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Cryolipolysis — Suprapubic Fat Reduction

Cryolipolysis uses controlled cooling to reduce localized subcutaneous fat at cleared body sites.[36] Skin burns, sensory injury and hernia have been reported.[34] When applied to the suprapubic region, it serves as a nonsurgical alternative to liposuction for reducing the fat pad that buries the penile shaft. One prospective study (Azab 2021, n = 46) reported increased apparent penile length between measurements made before the first and third of three suprapubic cryolipolysis sessions.[1]

For the broader male cosmetic-genital-surgery decision framework, see the Male Cosmetic Genital Surgery atlas page. For the surgical alternative, direct fat-pad excision, see Suprapubic Lipectomy. For the broader buried-penis condition, see Adult-Acquired Buried Penis.

I. Definition and Concept​

Cryolipolysis exploits the observation that lipid-rich adipocytes are more susceptible to cold injury than surrounding water-rich cells (skin, nerves, vasculature). A vacuum applicator draws a skin-fat fold against cooling surfaces. In cited flank protocols, applicator settings were −10°C for 60 minutes or −11°C for 35 minutes, while measured abdominal subdermal temperatures remained above 0°C.[9][18] This induces crystallization of cytoplasmic lipids within adipocytes, triggering a cascade of apoptosis, panniculitis, and gradual adipocyte clearance over 2–4 months.[2][3][4]

The concept derives from the clinical observation of "popsicle panniculitis," cold-induced fat necrosis in children's cheeks after prolonged cold exposure, described decades before the technology was developed.[4]

II. Mechanism of Action​

The proposed mechanism proceeds through this sequence, based on human histology, pig and mouse models.[2][5][6][7][8]

  1. Cooling phase. In Sasaki's six-patient abdominal pilot, mean subdermal temperature fell from 34°C before treatment to 14.0°C with a large applicator and 12.2°C with a small applicator at 30 minutes; both remained above 0°C through 60 minutes.[9]
  2. Lipid crystallization. Adipocyte lipids are proposed to crystallize with cooling, producing preferential adipose injury.[36]
  3. Adipocyte membrane disruption. Crystallization causes loss of cellular integrity and membrane disruption, evident histologically in all treated areas.[5]
  4. Apoptosis initiation. Apoptosis is the primary cell-death pathway, with some necrosis also occurring.[6][8]
  5. Inflammatory panniculitis. An inflammatory infiltrate of immune cells (macrophages, lymphocytes) appears at the treatment site within 2–3 days, peaking at 14–30 days.[7][8]
  6. Phagocytic clearance. Macrophages engulf lipid debris and dead adipocytes; this process occurs gradually over 2–4 months.[4][8]
  7. Connective-tissue remodeling. Focal dissolution and homogenization of collagen fibers with dissolution of interlobular fibrous septa; neocapillarization observed at 45–60 days.[5]
  8. Fat-layer reduction. Fat thickness decreases measurably. A systematic review of 19 studies reported average reductions of 14.67–28.5% by caliper and 10.3–25.5% by ultrasound.[3][9]

Additional mechanisms. A pilot study suggests cryolipolysis may also promote conversion of white adipocytes to brown / beige adipocytes ("browning"), with increased expression of UCP-1, PPAR-γ, and PPAR-α markers in treated tissue.[6]

Selectivity. Early clinical and animal reports describe preferential adipose injury from controlled cooling.[2][4][8] Skin freeze burns and sensory or motor nerve injury have nevertheless been reported clinically.[23][34]

III. FDA Clearance History​

Cryolipolysis (CoolSculpting, originally ZELTIQ Aesthetics, now Allergan / AbbVie) has received sequential FDA clearances for multiple body areas.[2][10][11][12][31]

  • 2010. Flanks (love handles); first FDA authorization (De Novo).[31]
  • 2012. Abdomen.[31]
  • 2014. Thighs.[11][31]
  • 2015. Submental area (double chin).[10][31]
  • Subsequent clearances for upper arms, back / bra fat, banana roll (infragluteal), and lateral thighs.

