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AJOPS | PUBLISHED: 15-03-2019 Aes

Frostbite following cryolipolysis: a case report

Kin Seng Tong BM BCh,1 Daniel C Williams BSc MBBS,2,3 Patricia Terrill MBBS FRACS2,4

1 University of Oxford Background Medical Sciences Division John Radcliffe Cryolipolysis is a non-invasive body contouring Headley Way procedure that aims to achieve focal of Oxford subcutaneous fat by means of confined areas of cold UNITED KINGDOM exposure. The observation that adipose is 2 Department of Plastic and Reconstructive preferentially susceptible to cold injury compared Frankston Hospital to was first recognised by Hochinsinger in Peninsula Health 1 Frankston, Victoria 1902. A review article in 2013 identified further cases reported by several authors since the 1940s.2

3 Department of Surgery It was not until 2008 that the idea of applying this Griffith University School of Medicine concept for aesthetic purposes was reported in Southport, Queensland the porcine model.2,3 It was shown that the precise AUSTRALIA application of cold temperatures selectively 4 Department of Surgery triggered apoptosis in adipocytes with sparing Clinical School at Monash University Melbourne, Victoria of the overlying skin. Two days post-treatment, a AUSTRALIA and monocyte infiltrate was noted in OPEN ACCESS the subcutaneous fat, which intensified with time

Correspondence as the adipocytes reduced in size in association with an increase in lipid-laden mononuclear Name: Patricia Terrill inflammatory cells.3–5 Address: Department of Plastic and Reconstructive Surgery Sasaki et al6 studied the skin and subdermal Frankston Hospital temperature changes in subjects during and Peninsula Health 2 Hastings Road after cryolypolysis. By completion of a one-hour Frankston, Victoria, 3199 treatment, skin and subdermal temperatures AUSTRALIA fell to between 9.5 and 13.9°C. Experimentally, at Email: [email protected] temperatures of approximately 10°C intracellular Phone: +61 419 336 592 ‘lipid ice’ forms, which may contribute to Citation: Tong KS, Williams DC, Terrill P. following immediate cell or delayed apoptosis.3 Many cryolipolysis: a case report. Aust J Plast Surg. 2019;2(1):110–113. other additional mechanisms of injury of the fat https://doi.org/10.34239/ajops.v2i1.99 cells have been postulated, including alterations Accepted for publication: 15 August 2018 in cell osmoregulation, reduced Na+/K+-ATPase Copyright © 2019. Authors retain their copyright in the activity and adenosine levels, intracellular lactic article. This is an open access article distributed under the Creative Commons Attribution Licence which permits acidosis, free radicals and ischaemic reperfusion unrestricted use, distribution and reproduction in any type injury.6 When skin is exposed to cold, the medium, provided the original work is properly cited. degree of damage is related to the thermal Section: Aesthetic properties of the material it is exposed to, the

Australasian Journal of Plastic Surgery 110 Volume 2 Number 1 2019 Tong, Williams, Terrill: Frostbite following cryolipolysis: a case report AJOPS | CASE REPORT temperature of that material, the duration of that The lesions were initially treated conservatively exposure and the force applied. The estimated with Acticoat™ (Smith & Nephew, London, United freezing point of human finger skin is -0.6°C. As the Kingdom) and IntraSite Conformable™ (Smith & skin surface temperature falls from -4.8 to -7.8°C, Nephew, London, United Kingdom) dressings while the of frostbite increases from 5 to 95 per cent.7 awaiting demarcation. A week later, the central These skin temperatures are well below the skin areas remained pale and insensate and the temperatures detected by Sasaki during correctly underwent debridement of the with split- functioning and performed cryolipolysis. thickness skin grafting. At the time of operation Cryolipolysis is currently gaining popularity as an the main concern was the status of the underlying alternative to traditional liposuction due to its high fat and whether it would be sufficiently viable to and low incidence and duration of side support a skin graft—fortunately, in this case, it effects.8,9 Common side effects include erythema, was (Figure 2). bruising, oedema, pain and diminished sensation, all of which are usually transient.7 Frostbite injuries following cryolipolysis are exceedingly rare.10,11 We report a case of severe frostbite following a cryolipolysis session that required surgical intervention with resultant permanent scarring.

Keywords: body contouring, frostbite, cryolipolysis

Case A 40-year-old female presented to plastic surgery outpatients with two large, tense blisters on her left medial knee. She reported undergoing Fig 2. Appearance of wounds in the operating theatre simultaneous cryolipolysis to both medial knees with an unknown brand device at a private clinic The fat was discoloured but punctate was two days previously. On examination, there were visible from the septae. of the debrided adjacent bullae, each approximately 15×6 cm in tissue was reported as congested viable fat with diameter, on her left medial knee (Figure 1). On superficial organizing fat necrosis and focal deroofing the blisters, there was a pink peripheral . zone with preserved capillary return and a pale, The patient experienced good graft take and the insensate central area, suggestive of a full-thickness wounds were completely healed by six weeks. . The incident, however, left the patient with two oval with a slight contour deformity on the medial aspect of the left knee (Figure 3), as well as significant psychological trauma.

