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Paradoxical Adipose Hyperplasia Treatment

Paradoxical Adipose Hyperplasia Treatment


Paradoxical Adipose Hyperplasia

Dr. Smith tapped as expert to discuss PAH and its treatment by CNN.

What is CoolSculpting?

CoolSculpting is a very popular method of noninvasive body contouring. By placing applicators on different parts of the body, CoolSculpting can reduce fatty bulges by an average of 22 to 23% without surgery. Until the introduction of Emsculpt Neo, CoolSculpting was the most effective way to remove fat without surgery. For more information about Emsculpt Neo, which can reduce fat by an average of 30% and simultaneously increased muscle mass by an average of 25%, please click here. 

How does Coolsculpting work?

Coolsculpting relies on a process called cryolipolysis to destroy fat cells. Cryolipolysis is demonstrated in the video shown here. During the CoolCculpting procedure, tissue in the treatment area is drawn into the applicator with high suction. The applicator then cools the tissue your critical temperature at which fat cells are selectively destroyed. Specifically, the cold temperature triggers programmed cell death, or apoptosis, and then the body naturally flushes out the dead fat cells.

What is Paradoxical Adipose Hyperplasia (PAH)?

Paradoxical adipose hyperplasia (or PAH) is a process in which fatty tissue grows instead of shrinks in response to CoolSculpting and cryolipolysis. Areas affected by PAH often look like raised fatty tissue in the shape of the CoolSculpting or cryolipolysis applicator. They tend to be firmer to the touch than surrounding fat. Paradoxical adipose hyperplasia most frequently occurs three to six months after a cryolipolysis or CoolSculpting treatment. The frequency with which paradoxical adipose hyperplasia or PAH occurs is up for debate and likely under reported. Literature review puts the incidence as being from approximately .05% to 0.39% in some studies and as high as .72% or one in 138 treatments in another study. While PAH or paradoxical adipose hyperplasia is not common, it can pose a significant problem for those who are affected.

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What causes PAH?

While the exact cause of PAH is not known, there are a few interesting theories. One theory suggests that certain fat cells for whatever reason are more able to withstand cold temperatures than others. These cells are essentially selected for and survive CoolSculpting and cryolipolysis. It is thought that signaling molecules called hypoxia-inducible factors, or HIFs, initiate a cascade in the body that causes blood vessel growth and ultimately the enlargement of existing surviving fat cells and the creation of new fat cells in paradoxical adipose hyperplasia (or PAH). Another interesting theory takes a cue from a different medical device, called BRAVA. BRAVA is a special bra that is worn to treat the breasts with suction or “negative pressure therapy” as a pre-treatment before breast augmentation with fat grafting. The suction from the BRAVA device causes increased blood supply and the upregulation of other growth factors in the treatment area to improve the take of fat that is grafted to the breasts as part of a breast augmentation procedure. For more information on fat grafting or fat transfer please click here.  It is thought that like the suction used in the BRAVA device, the suction used in cryolipolysis or CoolSculpting may favor the survival and growth of a certain population of fat cells.

What areas are most frequently affected by PAH?

Any area treated with CoolSculpting or cryolipolysis could theoretically be affected by paradoxical adipose hyperplasia. In Dr. Darren Smith’s experience in treating these patients, the abdomen appears to be the most frequently affected area. However, the abdomen is also one of the areas most frequently treated with CoolSculpting or cryolipolysis, so this finding could be skewed.


Related Content: Love Handle liposuction 

This is a woman in her forties shown before and a few months after VASER liposuction and BodyTite for paradoxical adipose hyperplasia.

How is PAH treated?

Paradoxical adipose hyperplasia can often be completely treated or significantly improved by an expert plastic surgeon. Dr. Darren Smith has significant experience in treating paradoxical adipose hyperplasia from CoolSculpting procedures performed at other practices (Dr. Smith does not offer Coolsculpting as he prefers other noninvasive body contouring options; Emsculpt Neo ).

Noninvasive methods of treating paradoxical adipose hyperplasia generally do not work well. Such methods may include additional treatments with CoolSculpting or cryolipolysis, injections of Kybella, or treatments with other noninvasive fat reduction devices such as SculpSure. In many cases of paradoxical adipose hyperplasia, liposuction alone can affectively treat the issue. In some cases with extremely fibrous or rigid fat deposits, the use of energy such as ultrasound with VASER (read more about VASER or radiofrequency with BodyTite may be indicated. These devices, or in severe cases even a full abdominoplasty, may be necessary to treat skin access that is associated with paradoxical adipose hyperplasia. Given the nuances in designing a customized treatment approach, it is recommended that you consult with a board-certified plastic surgeon that is very familiar with this entity.

