Thermage is well known as a premium, non-invasive skin tightening and lifting procedure. The latest Thermage CPT system is supposed to tighten skin, lift saggy features and smoothing wrinkles – with minimal downtime and increased comfort.

Aging skin loses collagen in the deep skin layers. This causes wrinkles to form and sagging to happen. Thermage is FDA approved technology which uses heat from radio-frequency to tighten and lift skin by stimulating collagen in the skin.

This was great news to people looking for a needle-free, completely non-surgical way to lift droopy skin and erase wrinkles.

In my opinion, it became popular because it promised people a visible result from one session, especially so for the fine lines and sagging eyelids for the upper face.

Normal skin (top) VS Aging skin (bottom)        

Are there any side effects from Thermage?

Thermage has recently come under a lot of scrutiny. On Realself.com, an online user experience platform, the Thermage treatment received a mere 46% rating (as of date of this writing) https://www.realself.com/Thermage/reviews , with many bad reviews about even the latest Thermage CPT.

The risks of Thermage are due to the use of heat from the exterior to tighten skin. The thin skin of the exterior is subject to the most heat and makes it very vulnerable to skin burns and discomfort.

In fact, most of the unsatisfied patients on Realself describe it as a painful experience, with burn marks left on the skin afterward, and still minimal results.

UPDATED (Sept 2019) The science: the effects of radiofrequency (otherwise known as RF) depends on the electrical conductivity of the tissue. Skin has up to 10x the conductivity compared to the conductivity of the layers beneath.

Therefore, when you’re using an RF device for face-tightening:

1. Results will vary depending on your skin’s individual electrical conductivity
2. You’re possibly going to end up with uncontrolled skin ablation (AKA burns) before you achieve the lifting of the underlying tissues!

Here’s a link to a clinical paper (2) that details the burn damage from Thermage CPT. In fact, this literature review (a very comprehensive clinical analysis) (4) analysed many studies carried out by various RF devices (including many by Thermage).

The review concluded that “most studies are not good clinical trials with high methodological quality, preventing a conclusive decision about the effectiveness and the actual role of RF in the treatment of wrinkles and skin laxity”.

The review also postulates that “The use of RF has been based more on marketing than on technical-scientific reasons, as there are a large number of devices available on the market and this number increases every day, without studies with good levels of evidence being carried out.”

The review concluded that “Based on the data exposed, it is clear that using RF for the treatment of skin laxity is still a myth to be clarified and its use should, therefore, be cautious in the professional practice, especially when the parameters are out of the recommended specifications.”

Updated (Sept 2019): Another high profile case of multiple burns caused by Thermage that happened in 2019 can be seen here.

As mentioned, a much higher energy delivery into surface skin, rather than the underlying sagging tissues, would result in some superficial skin benefits (brightening, improved texture etc), but it would be difficult to achieve other tightening effects without also facing a high risk of skin burns.

This cannot be mitigated by the use of stronger numbing agents or event sedation – these can actually mask the pain response when it starts to get dangerous for the patient and makes it easier to burn the patient.

Thermage can deliver good results but there are certain risks that one should be aware of.

What alternatives are there to Thermage Facelift?

The non-surgical facelift options for Thermage or Radiofrequency include those in a similar category or other different modalities. The broad categories are:

• Bulk heating treatments (like Thermage)
• Targeted heating treatments
• Cellular regenerative treatments
• Injectable treatments

Let’s analyse each of these categories further to see if they make more sense for lifting the deeper facial structures:

1. Bulk heating treatments

Personally, I’m not a big fan of using Radiofrequency heat on the delicate exterior layer of skin.

If you’re considering a non-surgical facelift, I strongly recommend treatments that use Long-Pulse or Ultra-Long-Pulsed Nd-Yag laser energy to heat deep tissues instead. This spares the skin surface and is also more affordable and comfortable (proven by clinical study 1 at end of this document)

While both use heat to stimulate collagen growth in the deeper skin layers, Thermage uses radiofrequency to heat tissues from the outside, whereas the treatments like the Fotona Starwalker VERSA3 and Dynamis PIANO heats deep tissues, sparing the skin surface.

Thermage heats the top layer of skin (top) while Long-Pulse Nd-Yag laser leaves top layer untouched (bottom)

As you can see from the diagrams, with radiofrequency devices like Thermage CPT and Exilis, radiofrequency works by heating the surface layers more so than the deep layers.

There is no way to deliver heat from the inside with a non-invasive radiofrequency device. Some RF devices try to cool the surface to make it more comfortable, but this also reduces effectiveness.

With the Starwalker VERSA3 and the Dynamis PIANO, however, long to ultra-long pulse laser beams selectively target deep skin layers to tighten fat and ligaments, whilst bypassing the surface skin layer (3).

