In a heartbreaking Instagram post, supermodel Linda Evangelista, 56, shared with her nearly 1 million followers the reason she has been evading the spotlight for the past five years—why she has become “a recluse,” as she says, “while [her] peers’ careers have been thriving.”
“I was brutally disfigured by Zeltiq’s CoolSculpting procedure,” she writes, citing a CoolSculpting complication called paradoxical adipose hyperplasia, or PAH, which can occur when the nonsurgical fat-freezing technology inexplicably backfires, causing fatty areas to enlarge rather than shrink. While the precise cause is unclear, some theorize that the device’s cooling effect may spark a stem cell reaction, leading to a proliferation of fat cells, explains Dr. Paul Jarrod Frank, a board-certified dermatologic surgeon in New York City.
Linda Evangelista’s CoolSculpting treatment
Evangelista says that her treatment—she received seven rounds of CoolSculpting between August 2015 and February 2016—“increased, not decreased, [her] fat cells, and left [her] permanently deformed, even after undergoing two painful, unsuccessful, corrective surgeries.” She goes on to say, “I have been left … ‘unrecognizable.’”
The ’90s-era icon, who shared catwalks with fellow legends like Christy Turlington, Naomi Campbell, Cindy Crawford, and Claudia Schiffer, says in her post that the PAH and subsequent surgeries “destroyed her livelihood” in addition to triggering “deep depression, profound sadness, and the lowest depths of self-loathing.”
“PAH is very traumatic for patients,” confirms Dr. Umbareen Mahmood, a board-certified plastic surgeon in New York City. “Those whom I’ve treated for PAH include fitness models, personal trainers, actors, and influencers—many of whom have careers tied to their physical appearance, and this causes them further emotional stress.”
Evangelista has filed a lawsuit against the manufacturer of CoolSculpting, Zeltiq Aesthetics, a subsidiary of Allergan.
Paradoxical adipose hyperplasia diagnosis
The court documents reveal that Evangelista had her abdomen, flanks, back, bra line, inner thighs, and chin treated by a board-certified dermatologist—and that within a few months of her final treatment, she developed “hard, bulging, painful masses under her skin in those areas of her body treated with Zeltiq’s CoolSculpting System.” Evangelista was diagnosed with PAH in or around June 2016. “Full body liposuction” was performed, to attempt to correct the PAH, but according to Evangelista, the bulges recurred. She underwent a second round of lipo, which was also unsuccessful and supposedly left her with keloid scarring.
Evangelista alleges that Zeltiq “failed to adequately warn and/or intentionally concealed the incidence and occurrence of known serious adverse events, including, but not limited to, paradoxical adipose hyperplasia.” She’s seeking $50 million in damages for “severe and permanent personal injuries and disfigurement, her pain and suffering, severe emotional distress and mental anguish, and the economic losses she sustained as the result of being rendered unemployable and unable to earn an income as a model.”
Referring to advertising campaigns that promote CoolSculpting as “a safe and effective noninvasive alternative to liposuction,” the filing also accuses Zeltiq of “unlawful, false, misleading, and deceptive marketing practices”—a contention underscored in a separate class action lawsuit that was filed against the company in June 2021. The suit aims to represent not only CoolSculpting patients who’ve suffered PAH, but anyone who has purchased one or more cycles of the fat-reduction treatment.
Rare CoolSculpting complications and side effects
While CoolSculpting supporters have been quick to point out that PAH is, in fact, listed among the potential adverse events on the CoolSculpting website, Evangelista’s attorney maintains that “Zeltiq’s marketing material and the CoolSculpting website failed to mention the risk of PAH until after Ms. Evangelista underwent the procedures.” In a formal statement, which the supermodel posted to her Instagram days after announcing the CoolSculpting lawsuit, her attorney asserts that “Zeltiq failed to even include any general warning on CoolSculpting’s main homepage until February 2019″—yet the company purportedly disclosed the risk of PAH to its investors years prior, warning them, in 2012, “of possible ‘additional liability from claims related to known rare side effects,'” ranging from late-onset pain to hernia to PAH.
(RealSelf reached out to Zeltiq and Evangelista for comment and has not yet heard back.)
As RealSelf has previously reported, CoolSculpting comes with some under-the-radar risks—PAH being chief among them. “PAH is localized to the treated areas—specifically, where the applicator was placed,” explains Dr. Mahmood. “I’ve seen it in various places, including the abdomen, arms, back, and submental area [under the chin].”
Is PAH from CoolSculpting rare?