Off-label suprapubic application. The suprapubic / mons-pubis region is outside CoolSculpting Elite's listed cold-assisted lipolysis indications.[1][13][33] Azab reported suprapubic cryolipolysis; Mineroff's PubMed search found no additional clinical suprapubic study.[1][13] Suprapubic treatment is outside CoolSculpting Elite's listed indications, and its manual prohibits placement on genitalia or inguinal creases.[33]

IV. Suprapubic Application — The Key Study​

Azab 2021 reported a prospective study of cryolipolysis for suprapubic fat reduction and apparent penile length.[1]

  • Design. Prospective, n = 46 males, single-arm (no control group).
  • Population. Men complaining of "buried short apparent small-size penis" due to suprapubic fat.
  • Protocol. Three consecutive suprapubic cryolipolysis sessions.

Results. Mean apparent stretched penile length (skin to glans tip) increased progressively. The abstract reports the values at sessions 1, 2 and 3 and states that measurements were recorded before the three sessions. If each value was taken before that session's treatment, the final value reflects two completed sessions.

SessionApparent SPL
Session 1 (baseline)12.1 ± 0.5 cm
Session 212.66 ± 0.48 cm
Session 312.88 ± 0.72 cm
Total gainabout 0.78 cm (p < 0.001)

Suprapubic skinfold thickness (adipometer) fell from 2.99 ± 0.49 cm to 2.37 ± 0.48 cm and 2.00 ± 0.37 cm at sessions 1, 2 and 3 (p < 0.001), a reduction of about 33%.[1]

The Mineroff 2023 narrative review of minimally invasive treatments for suprapubic adiposity found no clinical studies of cryolipolysis for this indication in its PubMed search and called for such studies; its search did not capture Azab 2021.[13][1] No comparison of cryolipolysis with liposuction for the suprapubic area has been published.

V. General Efficacy Data (All Body Sites)​

Fat-reduction measurements​

The Ravindran 2025 systematic review and meta-analysis included 30 studies and 3,158 participants overall; its 12-week BMI (n = 256), waist-to-hip ratio (n = 60), and abdominal-circumference (n = 211) estimates came from outcome-specific subsets.[14]

  • BMI. The pooled 12-week difference from baseline was −1.80 kg/m² (n = 256; 95% CI −2.98 to −0.62; I² = 94%; p = 0.003).[14]
  • Waist-to-hip ratio. MD −0.09 (95% CI −0.16 to −0.02; p = 0.01).
  • Abdominal circumference. MD −3.56 cm (95% CI −4.98 to −2.15; p < 0.001).
  • Direct fat thickness in the 2025 synthesis. The suprailiac estimate decreased (n = 52; MD −5.22 mm, 95% CI −9.03 to −1.42), while pooled subcutaneous, thigh and abdominal-ultrasound thickness estimates were not statistically significant.[14]
  • Average reduction in caliper measurement was 14.67–28.5% in the Ingargiola 2015 review of 19 studies.[3]
  • Average reduction by ultrasound was 10.3–25.5% in the same review.[3]
  • Three of the 19 reviewed studies assessed serum lipids or liver function tests and reported no significant changes.[3]

Patient satisfaction​

  • The pooled satisfaction rate was 80.4% among 479 participants contributing satisfaction data to the meta-analysis.[14]
  • In a prospective single-cohort study of abdomen and flank treatment (112 treated, 106 evaluable), 89.6% were "satisfied" or "very satisfied" at 12 weeks.[15]
  • In the same study, 93.4% would recommend it to a friend and 90.6% reported "noticeable" or "very noticeable" fat reduction.[15]