Discussion Frostbite injuries following treatment with cryolipolysis devices are very rare, with only two cases reported in the literature.10,11 Choong and colleagues10 described a burn injury occurring in the left flank after a visit to an unregulated beauty salon. It resulted in necrosis of the skin and underlying fat, which healed by secondary 11 Fig 1. Initial presentation with two large, tense blisters on the left medial intention. Nseir and colleagues treated a patient knee

Australasian Journal of Plastic Surgery 111 Volume 2 Number 1 2019 Tong, Williams, Terrill: Frostbite following cryolipolysis: a case report AJOPS | CASE REPORT

correctly or there was a fault with the machine. The Coolsculpting® device has a built-in freeze- detection sensor and software to monitor changes in the skin and will automatically shut the unit down if a freeze is detected. This should minimise the risk of frostbite injury but these features may not be present on other-branded or generic units.

Conclusion Frostbite injuries are an extremely rare and potentially avoidable of cryolipolysis. Clinicians should raise the awareness of their to this possible adverse effect and advise Fig 3. Appearance of scars six months post-debridement them to seek cosmetic procedures only from with skin necrosis following routine cryolipolysis certified reputable providers that use approved by a dermatologist. They did not report on the devices. viability of the underling fat. The burns were Disclosure excised and directly closed. In both cases, initial The authors have no financial or commercial treatment involved a conservative approach with conflicts of interest to disclose. dressings to allow for evolution of the injury. Subsequent management differed based on the References anatomical site, size and severity of lesions. In 1 Hochsinger C. Uber eine akute kongelative Zellgewebsver- our case, the underlying fat remained viable, hartung in der Submentalregion bei Kindern. Mschr Kin- supporting the use of a split-thickness skin graft to derheilk. 1902;1:323–27. restore the integrity of the large area of skin deficit. 2 Jalian HR, Avram MM. Cryolipolysis: a historical perspec- tive and current clinical practice. Semin Cutan Med Surg. Unfortunately, many imitation devices with 2013;32:31–34.PMid:24049927 unknown safety and effectiveness have now 3 Manstein D, Laubach H, Watanabe K, Farinelli W, Zurakow- emerged in the market for cryolipolysis treatment. ski D, Anderson RR. Selective cryolysis: a novel method of non-invasive fat removal. Lasers Surg Med. 2008;40(9):595– In this case there is uncertainty surrounding the 604. https://doi.org/10.1002/lsm.20719 PMid:18951424 make of device but the simultaneous treatment of 4 Zelickson B, Egbert BM, Preciado J, Allison J, Springer K, two areas appears inconsistent with the approved Rhoades RW, et al. Cryolipolysis for noninvasive fat cell destruction: initial results from a pig model. Dermatol and reputable Coolsculpting® (Zeltiq Aesthetics, Surg. 2009;35(10):1462–470. https://doi.org/10.1111/j.1524- Pleasanton, California, USA) branded device 4725.2009.01259.x PMid:19614940 because it has only a single applicator per unit. 5 Avram MM, Harry RS. Cryolipolysis for subcutaneous fat layer reduction. Lasers Surg Med. 2009;41(10):703–08. In our patient we were unable to determine the https://doi.org/10.1002/lsm.20864 PMid:20014262 11 exact mechanism of the frostbite. In Nseir’s case, 6 Sasaki G, Abelev N, Tevez-Ortiz A. Noninvasive selective the handpiece was found to be lacking gel, resulting cryolipolysis and reperfusion recovery for localised natural in direct skin contact with the cooling plates. We fat reduction and contouring. Aesth Surg J. 2014;34(3):420– 31. https://doi.org/10.1177/1090820X13520320 can only speculate that a similar error may have PMid:24598865 occurred during our patient’s procedure, as the gel 7 Geng Q, Holmer I, den Hartog EA, Havenith G, Jay O, Mal- sheets that are positioned beneath the applicator chaire J, Piette A, Rintamaki H, Rissanen S. Temperature can tear or move, thereby inadvertently exposing limit values for touching cold surfaces with the fingertip. Ann Occup Hyg. 2006;50(8):851–62.PMid:16777911 skin directly to the applicator. Alternatively, the 8 Stevens G, Pietzrak LK, Spring M. Broad overview of a vacuum pressure may not have been applied clinical and commercial experience with Coolsculpt- ing. Aesth Surg J. 2013;33(6):835–46.https://doi. org/10.1177/1090820X13494757 PMid:23858510

Australasian Journal of Plastic Surgery 112 Volume 2 Number 1 2019 Tong, Williams, Terrill: Frostbite following cryolipolysis: a case report AJOPS | CASE REPORT

9 Ingargiola MJ, Motakef S, Chung MT, Vasconez HC, Sasaki GH. Cryolipolysis for fat reduction and body contour- ing: safety and efficacy of current treatment paradigms. Plast Reconstr Surg. 2015;135(6):1581–590. https://doi. org/10.1097/PRS.0000000000001236 PMid:26017594 PM- Cid:PMC4444424 10 Choong WL, Wohlgemut HS, Hallam MJ. Frostbite fol- lowing cryolipolysis treatment in a beauty salon: a case study. J Wound Care. 2017;26(4):188–90. Available from: http://www.magonlinelibrary.com/doi/10.12968/ jowc.2017.26.4.188 11 Nseir I, Lievain L, Benazech D, Carricaburu A, Rossi B, Auquit-Aukbur I. Skin necrosis of the thigh after a cryolip- olysis session: a case report. Aesthetic Surg J. 2018;38(4):73– 75. Available from: https://academic.oup.com/asj/arti- cle/3045381/Skin

Australasian Journal of Plastic Surgery 113 Volume 2 Number 1 2019