Greater than a dozen years in the past, a medical gadget hit the market with a tantalizing promise: It may freeze away cussed pockets of fats rapidly, painlessly and with out surgical procedure.

The gadget, known as CoolSculpting, was coming into an already-crowded magnificence trade promoting flatter stomachs and tauter jaw strains, however it had a bonus: a vaunted scientific pedigree. The analysis behind its improvement got here from a lab at Harvard Medical College’s major instructing hospital, a element famous routinely in information options and speak present segments.

The pitch labored. CoolSculpting machines are actually widespread in dermatology and cosmetic surgery places of work and medical spas, and the expertise has generated greater than $2 billion in income.

Cryolipolysis, the technical time period for the process, entails inserting a tool onto a focused a part of the physique to freeze fats cells. Sufferers sometimes bear a number of therapies on the identical space. In profitable circumstances, the cells die and the physique absorbs them.

However for some individuals, the process ends in extreme disfigurement. The fats can develop, harden and lodge within the physique, typically even taking up the form of the gadget’s applicator. This facet impact, known as paradoxical adipose hyperplasia, often requires surgical procedure to right. “It elevated, not decreased, my fats cells and left me completely deformed,” the supermodel Linda Evangelista wrote in 2021 of her expertise with CoolSculpting.

Allergan Aesthetics, a unit of the pharmaceutical big AbbVie that now owns CoolSculpting, says that is uncommon, occurring in 0.033 p.c of therapies, or about 1 in 3,000.

However a New York Occasions examination — drawing on inside paperwork, lawsuits, medical research and interviews — signifies that the chance to sufferers could also be significantly increased.

The corporate behind CoolSculpting has retained consultants who’ve written about low dangers of P.A.H. in medical journals and on-line channels. It has additionally restricted sufferers from speaking about the issue via confidentiality agreements and, at one level, stopped reporting the facet impact to federal regulators after an auditor from the Meals and Drug Administration decided that it didn’t qualify as a life-threatening or severe harm.

Greater than a dozen docs interviewed by The Occasions mentioned the producer’s estimate of the chance was sharply decrease than what they’d noticed of their practices or analysis — partly as a result of the facet impact can take many months to turn out to be seen, and sufferers don’t at all times join it to CoolSculpting. Generally the impact is delicate, and sufferers consider they’ve simply gained weight again.

“P.A.H. is probably going being underreported and misdiagnosed,” a 2020 research on paradoxical adipose hyperplasia discovered.

In 2017, Dr. Jared Jagdeo, a dermatologist who was then a marketing consultant for CoolSculpting’s producer, and two co-authors wrote in a journal article that the facet impact needs to be reclassified. Its growing incidences, they wrote, met the World Well being Group’s standards for a “widespread” or “frequent” opposed occasion, as a substitute of a “uncommon” one.

Since CoolSculpting’s debut, the reported frequency of P.A.H. has quietly and steadily climbed — even in firm estimates — highlighting flaws in the best way the F.D.A. clears medical units to be used and screens them after they’re available on the market.

The company depends on hospitals, docs, shoppers and gadget producers to report any “opposed occasions,” a system that has typically been criticized as successfully turning sufferers into long-term take a look at topics. Hospitals and producers are required to report deaths and severe accidents, whereas personal docs’ places of work and shoppers are usually not obligated to report something.

Allergan declined to answer detailed questions from The Occasions. The corporate emailed two statements that learn, partly, “CoolSculpting has been properly studied with greater than 100 scientific publications.” Greater than 17 million therapies have been offered, Allergan famous.

The statements known as the facet impact uncommon and mentioned it was properly documented within the data the corporate gives for sufferers and docs. Allergan additionally mentioned, “We’re compliant with all opposed occasion reporting necessities.”

Gina D’Addario, 40, who used to promote cable TV and web providers door-to-door in Syracuse, N.Y., tried CoolSculpting on her abdomen in 2017. “I simply needed to pamper myself,” she mentioned.