The Steps of Treating Paradoxical Adipose Hyperplasia (PAH)

After performing many successful paradoxical adipose hyperplasia treatments, Dr. Darren Smith has developed a four step strategy to manage this often stubborn problem:

Step 1

Numb the treatment area - The first step of PAH treatment is essentially the same as standard liposuction: tumescent solution (blue circles in the cartoon below) is introduced to the treatment area to eliminate pain and minimize bleeding and bruising. The difference is that we tend to use more tumescent solution in PAH cases because we need to be more aggressive to remove the fibrous PAH fat. Also, while in many standard liposuction cases we will offer IV sedation or even awake procedures for smaller areas, we strongly recommend general anesthesia for PAH cases. This ensures you are comfortable enough for Dr. Smith to be sufficiently aggressive to remove as much PAH fat as possible.

Step 2

Melt the PAH fat - PAH fat is much more fibrous and firm than regular fat. While in standard liposuction cases we can often go straight to suctioning the fat out of the treatment area with a thin metal tube, or “cannula”, this does not work as well with PAH fat. A cannula is essentially a straw with suction attached. Imagine sticking a straw into a scoop of ice cream and sucking. Not much would happen. That is essentially the case with a cannula and PAH fat.

To effectively remove PAH fat, we first melt it with VASER  ultrasound energy. After being melted with VASER, suctioning PAH fat with a cannula is more like sipping a milkshake through a straw: it works a great deal better.

Step 3

Remove the PAH fat - After melting the PAH fat with VASER, the next step is the same as in standard liposuction. We suction the unwanted PAH fat out of the treatment area with a cannula.

Step 4

Tighten the skin (if needed) - If the PAH fat has caused significant skin stretching, skin tightening with bipolar radiofrequency energy (BodyTite)  can be used to tighten the loose skin. This is not to be confused with unipolar radiofrequency energy (Renuvion Jplasma) which is no-longer recommended by the FDA for skin tightening due to high risks of complications. BodyTite has a much better safety profile as the heat produced is precisely controlled. In cases of severe skin laxity, an abdominoplasty, or tummy tuck, may be appropriate.

Symptoms of paradoxical adipose hyperplasia

Paradoxical adipose hyperplasia causes fat to grow instead of shrink in areas treated with CoolSculpting. This new fatty growth tends to be more firm than surrounding fat.

How long does PAH take to develop after CoolSculpting?

This is very variable, but 6 to 9 months seems to be a reasonable estimate.

Paradoxical adipose hyperplasia on face

Paradoxical adipose hyperplasia can occur in any body area treated with CoolSculpting. The only place on the face that can be CoolSculpted with FDA clearance is the chin, so the chin is the only part of the face that should be affected by PAH.  However, if CoolSculpting or cryolipolysis is performed off label for other areas of the face, those could theoretically be affected by paradoxical adipose hyperplasia as well. 

Paradoxical Adipose Hyperplasia (PAH) of the Chin: Before and After VASER Liposuction

PAH Cost

VASER Melt PAH fat before removal $2000 $2500 $3000
PAH Liposuction Removal of PAH fat $4500 $5000 $5500
BODYTITE Tighten loose skin (if needed) $2000 $2500 $3000

This table presents a reasonable expectation for low, average, and high prices for different methods of paradoxical adipose hyperplasia (PAH treatment in New York City (NYC). These prices are per area treated, and do not include facility fees or anesthesia fees if applicable.

Tummy Tuck with PAH Correction

Real patients with PAH treated by Dr. Darren Smith. (PAH Before & After Photos)

Before and 5 days after liposuction to correct paradoxical adipose hyperplasia of waist
Paradoxical Adipose Hyperplasia Before & After Photo
Paradoxical Adipose Hyperplasia Before & After Photo
This patient is shown before and just 1 month after PAH correction with VASER liposuction and BodyTite RF skin tightening. This is just the very early outcome. Full results are generally visible at about 6 months.
This is a woman in her forties shown before and a few months after VASER liposuction and BodyTite for paradoxical adipose hyperplasia.
This is a woman in her forties shown before and a few months after VASER liposuction and BodyTite for paradoxical adipose hyperplasia.

Before and After VASER Liposuction for Paradoxical Adipose Hyperplasia (PAH) from CoolSculpting

We are so proud to be able to make people feel this way! 

To explore having a PAH Treatment in NYC, call the office of Dr. Darren M. Smith, MD, today or book an appointment online.

+1 212-633-0627

This is a woman in her forties shown before and a few months after VASER liposuction and BodyTite for paradoxical adipose hyperplasia.



Paradoxical Adipose Hyperplasia Quiz

1 / 5

True or False: PAH can happen after any body contouring treatment.

2 / 5

True or False: In PAH, fat growth occurs only where CoolSculpting applicators were placed.

3 / 5

True or False: The fat that grows in PAH is more firm than regular fat.

4 / 5

True or False: PAH is easy to treat with liposuction.

5 / 5

True or False: PAH happens right after a CoolSculpting treatment.

Your score is




  • Darren M. Smith MD
  • Darren M. Smith MD
  • Darren M. Smith MD
  • Darren M. Smith MD

All photos are of models except before and after images.

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