Multiple treatments​

In McKeown and Payne 2021 (28 patients, 58 body areas, mean 2.8 cycles per area), skinfold thickness fell 40% at 12 weeks in the 27 responders. Among treatment responders, skinfold reduction was greater with ≥ 3 cycles than with 1–2 cycles (p = 0.01); at 12 weeks, patients reported satisfaction with 51 of 58 treated areas (88%).[16]

VI. Treatment Protocol​

Standard treatment parameters.[2][3][9][17][18]

  • Temperature. Profiles depend on the applicator: CoolSculpting Elite lists settings down to −11°C for vacuum/flat applicators and −13°C for surface applicators. Neither Azab’s abstract nor the manual establishes a suprapubic setting.[1][33]
  • Duration. Cycle length depends on the applicator; CoolSculpting Elite uses 35–75 minutes. In a 19-subject split-flank prototype study, 35-minute CoolCup and 60-minute CoolCore cycles had similar fat-layer reduction at 12 weeks.[21][18]
  • Applicator selection. Vacuum cup-shaped applicators of various sizes; flat-cup applicators for inner thighs and arms; small applicators (CoolMini) for submental and small areas.
  • Post-treatment massage. 2 minutes of manual massage immediately after applicator removal (1 minute of vigorous kneading, then 1 minute of circular massage). In Boey 2014 (10 women treated on the lower abdomen), ultrasound fat-layer reduction was 68% greater on the massaged side at 2 months (n = 9; p = 0.0007); the 44% difference at 4 months (n = 8; p = 0.1) was not statistically significant.[19]
  • Number of sessions. 1–3 sessions per area, spaced 4–8 weeks apart.
  • Results timeline. Fat reduction develops gradually over the first 3 months; the cited studies also report outcomes at 6 months.[4][9][20]

For the suprapubic application (extrapolated from Azab and general protocols).[1]

  • If an applicator is placed over the suprapubic fat pad, follow device-specific protection steps: apply a new, correctly sized, intact gel pad, ensure it extends beyond the applicator edges, and check that it does not slip; direct cooling-surface contact can injure skin.[33] -If CoolSculpting Elite is considered, its manual warns against treatment of genitalia or inguinal creases and of areas with <1 cm subcutaneous fat; assess for adjacent hernia and superficial neurovascular structures.[1][33]
  • Three sessions, as used by Azab.
  • Post-treatment massage of the treated area.
  • Care to avoid proximity to the penile shaft and scrotal structures.

Newer dual-applicator systems (CoolSculpting Elite) allow simultaneous bilateral treatment, reducing total procedure time. In the Geronemus 2026 multicountry prospective study (110 treated, 96 evaluable for satisfaction), 83.3% (80/96) were satisfied with midsection results at 12 weeks after final treatment; mean midsection fat-volume loss of 194.8 mL at that time came from a separate 3D-imaging subset.[21]

VII. Adverse Events​

Common (minor, self-limiting)​

Outcome-specific pooled proportions in Ravindran 2025; contributing samples differed by event (n = 59–388).[14]

EventIncidence
Numbness49.5%
Erythema44.5%
Edema30.5%
Pain28.8%
Sensitivity25.4%
Tingling15.2%
Hyperpigmentation2%

Most adverse events resolve within 1–4 weeks; numbness may persist for approximately 3 months.[22] A 2026 prospective observational study of clinic patients recruited as device monitors in Japan (n = 1,553 treatment areas) reported that the overall AE rate decreased from 71.6% immediately after treatment to 1.3% at 3 months.[22]

Serious / rare complications​

The Hedayati 2020 systematic review (53 articles) lists these.[23]

  • Severe / persistent pain. Rare; may last weeks to months.
  • Dysesthesia. Altered sensation at the treatment site.
  • Motor neuropathy. Extremely rare case reports.
  • Skin hyperpigmentation. More common in darker skin types.
  • Contour irregularities. Indentations, asymmetries, soft-tissue atrophy.[24]
  • Paradoxical adipose hyperplasia (PAH). See below.

