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Paroxysmal adipose hyperplasia (PAH)


Paroxysmal Adipose Hyperplasia (PAH) is a medical condition characterized by a visible increase in tissue volume within the treated area, which typically manifests 2 to 5 months after cryolipolysis treatment for localized fat reduction. This phenomenon, posing an inherent risk during cryolipolysis, was first documented in medical literature by Jalian et al. in 2014. Their histological analysis of tissue samples obtained through abdominoplasty revealed several notable findings, including thickened fibrous septae, increased vascularity, adipocyte hyperplasia, and a higher male predominance among patients who developed PAH. Clinically, affected individuals present with firm areas of greater volume than the targeted fat, often exhibiting a distinct "brick"-like appearance.

The etiology of PAH is multifaceted and encompasses various proposed mechanisms, such as hypertrophy of pre-existing adipocytes, recruitment of preadipocytes/stem cells, or a response to hypoxia induced by fat septal thickening.

In a comprehensive study conducted by Nikolis and Enright, a total of 2,114 patients were assessed, with 9 individuals (0.42%) developing PAH following 13 treatment cycles (0.15%) at eight Canadian centers between 2015 and 2019. Notably, the majority (61.5%) of PAH cases occurred after a single treatment, and a higher proportion (55%) of male patients were affected, consistent with the findings reported by Jalian et al. PAH was observed in all treated areas. Among the affected patients, six achieved resolution of PAH through liposuction, while one underwent repeat cryolipolysis without any improvement. Although studies with smaller sample sizes have reported higher incidence rates, suggesting potential underestimation of PAH prevalence, a consensus panel report published in 2022 revealed that eight out of eleven international experts had encountered PAH associated with cryolipolysis. The panel strongly recommended liposuction as the first-line treatment for PAH.

Notably, there has been a surge in media coverage regarding PAH, including reports of high-profile cases. Analysis of the FDA Manufacturer and User Device Experience database for the first three months of 2023 revealed 300 entries related to "CoolSculpt," with 97% of these cases primarily reported by patients and associated with PAH.

While submental PAH currently represents a minority of reported cases (13%), it is crucial to consider that treatments for submental and submandibular areas received FDA clearance several years after the initial device approval. With the growing popularity of these treatments, the incidence of submental PAH may rise. PAH is a rare but documented complication of cryolipolysis that can lead to disfigurement. Spontaneous resolution of PAH has never been reported, but the condition can be effectively treated with suction (recommended as the first-line approach) or direct lipectomy, resulting in satisfactory outcomes. It is imperative for plastic surgeons to be well-versed in PAH as a significant clinical entity.

Recommended Treatment for Paroxysmal Adipose Hyperplasia:

Dr. De La Cruz's comprehensive multi-modal approach for the treatment of Paroxysmal Adipose Hyperplasia (PAH) involves a combination of advanced techniques aimed at achieving optimal outcomes. Addressing PAH requires careful consideration, as traditional liposuction techniques may lead to contour irregularities and bleeding due to the presence of fibrosis and excess fibrous tissue. However, advanced treatment options such as VASER liposuction combined with Renuvion have demonstrated promising outcomes in managing PAH. The treatment protocol includes:

1) VASER Liposuction: This advanced ultrasonic-assisted liposuction technique utilizes ultrasonic energy to selectively emulsify and remove adipose tissue. VASER liposuction is known for its ability to minimize blood loss, reduce contour irregularities, and provide precise fat removal, resulting in improved body contouring. By emulsifying the fatty tissues and thick fibrous tissues, VASER liposuction allows for precise and controlled removal of excess fat

2) MicroAire Power Assisted Liposuction: Complementing VASER liposuction, the use of MicroAire Power Assisted liposuction can further enhance the treatment of PAH. This technique utilizes a vibrating cannula to gently break up fibrous tissue and facilitate the removal of excess fat. By reducing trauma to the surrounding tissues, MicroAire Power Assisted liposuction ensures a more precise and controlled fat removal process.

3) Renuvion: Renuvion, also referred to as J-Plasma, is an innovative technology that can be utilized in conjunction with VASER liposuction or MicroAire liposuction to optimize the overall results of the procedure. Renuvion combines radiofrequency energy with helium gas to deliver controlled heat energy to the deeper layers of the skin. This stimulates collagen production and tightens the skin from within, improving skin laxity and optimizing the final aesthetic outcome.

4) Hi-Definition Liposuction Technique: Dr. De La Cruz specializes in the application of the Hi-Definition Liposuction technique, which involves precise sculpting of the body to create more defined contours. By selectively targeting specific areas, Dr. De La Cruz tailors the procedure to each patient's unique anatomical features and desired outcomes.

By employing this comprehensive multi-modal approach, Dr. De La Cruz offers patients a personalized treatment plan for PAH. This strategy not only involves the removal of excess adipose tissue but also addresses skin retraction and overall body contouring, leading to improved aesthetic outcomes. Dr. De La Cruz's expertise and proficiency in these techniques ensure the highest level of care and patient satisfaction. PAH poses a significant challenge following cryolipolysis, and it is imperative to explore innovative approaches for its management. VASER liposuction combined with Renuvion has emerged as a promising solution, offering improved outcomes and reduced risks compared to traditional liposuction techniques.

Figure 1: Before & After Photos of Large Volume Hi-Definition Liposuction  (2 months after surgery) performed by Dr. Emmanuel De La Cruz, Houston Plastic Surgeon

Figure 2: Before & After Photos of 4 D VASER Liposuction (Back View 2 months after surgery)

What areas of the body can be treated with liposuction?