Ms. D’Addario mentioned she seen a big mass in her stomach about 9 months later. She thought it was weight acquire, however weight-reduction plan and train didn’t assist. The bulge grew so massive, she mentioned, that her leg would stumble upon it when she tried to work out. It didn’t happen to her, or the various docs she noticed, that the mass may very well be related to CoolSculpting, till Ms. Evangelista went public years later.

Since being recognized with P.A.H. in 2022, Ms. D’Addario has had a number of surgical procedures, together with a tummy tuck and liposuction, and might have extra. She mentioned Allergan provided her $10,000 to assist cowl the prices, contingent on her signing a confidentiality settlement. She declined.

“I want I cherished my physique again then,” she mentioned, referring to a time earlier than she had CoolSculpting. “To return to that day, I want I may, as a result of I might by no means have gotten it accomplished.”

Movie star Cachet

The F.D.A. initially cleared CoolSculpting in 2010 to be used on love handles after Zeltiq, the small firm that developed the gadget, submitted a research of 60 topics. That research’s modest dimension is typical for medical units, whereas drug approvals typically require a lot bigger scientific trials. Subsequent research led to clearances to be used on different physique components.

CoolSculpting made an look on “Conserving Up With the Kardashians” and was praised on “The Dr. Oz Present” as a game-changing therapy that sufferers may get throughout their lunch hour. Goop, Gwyneth Paltrow’s wellness web site, notes that it requires “little to no downtime.” The process grew to become probably the most well-liked choices within the physique contouring trade.

The price of CoolSculpting varies relying on the supplier and the variety of classes, however on common a shopper spends $3,200, in accordance with the producer.

A part of its broad enchantment is that it isn’t surgical procedure. Dr. Terrence Keaney, a marketing consultant for Allergan and a dermatologist in Arlington, Va., whose present apply has carried out greater than 4,000 CoolSculpting therapies since 2021, described it because the “gold commonplace in nonsurgical fats discount.”

“CoolSculpting has the very best risk-benefit profile,” added Dr. Keaney, who has provided the therapy for greater than a decade and mentioned he had noticed two sufferers develop P.A.H.

However as CoolSculpting’s recognition quickly grew, issues have been quietly creating for some sufferers. In 2011, quickly after the preliminary F.D.A. clearance, Zeltiq realized of an individual whose handled fats had solidified right into a noticeable mass, in accordance with an inside firm doc obtained by The Occasions.

The subsequent yr, two physicians on the corporate’s medical advisory board — Dr. R. Rox Anderson, an inventor of CoolSculpting, and Dr. Mathew Avram, director of the Massachusetts Basic Hospital Dermatology Laser and Beauty Heart — wrote an inside evaluate of 11 sufferers experiencing the facet impact.

Zeltiq notified the F.D.A. But it surely was not till 2014, greater than two years after the corporate had realized of the facet impact, that P.A.H. entered the medical literature, via an article in The Journal of the American Medical Affiliation. Dr. Avram and Dr. Anderson have been amongst its authors.

In an interview, Dr. Avram mentioned he had made a concerted effort to alert the general public of the facet impact as quickly as he realized about it from Zeltiq in 2012.

“The very first thing we did was we printed it out, so there may very well be as a lot consciousness of it as potential,” he mentioned.

As to the hole between the corporate’s findings and the article’s publication, Dr. Avram mentioned it had taken time to investigate the information, write the report and bear the journal’s evaluate course of. Within the interim, he mentioned, he introduced details about P.A.H. at medical conferences.

Dr. Anderson didn’t reply to requests for remark.

A Warfare of Numbers

When Dr. Avram and Dr. Anderson printed data on the facet impact in 2014, they estimated that its prevalence was 0.005 p.c, or about 1 in each 20,000 therapies.