Paradoxical adipose hyperplasia (PAH)​

PAH can present as a well-demarcated, firm enlargement of treated fat that exceeds the original volume, often developing 2–5 months after cryolipolysis; diagnosis can occur later. Across six studies, mean time to clinical recognition ranged from 2.75 to 16.1 months.[2][25][26][27][28][32]

Incidence. Jalian 2014 estimated PAH at 0.0051% from 33 manufacturer-reported cases and more than 650,000 treatment cycles; subsequent studies reported higher per-cycle rates.[2][27]

  • 0.05–0.39% per treatment cycle in the Nikolis 2021 multicenter review (8,658 cycles, 2,114 patients), against a manufacturer-quoted rate of 0.025%.[27]
  • 0.67% at one academic center (Cox 2022; 4 cases).[25]
  • 4 of 398 patients at one center (Stroumza 2018).[28]
  • 0.22% pooled incidence (95% CI 0.10–0.47) in a 2025 systematic review and meta-analysis (28 studies, 13,078 patients; low-certainty evidence). Only 4 studies had follow-up of 16 weeks or more.[32]
  • PAH is likely underreported.[12][26][32]

Risk factors.[2][25][27]

  • Male sex. Jalian 2014 noted that PAH seemed more common in men, and 55% of cases in the Nikolis series were male.[2][27] The pooled sex comparison was inconclusive: only 7 PAH cases contributed (4/566 men and 3/3,115 women; RR 5.31, 95% CI 0.25–110.96).[32]
  • Older device models (possible association). In Nikolis, 76.9% of PAH cases involved older units and site-level per-cycle incidence was more than 75% lower after newer models were introduced; a 2025 review could not pool risk by device.[27][32]
  • European ethnic origin. 77.8% of PAH cases were of European ethnic origin; the series gives no population denominator.[27]
  • No single unifying risk factor identified.[2]

Pathophysiology. Unknown. Histology shows nonspecific panniculitis.[28] One hypothesis suggests that some adipocytes may be "naturally selected" for survival due to inherent cold tolerance, and the inflammatory response may stimulate adipogenesis or hypertrophy in surviving cells.[12]

Management.[25][26][28]

  • Spontaneous resolution has not been reported (Jalian), although 3 of 4 patients in the Stroumza series stabilized without treatment.[2][28]
  • Surgical correction with liposuction, abdominoplasty, or both has been used.[25][26]
  • In the Cox series, none of the 4 surgically treated patients had documented PAH recurrence at mean follow-up of 13.8 months and 3 had no residual deformity at final review, but 3 required revision liposuction for residual deformity.[25]

VIII. Contraindications​

Cold-related contraindications and warnings.[23][29][37] The first three disorders below are formal CoolSculpting Elite contraindications; cold urticaria is a manufacturer warning for an unstudied cold-sensitive population.

  • Cryoglobulinemia.
  • Cold agglutinin disease.
  • Paroxysmal cold hemoglobinuria.
  • Cold urticaria.

Additional avoidance advice and device warnings.[23][29][33][34]

  • Raynaud disease or pernio (chilblains): FDA guidance advises against fat freezing in these groups.[34][33] A retrospective Raynaud series found no exacerbations among selected patients with mild–moderate disease[29]; this does not establish general safety, and FDA guidance still advises avoidance.[34]
  • Avoid treatment in or near a hernia or structurally weak scar; examine for abdominal or femoral hernia before using a vacuum applicator. Recent surgery or scar tissue in the field can increase wound-separation risk, and treatment near or over implants should be avoided.[34][33]
  • Impaired peripheral circulation or sensation in the treatment area, or a neuropathic disorder such as diabetic neuropathy; the Elite manual advises against use where local sensation or perfusion is decreased.[33]
  • Open or infected wounds.
  • Dermatitis or eczema in the treatment area.
  • Pregnancy or lactation.[33]
  • Bleeding disorder or concomitant anticoagulant use (increased bleeding risk).[33]
  • Known allergy to fructose, glycerin, isopropyl alcohol or propylene glycol in treatment supplies (possible anaphylaxis).[33]

Suprapubic-specific considerations.

