In recent years, physicians have explored vast possibilities of treating fat in subtle ways via lasers and other devices. Among these is cryolipolysis, one of the most discussed and anticipated procedures in cosmetic dermatology. Unlike a laser, cryolipolysis works by cooling the skin, which in turn allows the physician to sculpt the body by eliminating fat in gradual and subtle ways. The procedure is still in its infancy, but given high interest expressed by physicians and manufacturers, it appears to be on the horizon. Zeltiq's CoolSculpting device is among the first devices to perform cryolipolysis and may garner FDA clearance in the near future. Ahead, one of the device's creators, Dieter Manstein, MD, reflects on the benefits of CoolSculpting and the future of cryolipolysis.

Can you explain how CoolSculpting by Zeltiq works and what separates it from other fat-treating procedures currently available?
CoolSculpting is able to induce selective damage to the subcutaneous fatty tissue by controlled application of cold in a completely non-invasive manner, according to Dr. Manstein. “Under specific conditions, fat cells are most susceptible to cold injury and an apoptotic fat cell death is triggered. This means the fat cells are dying in a more gradual manner, resulting in marked fat loss over a period of approximately three months,” he observes. First results are typically noticed after approximately three weeks. A selective biological response of the fatty tissue is unique to the CoolSculpting procedure. “Other procedures (e.g. focused ultrasound, mesotherapy with PDC) destroy tissue in a non-selective manner. For such procedures it is attempted to mainly affect fatty tissue by either focusing (ultrasound energy) or injecting (mesotherapy) into the fat layer. Such non-selective methods cause a more traumatic cell injury (necrosis). The tissue is typically more prone to develop fibrosis after such sudden and violent cell death,” notes Dr. Manstein.

How would you situate cryolipolysis among other similar procedures, and how do you see it continuing to develop?
“CoolSculpting is a very safe procedure which has selective effects confined to the fatty tissue,” says Dr. Manstein. “Additionally, performing the procedures is safe as long as there is fat left to be removed. CoolSculpting is a completely automated procedure, meaning after the handpiece is attached to the treatment area the operator does not have to stay with the patient,” he explains. This is also unique to the CoolSculpting procedure and minimizes any time burden to either physicians or physician extenders, according to Dr. Manstein. “The selectivity of the CoolSculpting procedure is key for further developments.” Current applicators are designed to fit within the flank and abdominal area. However due to the selectivity of the CoolSculpting method it will likely be possible to treat within areas above bones (male breast), or areas in close proximity to vessels and nerves like upper arms and inner thighs. It would be challenging to apply non-selective fat removal methods to any of these body areas,” Dr. Manstein observes.

How do patients respond to treatment, in terms of happiness with results, pain, downtime, etc.?
“The procedure has a predictable response and allows for approximately 0.5 to 1cm fat layer reduction within the treatment area,” Dr. Manstein says. This is relatively independent for any patient. “The satisfaction of patients is typically related to relative fat layer removal. Therefore patient selection is very important and this treatment is not appropriate for ‘debulking' obese patients. It would take too many treatments to obtain any meaningful reduction of volume and weight,” explains Dr. Manstein. However, he notes, if the patient exhibits localized fat bulges, these respond very well, and bulges are nicely flattened typically within one or two treatments. In addition, there is no pre- or post-treatment care necessary, nor any need for pain medication during nor after the treatment. “The patients typically experience during the treatment some ‘pulling sensation' as the vacuum of the applicator draws on the skin,” Dr. Manstein explains.

Patients are advised also that they will experience a stinging sensation during the first several minutes of the treatment, according to Dr. Manstein. If they do so, it will disappear a few minutes into the treatment. “Due to the applied vacuum it is possible to experience some bruising in the treatment area, however most patients do not have any bruising. Paraesthesia is typically experienced within the treatment area for a few days and can last for up to several weeks,” he observes. While patients have no restrictions of activities after treatment, Dr. Manstein recommends postponing vigorous exercise for a day or two. Other minor adverse events are possible as well, though Dr. Manstein emphasizes that they are minor and rare. “Few patients have reported some induration or discomfort in the treatment area lasting for up to six weeks, but this is limited to a very small set of patients and has always resolved spontaneously.”

Can you discuss how physicians who perform cosmetic services would integrate a device such as this into practice?
Because CoolSculpting is safe, easily performed and fully automated, there is minimal training necessary to provide the treatment, according to Dr. Manstein. “Proper patient selection is key for providing high patient satisfaction. The provider offering CoolSculpting should be educated with respect to selection criteria and proper documentation to ensure successful treatment,” he says. “The introduction of CoolSculpting into an aesthetic office offers a meaningful extension of the spectrum of services and solutions to patients. As the procedure is performed with only minimal time involvement of the provider, has great safety profile and virtually does not require any post-care, it merges very well into a prospering aesthetic practice.”

As fat-melting procedures continue to develop, how do you suggest dermatologists capitalize on the potential of procedures such as cryolipolysis?
Dr. Manstein points out that at this point there are no other selective, non-invasive procedures on the horizon. However, the success he's seen with this device presents many opportunities for physicians and patients. “Many of the aesthetically motivated patients have some localized bulges they cannot control with diet and exercise. CoolSculpting is a great opportunity to offer these patients a predictable, new solution to their problem with no downtime,” Dr. Manstein says. “I also noticed that this procedure started to funnel new patients into the office as they search specifically for providers of the CoolSculpting procedure. Such patients are typically also interested in other aesthetic procedures and often schedule subsequent appointments for other aesthetic treatments, e.g. fillers or neurotoxins.”