The earlier yr, nevertheless, a physician advising Zeltiq had estimated the chance to be greater than double that quantity — 0.011 p.c, or about 1 in each 10,000 therapies — in accordance with a doc despatched to firm executives, a replica of which was obtained by The Occasions.

Extra discrepancies in knowledge would comply with, partly as a result of the corporate and its consultants used the variety of therapies to calculate the chance of P.A.H., whereas physicians observing the facet impact often used the variety of sufferers.

For instance, if two sufferers every underwent 10 classes of CoolSculpting and one developed P.A.H., the corporate’s technique would yield an incidence of 1 in 20 therapies, or 5 p.c. Calculating the frequency by affected person, nevertheless, would produce an incidence of 1 in 2 sufferers, or 50 p.c.

Allergan advises getting not less than two therapies, and lots of suppliers counsel extra, growing sufferers’ probabilities of in the end creating the facet impact.

Evan Mayo-Wilson, an affiliate professor of epidemiology on the College of North Carolina Gillings College of World Public Well being, mentioned he thought sufferers would favor to be instructed their total danger, not the chance per therapy. “I feel a affected person needs to know, ‘What’s the chance that if I begin this, I’m going to have an opposed response?’” he mentioned.

Dr. Jose Rodríguez-Feliz, a plastic surgeon in Miami, mentioned he and his colleagues grew skeptical that the facet impact was as uncommon as Zeltiq claimed.

In 20 months, 4 sufferers out of 510 who underwent CoolSculpting at their apply — about 1 in each 128 — have been recognized with P.A.H., in accordance with a 2016 letter to the editor of a medical journal from Dr. Rodríguez-Feliz and two co-authors.

“We felt that the distinction was so massive that we wanted to place it on the market,” Dr. Rodríguez-Feliz mentioned in an interview.

This grew to become a sample. In medical journals, docs reported observing a considerably increased incidence than what the corporate was reporting. In 2017, a bunch of docs printed that barely greater than 1 p.c — or about 1 in each 100 — of their CoolSculpting sufferers developed the facet impact. On the identical time, physicians and scientists who have been consultants for the producer printed far decrease percentages.

As an example, Dr. Gordon Sasaki, a plastic surgeon who on the time consulted for Zeltiq, printed a letter in response to Dr. Rodríguez-Feliz saying that the latest incidence was 0.025 p.c, or 1 in each 4,000 therapies.

Allergan, which acquired Zeltiq for $2.5 billion in 2017, now tells sufferers and docs that the incidence is about 1 in each 3,000 therapies — almost seven occasions the preliminary estimates.

The corporate calculates this based mostly not on therapies carried out, however on therapies offered, which may lower the incidence it studies: Sufferers can purchase a number of therapies in bundles and don’t essentially use all of them.

CoolSculpting has been an enormous moneymaker, bringing in additional than $2.2 billion between 2011 and 2019, in accordance with firm monetary studies and data filed with the Securities and Change Fee. (Allergan, which was acquired by AbbVie in 2020, declined to share newer gross sales knowledge.)

One main beneficiary has been Massachusetts Basic Hospital, the Harvard-connected medical establishment the place the expertise behind CoolSculpting was developed. In a 2011 S.E.C. submitting, Zeltiq detailed a monetary windfall for the hospital, together with 7 p.c of internet gross sales and tens of millions in lump sum funds tied to hitting numerous gross sales milestones.

A consultant for the hospital declined to say how a lot cash it has obtained from CoolSculpting.

‘That’s Not Me’

In 2015, the F.D.A. appeared involved that Zeltiq was overlooking the chance of P.A.H., in accordance with correspondence obtained by The Occasions.

The company cautioned that an organization research, inspecting sufferers as much as 12 weeks after their procedures, could not have been enough as a result of the fats bulges can emerge after that window of time.

The F.D.A. additionally famous that as of April 2013, the corporate had stopped reporting P.A.H. circumstances to the company, despite the fact that the situation doesn’t resolve by itself and often requires surgical procedure to right. F.D.A. pointers round “severe opposed occasions” state that if surgical intervention is required, or if an harm ends in hospitalization or everlasting bodily injury, the problem needs to be reported.