  • Proximity to the penile shaft and scrotum: applicator placement must avoid direct cooling of genital structures.
  • Thin suprapubic skin in lean patients may increase the risk of skin injury (theoretical).
  • In patients with apparent penile burial, penile skin changes, suspicious lesions, or voiding symptoms warrant evaluation for lichen sclerosus, penile cancer, or urethral disease before isolated fat-pad treatment.[38]
  • Published suprapubic cryolipolysis safety data remain limited to the Azab series.[1]

IX. Comparison: Cryolipolysis vs Suprapubic Lipectomy​

FeatureCryolipolysisSuprapubic Lipectomy
InvasivenessNoninvasiveLiposuction is minimally invasive; open lipectomy and escutcheonectomy require open excision
AnesthesiaNone requiredLocal ± sedation, or general
Fat reduction14.67–28.5% skinfold-thickness reduction by caliper or 10.3–25.5% fat-layer reduction by ultrasound at non-suprapubic sites[3]No directly comparable fat-layer-thickness outcome on the linked surgical page
Number of sessionsVariable at other sites; Azab used three suprapubic sessions, but an optimal suprapubic regimen is unestablished[1][17]Usually 1
DowntimeGenerally little or no scheduled recovery time, although pain, edema, or numbness may persist for days to weeks[14][33]Varies by liposuction, open excision, or multicomponent reconstruction
Results timelineGradual over 2–4 monthsImmediate (swelling resolves 4–6 weeks)
Apparent penile length gain0.78 cm between pre-session 1 and 3 measurements (Azab 2021)[1]Isolated infrapubic liposuction increased measured length at 3 months[35]
Suprapubic fat reduction~33% reduction in adipometer skinfold thickness between measurements before sessions 1 and 3 (Azab 2021)[1]No comparable percentage reported in the Ghanem abstract[35]
ComplicationsNumbness and erythema are common; PAH, severe freeze burns and hernia can require intervention[14][34]Hematoma, seroma, contour irregularity, infection
Skin managementDoes not excise excess suprapubic skinEscutcheonectomy removes suprapubic skin and fat; liposuction alone does not excise skin
FDA status for suprapubicOff-labelNot FDA-regulated (surgical)
Published suprapubic evidenceAzab 2021 prospective study, n = 46[1]Ghanem 2017 case series, n = 10[35]

X. Systemic Safety​

In an uncontrolled cohort of 30 women, total and LDL cholesterol were lower after three cryolipolysis sessions; a 2025 meta-analysis found no significant pooled change in serum lipids or transaminases among 126 participants.[39][14]

  • Only three of the 19 studies in the Ingargiola 2015 review assessed serum lipids or liver tests; those studies reported no significant lipid changes.[3]
  • No significant change in liver function tests was noted in the same review.[3]
  • Gradual phagocytic clearance of adipocyte debris avoids the bolus lipid release that could theoretically affect hepatic or cardiovascular function.
  • Nelson’s 2009 review reported no scarring or ulceration in studies available then.[4] FDA guidance now documents severe partial- or full-thickness freeze burns after fat freezing.[36]

XI. Limitations and Evidence Quality​

Several caveats apply to the cryolipolysis literature.[13][30]

