Response to: Shockwave Therapy for the Prevention of Paradoxical Adipose Hyperplasia After Cryolipolysis: Myth or Reality?

I would like to respond to the Letter to the Editor on the manuscript entitled “A Multicenter Evaluation of Paradoxical Adipose Hyperplasia Following Cryolipolysis for Fat Reduction and Body Contouring: A Review of 8658 Cycles in 2114 Patients.” 1,2 The author of the letter stipulates that the utilization of shockwave therapy has eliminated all cases of Paradoxical Adipose Hyperplasia (PAH) following CS in 2291 consecutive cycles. The author further attributes this to the combination treatment and more specifically to the anti-fibrosclerotic effect and decreased oxidative stress on post-cryolipolysis tissues.3 The observations are based on 30 patients satisfying inclusion criteria for their published review from a pool of 64 patients having 2 or greater cryolipolysis cycles followed by shockwave therapy. In the study, the author reported that 76.7% of patients found the therapy comfortable, 68.3% of patients were satisfied with the results, and 57.7% had their expectations met. The follow-up was a minimum of 12 weeks, but the mean follow-up was not reported for the group. Unfortunately, the challenge in interpreting the results resides in the following points: (1) less than 50% of patients treated (n = 64) were re-evaluated (n = 30) and of those re-evaluated, one-half were evaluated by email; and (2) the average length of follow-up is not mentioned, although the email and clinical follow-up at 3 months may not capture subtle changes initially present because a full-blown PAH picture may take more time to appear.3-6 In fact, the general recommendation is to avoid treating PAH cases until 12 months following cryolipolysis treatment, given the delayed presence of PAH and the uncertainty as to when the process arises and fully ends. Finally, the utilization of non-clinical follow-up is challenging. The patients who have historically been diagnosed with PAH largely assumed the treatment did not work and frequently believed the hypertrophy of a previously treated region was a result of slow weight gain. It would be beneficial to assess the reported 68.3% rate of “satisfaction” and 57.7% rate of “met expectations” following the treatment and evaluate why the numbers are on the lower side. A non-clinical or remote evaluation makes the diagnosis of PAH difficult, especially in light of the realization that many clinicians often have difficulty in making the initial diagnosis themselves unless they have either seen previous cases or the hypertrophy is truly exaggerated when combined with a clinical picture of minimal or small increase in weight compared with pretreatment weights. All in all, the concept put forth merits evaluation because the number of cycles in this center is significant without any obvious cases of PAH present; thus, I would urge the author to pursue a prospective clinical trial evaluating the 2 technologies with a 12-month follow-up, because anything we can do to prevent unwanted cases of PAH is very worthwhile. The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The author received no financial support for the research, authorship, and publication of this article.

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