Liposuction can be used to remove unwanted areas of localized fat from nearly any area of the body, and is most commonly used on the:

  • Stomach

  • Arms

  • Back

  • Hips

  • Knees

  • Love handles

  • Saddlebags

  • Neck

  • Chin

  • Thighs

In many cases, more than one area can be treated during the same procedure in order to reduce operating costs and recovery times. Your doctor will develop an individualized treatment plan for you during your initial consultation.

Figure 3: Before & After Photos of 4 D VASER Liposuction (Oblique View 2 months after surgery.)  Procedure performed by Dr. Emmanuel De La Cruz M.D.

What is the difference between VASER Liposuction versus Traditional Liposuction?

  • Recent randomized clinical trials showed that the VASER liposuction is superior over traditional liposuction methods.    With the VASER liposuction, there is LESS BLEEDING, and MORE SKIN RETRACTION compared to traditional liposuction methods. [1]

[1] Nagy, et al.  A multicenter, prospective, randomized, single-blind, controlled clinical trial comparing VASER-assisted Lipoplasty and suction-assisted Lipoplasty.  Plastic Reconstructive Surgery  2012 Apr;129(4):681e-9e 

  • There's also less contour irregularities with the VASER liposuction in the hands of an experienced plastic surgeon.   Dr. De La Cruz refined and honed his lipoplasty techniques, especially the 4D VASER liposuction, under the tutelage of Dr. Alfredo Hoyos, the pioneer of the 4D VASER High-Definition liposculpture.  

Patient Safety During Surgery


Dr. De La Cruz values patient safety during your surgery.  For large volume high-definition liposuction, there are certain criterias that should be met before your plastic surgery.

  1. For patients who have co-morbidities, such as Diabetes, obstructive sleep apnea, a medical and cardiac clearance are required prior to surgery. For patients whose age >45, a cardiac clearance from a cardiologist is required by Dr. De La Cruz prior to your surgery.  Safety is priority in our practice.

  2. Prevention of Infection:  During your surgery, a peri-operative intravenous antibiotics are given to prevent a wound infection.  Fat that is harvested for fat transfer (if included in your procedure) will be washed with antibiotic irrigation to further reduce your risk of infection.

  3. DVT Prophylaxis:  Dr. De La Cruz calculates your Caprini Score to evaluate your risk for Deep Venous Thrombosis. All patients would have an intermittent sequential compression device during your surgery to prevent a DVT.  Moreover, an anti-coagulant, such as Heparin or Lovenox, is given to further reduce your risk for a Deep Venous Thrombosis. 

  4. For large volume high-definition liposuction patients, all patients are admitted in the hospital overnight to monitor your recovery.  A hospitalist and Dr. De La Cruz would typically oversee your care while you are in the hospital.

  5. The use of the VASER liposuction system is associated with less bleeding when it comes to large volume liposuction.  A randomized clinical trial had shown that the VASER liposuction is associated with less bleeding during surgery when compared with traditional tumescent liposuction.  This is key when it comes to large volume liposuction.  It is essential to minimize your risk of bleeding when it comes to undergoing this procedure.

  6. Use of Tranexamic Acid to Prevent Bleeding. Tranexamic acid use has been associated with less bleeding in liposuction surgery.

How long does recovery take?


After the liposuction procedure, patients will be able to return to work and other regular activities as soon as they feel comfortable, which is usually after a few days. Exercise and other strenuous activities should be avoided for a few weeks. It is not uncommon to experience mild swelling, bruising and discomfort in the treated area, which can be reduced through pain medication and the use of compression garments.

There will be drainage tubes in the groin and sacral areas to collect any fluid for the first few days after treatment.

When will results be visible?


The results from the liposuction procedure are often visible right away, but will continue to improve as swelling and bruising subside. Typically, one would see the results 8 weeks after surgery.  Swelling will continue to decrease, and skin will continue to retract up to 6 months after surgery.  Scars usually heal well and will fade with time to become less and less noticeable.

The results of liposuction can be permanent as long as patients maintain a healthy and active lifestyle. If substantial weight is gained after this procedure, results may be altered.

What is Large Volume Liposuction?


Large volume liposuction is when the liposuction aspirate exceeds over 5 Liters. Certain states, such as New York and Florida, are limited to 4-5 Liters of fat that can be aspirated.  The maximum amount of fat that can be harvested or aspirated depends on the amount of tumescent fluid and lidocaine in the tumescent fluid infused.  One cannot exceed over 35 mg/kg of lidocaine in the tumescent fluid.  Some studies have shown that the safety level of lidocaine in the tumescent fluid that can be infused can be up to 50 mg/kg.  Dr. De La Cruz does not exceed over 35 mg/kg to avoid any adverse outcome from lidocaine toxicity.  

Is there any criteria or pre-operative requirements before Large Volume Liposuction?


Dr. De La Cruz requires a cardiac clearance from your primary care physician, preferably from a cardiologist if your age is over 45.  For those patients with comorbidities, such as Diabetes, or has a family history of cardiac problems (such as heart attack), a cardiac clearance is also required for patients whose age is over 40.  Safety is our number one priority!

Where is the procedure performed?


Large volume high-definition liposuction is performed in a hospital.  Patients will be subsequently admitted overnight for observation, and for fluid maintenance.  Dr. De La Cruz and a hospitalist physician will oversee your care while you are in the hospital after surgery.  

Are there any risks or complications associated with liposuction?


Liposuction is considered a safe procedure with only minimal downtime and a low occurrence of mild side effects. However, as with any kind of treatment, there is a risk of complications such as infection, scarring, allergic reactions, hematoma or unsatisfactory results. Liposuction is one of the most commonly performed cosmetic procedures and is almost always performed with no serious complications.

Patients can reduce these risks by choosing an experienced doctor, such as a plastic surgeon, to perform their procedure and by following their doctor’s instructions before and after treatment.

» Schedule your Liposuction Consultation with Dr. De La Cruz today by calling 832.776.1134

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