  • Commercial bias. Many studies are industry-sponsored or conducted by investigators with financial relationships with device manufacturers. Atiyeh 2020 raised "serious concerns about integrity of many of these reports, particularly with respect to validity of photographic outcome documentation in addition to objectivity, conflict of interest issues, and commercial bias."[30]
  • Lack of rigorous methodology. Most studies are single-arm, uncontrolled, with subjective outcome measures (photographs, patient satisfaction). Few RCTs exist.[30]
  • Suprapubic data are limited. Only one study (Azab 2021, n = 46) has evaluated suprapubic cryolipolysis, with no control group, no long-term follow-up, and modest length gains (approximately 0.78 cm).[1]
  • No head-to-head comparisons with liposuction for the suprapubic area exist.[1][13]
  • Not a weight-loss procedure. Cryolipolysis is designed for localized fat reduction in patients near ideal body weight with discrete, pinchable fat bulges and is not effective for generalized obesity or large-volume fat reduction.[3][4]

XII. Clinical Summary​

Cryolipolysis is an FDA-cleared noninvasive technology for localized fat reduction. Across non-suprapubic treatment sites, the Ingargiola review reported average reductions of 10.3–25.5% in ultrasound-measured fat-layer thickness and 14.67–28.5% in caliper-measured skinfold thickness. Pooled satisfaction was 80.4% among 479 participants in the Ravindran review; in Tan’s abdomen/flank study, 95/106 evaluable participants (89.6%) were satisfied or very satisfied 12 weeks after final treatment. Reported adverse events were mostly minor and self-limiting.[3][14][15] Paradoxical adipose hyperplasia (PAH) is the main rare complication. Nikolis reported PAH incidence of 0.05–0.39% per treatment cycle, Cox reported 0.67% at one center among patients, and Mah pooled patient-level incidence at 0.22% (low-certainty evidence); the four Cox cases were treated surgically.[27][25][32] Sex-based risk differences were not statistically significant in the pooled analysis.[25][27][32] Patients are counseled about PAH before treatment.

For suprapubic fat reduction and apparent penile-length augmentation, cryolipolysis is a minimally studied noninvasive alternative to liposuction.[1] In Azab 2021 (n = 46, single-arm), measurements made before sessions 1 and 3 differed by 0.99 cm in suprapubic skinfold thickness and 0.78 cm in apparent stretched penile length (both p < 0.001).[1] The suprapubic area is not specifically FDA-cleared for cryolipolysis.[13] Azab used three suprapubic sessions; the number needed for an individual patient and the relative effect versus surgery remain unknown.[1][13]

See Also​

References​

1. Azab SS, Hamed HA, Elseginy A, Elzawahry HM, Ismail NN. Increase apparent penile length by cryolipolysis in the reduction of male suprapubic fat. Andrologia. 2021;53(3):e13963. doi:10.1111/and.13963

2. Jalian HR, Avram MM, Garibyan L, Mihm MC, Anderson RR. Paradoxical adipose hyperplasia after cryolipolysis. JAMA Dermatol. 2014;150(3):317–319. doi:10.1001/jamadermatol.2013.8071

3. Ingargiola MJ, Motakef S, Chung MT, Vasconez HC, Sasaki GH. Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment paradigms. Plast Reconstr Surg. 2015;135(6):1581–1590. doi:10.1097/PRS.0000000000001236

4. Nelson AA, Wasserman D, Avram MM. Cryolipolysis for reduction of excess adipose tissue. Semin Cutan Med Surg. 2009;28(4):244–249. doi:10.1016/j.sder.2009.11.004

5. Pugliese D, Melfa F, Guarino E, et al. Histopathological features of tissue alterations induced by cryolipolysis on human adipose tissue. Aesthet Surg J. 2020;40(7):761–766. doi:10.1093/asj/sjaa035

6. Palauro CRT, Meyer PF, Soares CD, et al. Effects of cryolipolysis on the conversion of white adipose tissue: pilot study. Lasers Surg Med. 2025;57(1):88–95. doi:10.1002/lsm.23839

7. Salma N, Wang-Evers M, Casper MJ, et al. Mouse model of selective cryolipolysis. Lasers Surg Med. 2023;55(1):126–134. doi:10.1002/lsm.23573

