positive for antinuclear antibodies. DISCUSSION Over the past few years, cryolipolysis has been shown to be a procedure without irreversible or major side effects.11 It seems to be an effective method used to reduce the subcutaneous fat layer, with an average reduction of 25% at 6 months.4 To date, no cases of severe skin lesions after cryolipolysis have been reported in the literature.9 Cold temperatures can cause skin burns known as frostbites and such complications should have been expected with this type of procedure. Freezing induces the formation of intra and extra cellular crystals leading to vasoconstriction, tissue hypoxia and arterio-venous thrombosis. This process may induce first, second, or third degree skin burns. In our case, skin necrosis was probably due to either a lack of gel on the interface or to the sliding of the hand piece during the procedure. In fact, the fibrous lateral thigh fat cannot be easily drawn into the 2 cooling plates by the hand piece’s vacuum. Stevens and Bachelor12 worked on a nonvacuum conformable surface applicator specific of the trochanteric area to improve the results of cryolipolysis. Our decision to conduct a necrosectomy with primary closure was motivated by the patients’ profession who requested a rapid wound healing with minimal scarring. Healing by secondary intention or skin graft are also potential treatments. However, these techniques, require long healing periods and result in inferior aesthetic outcome. Cryolipolysis has become a very popular alternative to liposuction with more than 450,000 procedures performed around the world.6 Thus, this isolated case (on one device, with one practitioner) does not allow us to draw final conclusions about this technique’s safety. This case highlights cryolipolysis potential risks and shows that caution is needed to avoid this kind of complications. Having standardized and high quality devices with conformable hand pieces seems paramount to obtain satisfying results while minimizing adverse events. CONCLUSION The occurrence of a single isolated case of skin necrosis postcryolipolysis arises questions about the safety of this technique. The use of certified material (ie, noncounterfeit devices) with hand pieces adapted to the treated area is important to ensure the patient’s safety. These procedures should be performed with extreme caution in order to minimize this type of adverse events. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERECNES 1. Manstein D Laubach H Watanabe K Farinelli W Zurakowski D Anderson RR. Selective cryolysis: a novel method of non-invasive fat removal. Lasers Surg Med . 2008; 40( 9): 595- 604. Google Scholar CrossRef Search ADS PubMed  2. Rotman H. Cold panniculitis in children. Adiponecrosis E frigore of Haxthausen. Arch Dermatol . 1966; 94( 6): 720- 721. Google Scholar CrossRef Search ADS PubMed  3. Beacham BE Cooper PH Buchanan CS Weary PE. Equestrian cold panniculitis in women. Arch Dermatol . 1980; 116( 9): 1025- 1027. Google Scholar CrossRef Search ADS PubMed  4. Krueger N Mai SV Luebberding S Sadick NS. Cryolipolysis for noninvasive body contouring: clinical efficacy and patient satisfaction. Clin Cosmet Investig Dermatol . 2014; 7: 201- 205. Google Scholar PubMed  5. Dierickx CC Mazer JM Sand M Koenig S Arigon V. Safety, tolerance, and patient satisfaction with noninvasive cryolipolysis. Dermatol Surg . 2013; 39( 8): 1209- 1216. Google Scholar CrossRef Search ADS PubMed  6. Ingargiola MJ Motakef S Chung MT Vasconez HC Sasaki GH. Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment paradigms. Plast Reconstr Surg . 2015; 135( 6): 1581- 1590. Google Scholar CrossRef Search ADS PubMed  7. Derrick CD Shridharani SM Broyles JM. The safety and efficacy of cryolipolysis: a systematic review of available literature. Aesthet Surg J . 2015; 35( 7): 830- 836. Google Scholar CrossRef Search ADS PubMed  8. Lee SJ Kim YJ Park JB Suh DH Kwon DY Ryu HJ. A case of motor neuropathy after cryolipolysis of the arm. J Cosmet Laser Ther . 2016; 18( 7): 403- 404. Google Scholar CrossRef Search ADS PubMed  9. Jalian HR Avram MM Garibyan L Mihm MC Anderson RR. Paradoxical adipose hyperplasia after cryolipolysis. JAMA Dermatol . 2014; 150( 3): 317- 319. Google Scholar CrossRef Search ADS PubMed  10. Leonard CD Kahn SA Summitt JB. Full-thickness wounds resulting from ‘do-it-yourself’ cryolipolysis: a case study. J Wound Care . 2016; 25( 4): S30- S32. Google Scholar CrossRef Search ADS PubMed  11. Ferraro GA De Francesco F Cataldo C Rossano F Nicoletti G D’Andrea F. Synergistic effects of cryolipolysis and shock waves for noninvasive body contouring. Aesthetic Plast Surg . 2012; 36( 3): 666- 679. Google Scholar CrossRef Search ADS PubMed  12. Stevens WG Bachelor EP. Cryolipolysis conformable-surface applicator for nonsurgical fat reduction in lateral thighs. Aesthet Surg J . 2015; 35( 1): 66- 71. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

Journal

Aesthetic Surgery JournalOxford University Press

Published: Apr 1, 2018

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