While providers are obligated to disclose all potential CoolSculpting side effects and complications as part of informed consent—those documents you sign and initial prior to treatment—PAH tends to be dismissed as lightning-strike rare. (Per the lawsuit, the consent form Evangelista signed stated, “It is unlikely but there is a small possibility of fat growing instead of going away.” It never mentioned PAH by name.)
While the earliest paper published on this complication put the risk at approximately 1 in 20,000, the current incidence is unknown. “The manufacturer-reported incidence was previously approximately 1 in 4,000 treatments, but more recent studies demonstrate a 1 in 138 incidence,” notes Dr. Mahmood. “The data is several years old and likely does not reflect the current incidence.”
An evaluation published in the Aesthetic Surgery Journal in 2021, reviewing 8,658 cycles of CoolSculpting in 2,114 patients, across eight Canadian clinics, between January 2015 and December 2019, found the risk of PAH to be less than 1 in 2,000. Researchers suggest that men may be more prone to the side effect and that PAH is more strongly correlated with older versions of the device. “The newer unit and applicator models have demonstrated a dramatic decrease of over 75% in the occurrence of PAH,” the authors state.
Still, Dr. Frank believes PAH “is severely underreported, because most providers downplay its incidence to the patients.” In some scenarios, he adds, “patients will notice fat growth in the area [following treatment], and their providers will say they gained weight, so let’s do it again.”
“I wouldn’t call PAH a common complication,” he adds, “but it is certainly not rare.”
With patients, like Evangelista, who’ve been treated multiple times across several potentially overlapping areas, “they can have PAH in a widespread distribution,” Dr. Frank notes. “I find that people who get multiple cycles in short periods of time—repetitive, in the same areas—tend to be the most at risk.” He finds that “the overwhelming majority of people who get CoolSculpting are not great candidates, they’re oversold, and they aren’t treated by a proper medical expert.”
Dr. Frank has treated hundreds of CoolSculpting-induced PAH cases and stresses that correcting the problem “is not easy—it can take multiple surgeries.” But in his experience, he says, “it is treatable, 100% of the time.” And while he’s never seen PAH return post-lipo, he acknowledges that “because the exact pathophysiology is unknown, anything is possible.”
More about paradoxical adipose hyperplasia (PAH)
Liposuction is the go-to treatment for PAH, but since previously frozen fat is essentially denatured—firm, scarred down, fibrotic—it can be quite difficult to remove, especially in a single operation. To free up the fat and make it easier to extract, surgeons will oftentimes enlist energy-based devices, like power-assisted liposuction (PAL) and ultrasonic tools like VASER. Still, PAH patients typically face a higher risk of contour irregularities—lumps, bumps, and uneven contours—as a result of the surgery.
“I’ve seen a fair number of PAH patients,” says Dr. Jason Pozner, a board-certified plastic surgeon in Boca Raton, Florida. “I have corrected it successfully in every case using VASER, which works very well on the fibrous areas.”
PAH is generally described as a reversible hiccup—though this clearly was not Evangelista’s experience. Dr. Mahmood tells us that in cases of severe PAH, which require more than one session of liposuction, “the tissue will not go back to being completely ‘normal,’ as it was originally.” In this respect, the so-called disfigurement could, indeed, be considered permanent.
In select cases, if the PAH covers the lower abdomen and is accompanied by loose skin, surgeons may perform a tummy tuck, to physically remove the damaged tissue. According to Dr. Mahmood, however, this is a rare event: “Many patients getting CoolSculpting have a few stubborn areas of fat that they want addressed—not a true pannus [or overhang of excess tissue]. So it is not very often that PAH patients need a full abdominoplasty, even if that would give them the best aesthetic result.”
Once a diagnosis has been made, Zeltiq will reportedly pay for surgical correction of the PAH, on the condition that the patient signs a “confidentiality agreement and release”—agreeing not to publicize their experience and to release the company of all claims—which is something that Evangelista refused to do, according to the court documents.
Evangelista’s post received an outpouring of love from the boldest names in beauty and fashion, commending her for her strength and transparency and reminding her of her eternal beauty and indelible influence. Members of the aesthetics community chimed in too, offering their services as well as assurances that her condition can be fixed and her confidence restored.
While this remains to be seen, hopefully Evangelista’s forthright admission about seeking cosmetic work and suffering unfortunate consequences—along with the public’s overwhelmingly supportive response to her story—will allow patients to honestly speak their truth, as Evangelista did, with their “head[s] held high.”