8. Zelickson B, Egbert BM, Preciado J, et al. Cryolipolysis for noninvasive fat-cell destruction: initial results from a pig model. Dermatol Surg. 2009;35(10):1462–1470. doi:10.1111/j.1524-4725.2009.01259.x

9. Sasaki GH, Abelev N, Tevez-Ortiz A. Noninvasive selective cryolipolysis and reperfusion recovery for localized natural fat reduction and contouring. Aesthet Surg J. 2014;34(3):420–431. doi:10.1177/1090820X13520320

10. Kilmer SL, Burns AJ, Zelickson BD. Safety and efficacy of cryolipolysis for non-invasive reduction of submental fat. Lasers Surg Med. 2016;48(1):3–13. doi:10.1002/lsm.22440

11. Zelickson BD, Burns AJ, Kilmer SL. Cryolipolysis for safe and effective inner thigh fat reduction. Lasers Surg Med. 2015;47(2):120–127. doi:10.1002/lsm.22320

12. Ho D, Jagdeo J. A systematic review of paradoxical adipose hyperplasia (PAH) post-cryolipolysis. J Drugs Dermatol. 2017;16(1):62–67. PMID 28095535

13. Mineroff J, Nguyen JK, Jagdeo J. Potential treatment modalities for suprapubic adiposity and pubic contouring. Arch Dermatol Res. 2023;315(6):1615–1619. doi:10.1007/s00403-023-02555-z

14. Ravindran R, Pizzol D, Rahmati M, et al. Cryolipolysis and associated health outcomes, adverse events, and satisfaction: a systematic review and meta-analysis. Obes Rev. 2025;26(8):e13925. doi:10.1111/obr.13925

15. Tan T, Snell B, Braun M, et al. High participant satisfaction achieved using cryolipolysis for fat reduction of the abdomen and flanks. Aesthet Surg J. 2022;42(7):760–770. doi:10.1093/asj/sjab421

16. McKeown DJ, Payne J. Significant improvement in body contour with multiple cycles of CoolSculpting: results of a prospective study. Dermatol Ther. 2021;34(2):e14850. doi:10.1111/dth.14850

17. Brassolatti P, de Andrade ALM, Nishioka MA, et al. The clinical impact of different cryolipolysis protocols: an integrative review. Aesthet Plast Surg. 2025. doi:10.1007/s00266-025-04864-2

18. Kilmer SL. Prototype CoolCup cryolipolysis applicator with over 40% reduced treatment time demonstrates equivalent safety and efficacy with greater patient preference. Lasers Surg Med. 2017;49(1):63–68. doi:10.1002/lsm.22550

19. Boey GE, Wasilenchuk JL. Enhanced clinical outcome with manual massage following cryolipolysis treatment: a 4-month study of safety and efficacy. Lasers Surg Med. 2014;46(1):20–26. doi:10.1002/lsm.22209

20. Coiante E, Pensato R, Hadji I, et al. Assessment of the efficacy of cryolipolysis on abdominal fat deposits: a prospective study. Aesthet Plast Surg. 2023;47(6):2679–2686. doi:10.1007/s00266-023-03369-0

21. Geronemus RG, Wang JV, Goldman MP, et al. Participant satisfaction, effectiveness, and safety with a novel dual-applicator cryolipolysis system: a prospective, multicountry study. Dermatol Surg. 2026;52(1):61–68. doi:10.1097/DSS.0000000000004797

22. Nishikawa A, Aikawa Y, Kono T. Adverse events associated with cryolipolysis treatment for body contouring: a prospective observational study with 3-month follow-up. Plast Reconstr Surg. 2026;157(4):532e–540e. doi:10.1097/PRS.0000000000012406

23. Hedayati B, Juhász M, Chu S, Mesinkovska NA. Adverse events associated with cryolipolysis: a systematic review of the literature. Dermatol Surg. 2020;46(Suppl 1):S8–S13. doi:10.1097/DSS.0000000000002524