On this case, an F.D.A. auditor had instructed the corporate that the facet impact didn’t meet the reporting standards, the doc mentioned.

The Occasions requested the F.D.A. why its auditor had made that judgment. A spokeswoman responded that “an announcement or recommendation given by an F.D.A. worker orally is an off-the-cuff communication that represents the very best judgment of that worker at the moment however doesn’t essentially signify the formal place of the F.D.A.”

Allergan declined to answer questions from The Occasions in regards to the F.D.A. doc, and the F.D.A. declined to clarify what had occurred after it questioned Zeltiq.

In interviews, greater than a dozen dermatologists and plastic surgeons, a few of whom used to supply CoolSculpting, mentioned they believed sufferers have been at a better danger for creating the facet impact than the corporate’s numbers counsel.

Dr. Erez Dayan, a plastic and reconstructive surgeon in Reno, Nev., mentioned he had handled dozens of sufferers with these disfigurements. “Loads of occasions, they’ll really feel that they induced it,” he mentioned. “Prefer it’s their fault, like ‘I ate an excessive amount of’ or ‘I didn’t train.’”

Kathryn Black, 32, an information analyst in Colorado, underwent CoolSculpting in December 2021 after which once more final yr for her double chin. Months later, she seen a mass within the form of the applicator forming in the identical space. In August, she was recognized with P.A.H.

“The toughest half is seeing pictures of myself, so I barely take any now,” she mentioned. “After I see one, I feel, ‘That’s not me.’”

Surgical procedure to repair the growths can value tens of hundreds of {dollars} and depart scars.

Allergan has helped cowl the price of surgical procedure for some sufferers with P.A.H., however that may be preceded by troublesome negotiations. The fee is often a part of a settlement settlement that features a confidentiality requirement, sufferers and docs mentioned.

The settlement is more likely to discourage some sufferers from reporting their situation to the F.D.A., mentioned Madris Kinard, a former public well being analyst for the company and the founding father of Machine Occasions, which analyzes medical gadget opposed occasion studies. Although sufferers can report anonymously, they could worry that it may very well be traced again to them, Ms. Kinard mentioned.

Confidentiality agreements also can make sufferers assume twice earlier than speaking about P.A.H. even with associates — not to mention on social media, an vital discussion board for sharing such data, mentioned Dr. Rita Redberg, a heart specialist on the College of California, San Francisco, who research the regulatory course of for medical units.

A Supermodel Sues

In 2021, Ms. Evangelista, probably the most recognizable supermodels of the Nineteen Eighties and ’90s, mentioned she had gone into an extended seclusion after creating P.A.H. She sued Zeltiq and introduced final summer season that she had settled with the corporate. Ms. Evangelista declined to remark for this text.

The yr she went public, the F.D.A. obtained over 1,100 studies of opposed occasions from CoolSculpting therapies — greater than in your entire earlier decade. Final yr, the company obtained greater than 1,900. A majority of all of the studies check with hyperplasia.

Ms. Kinard mentioned the spike, which she believes could be attributed partly to Ms. Evangelista, is “alarming as a result of the gadget has been round for a few years.”

Ms. D’Addario, who reported her situation to the F.D.A., mentioned that earlier than she knew what P.A.H. was, she would work out continuously, attempting to lose the fats that had emerged after CoolSculpting. Now, years later, she mentioned, she understands that it was not her fault.

However the “psychological trauma” from the mysterious methods her physique grew to become deformed, and the months of not understanding what was occurring, stay along with her, she mentioned: “I’m struggling now to at the present time. In all probability worse.”

Christina Jewett and Valeriya Safronova contributed reporting.

Analysis was contributed by Sheelagh McNeill, Kitty Bennett, Alain Delaquérière, Kirsten Noyes and Jack Begg.