24. Khan M. Complications of cryolipolysis: paradoxical adipose hyperplasia (PAH) and beyond. Aesthet Surg J. 2019;39(8):NP334–NP342. doi:10.1093/asj/sjy282

25. Cox EA, Nichols DS, Riklan JE, et al. Characteristics and treatment of patients diagnosed with paradoxical adipose hyperplasia after cryolipolysis: a case series and scoping review. Aesthet Surg J. 2022;42(12):NP763–NP774. doi:10.1093/asj/sjac219

26. Stein MJ, Smith D, Chia C, Matarasso A. Paradoxical adipose hyperplasia following cryolipolysis. Aesthet Surg J. 2024;44(10):1063–1071. doi:10.1093/asj/sjae077

27. Nikolis A, Enright KM. A multicenter evaluation of paradoxical adipose hyperplasia following cryolipolysis for fat reduction and body contouring: a review of 8658 cycles in 2114 patients. Aesthet Surg J. 2021;41(8):932–941. doi:10.1093/asj/sjaa310

28. Stroumza N, Gauthier N, Senet P, et al. Paradoxical adipose hypertrophy (PAH) after cryolipolysis. Aesthet Surg J. 2018;38(4):411–417. doi:10.1093/asj/sjx159

29. Yanes D, Sawaya J, Wanner M, Avram M. Predicting negative outcomes of cryolipolysis in patients with and without Raynaud disease. Dermatol Surg. 2021;47(5):675–677. doi:10.1097/DSS.0000000000002925

30. Atiyeh BS, Fadul R, Chahine F. Cryolipolysis (CLL) for reduction of localized subcutaneous fat: review of the literature and an evidence-based analysis. Aesthet Plast Surg. 2020;44(6):2163–2172. doi:10.1007/s00266-020-01869-x

31. U.S. Food and Drug Administration. ZELTIQ System (CoolSculpting) marketing authorizations: De Novo DEN090002 (flanks, August 24, 2010); 510(k) K120023 (abdomen, May 9, 2012), K133212 (thighs, April 9, 2014), K151179 (submental, September 24, 2015).

32. Mah AE, Razeghi P, Li C, et al. Incidence of paradoxical adipose hyperplasia after cryolipolysis: a systematic review and meta-analysis. Aesthet Surg J Open Forum. 2025;7:ojaf142. doi:10.1093/asjof/ojaf142

33. AbbVie. CoolSculpting Elite System User Manual. CS-UM-CM3-02-EN-M. pp ix–xii. User manual

34. U.S. Food and Drug Administration. Non-Invasive Body Contouring Technologies. Section: Thermal: Cold (Cryolipolysis or Fat Freezing). FDA guidance

35. Ghanem H, ElKhaiat YI, Motawi AT, AbdelRahman IFS. "Infrapubic Liposuction for Penile Length Augmentation in Patients with Infrapubic Adiposities." Aesthetic Plast Surg. 2017;41(2):441–447. doi:10.1007/s00266-017-0786-2

36. U.S. Food and Drug Administration. Non-Invasive Body Contouring Technologies. Section: Thermal: Cold (Cryolipolysis or Fat Freezing). FDA guidance

37. AbbVie. CoolSculpting Elite System User Manual. CS-UM-CM3-02-EN-M. pp x–xi. User manual

38. Daly WC, Klein RD, Myrga JM, Quiroga-Garza G, Rusilko PJ. "Lichen Sclerosus in Patients Undergoing Adult-Acquired Buried Penis Repair: A Large Cohort Review." Urology. 2025;205:260–264. doi:10.1016/j.urology.2025.07.061

39. Lopes-Martins RAB, Barbosa LV, Sousa MMB, et al. "The Effects of Body Cold Exposure (Cryolipolysis) on Fat Mass and Plasma Cholesterol." Life (Basel). 2024;14(9):1082. doi:10.3390/life14091082