The result is much less pain, a much lower risk of burns, as well as more effective heating of the underlying tissues to create results. Results are seen from the very first session – almost immediately.

Furthermore, with radiofrequency (Thermage), there is no way to customize the depth of heating apart from turning up the heat. With laser technology, the depth is customizable by adjusting the pulse-width without changing the power or making it hotter.

Used in different pulse durations and individual settings, it can create a range of effects from the tightening of fat sagging to the removal of excessive fat. In fact, the effects of the Ultra-Long-pulse on the SP Dynamis can even reach bone-deep.

Depending on the individual concern, the treatment can be tuned to create instant face slimming, or simple skin tightening for those without excessive facial fat.

This means treatments can be effectively customized for people of all skin types, fair or tan, thin or thick.

Most impressively, a clinical study (1) done recently showed that the VERSA3 long pulse Nd-Yag showed better results when compared to the Thermage in a split-face study. Not just slightly, but more than 150% better on the Laser treated side compared with the Thermage treated side in terms of overall improvement.

For the lower face only, lasers were found to give better results too but also mentioned that a larger study would be necessary to validate this.

Starwalker VERSA3/Dynamis PIANO in comparison with better known facelifting technology:

• Better results
• Safer from burns
• Able to customize depths of treatment for different skin thickness
• More comfortable
• Safe for all skin types

My personal treatment technique

The Fotona Starwalker VERSA3 and Dynamis PIANO is a 45 min long session. During the treatment, pulses of a deep heating laser will rejuvenate the skin. It is used throughout the whole face, including the fine lines around the eyes and the associated ‘eye bags’.

After a single session, the skin will be visibly tightened and may be slightly red for less than an hour. There is virtually no downtime and you can return to any activities immediately after the procedure.

In summary, before considering any form of non-surgical facelifting, it is best to read up on the technology behind it. Heat as a form of collagen stimulation is fine, but from my medical point of view, applying heat directly to the top layer of the skin using radio-frequency technology can be a very risky process.

If you’re still interested in non-surgical facelifts, ask your physician for Long/Ultra-Long-Pulse Nd-Yag laser energy treatments. It is a much safer, more effective and less costly alternative. You’d thank me later.

2. Targeted heating treatments

HIFU devices like Ultraformer and Ultherapy are popular facelifting treatments that treat the deeper skin layers, making them safe and effective. These devices make use of ultrasound beams that are focused on different depths below the skin, creating zones of tightening at various layers that can be customised to persons/areas.

Microneeding RF with insulated needles can also precisely target the deep underlying layers with minimal surface damage.

Me at a Regional AGNES microneedling training session. 

As you can see, this makes much more sense than using heat on the surface, especially if most of the sagginess is from the underlying ligamental or fat structures!

My personal treatment technique

I strongly prefer the Ultraformer HIFU to other brands because of its speed and comfort. AGNES microneedling RF is also the gold-standard of microneedling RF treatments.

3. Injectable Treatments

It’s common knowledge that injectable treatments give more drastic and more immediate results.

While injectable treatments on the skin layer (wrinkle or skin booster) can help skin texture and superficial improvements, it is again noteworthy that it is injections that are done below the skin layer that help most with face-lifting. These are:

1. Filler injections that are commonly done around facial hollows that also serve to reinforce the support points of loose ligamental areas.
2. Thread lifts make use of suture material implanted underneath the skin, usually in the subcutaneous layer to lift or reposition fat layers.
3. Neurotoxin (aka Botox) treatments can relax antagonistic muscles and even prevent facial sagging.

Me giving a talk in Malaysia for Double Fix Thread lifts 

Related: Is Taiwan’s famous 水光针 really medically proven?

My personal treatment technique

I strongly encourage injectable treatments for those who want instant and visible results. Injectables are quite irreplaceable in aesthetic medicine, as they are minimally-invasive but can give results that resemble surgical treatments.

The appropriate treatment depends heavily on the individual selection and doctor expertise. I find that a mix of various injectable treatments, with or without non-injectable treatments, usually yield the most drastic and long-lasting results.

Untreated vs Treated
Immediate effects of injectable treatments seen

Conclusion

Facial sagging can bother every ageing individual, and the appropriate solution may not be so obvious in a world full of gimmicks and marketing hype.

Facelifts can be a costly investment, and it may be worthwhile to properly understand what treatments you are going for so that you don’t end up disappointed! If you’d like to find out more about Facelift Options in Singapore, read my article on Doctorxdentist.

The views expressed in this article are strictly my own and based heavily on medical research and experience. I have experience with Thermage as well as all other devices/techniques mentioned in this article. With increasing interest in medical aesthetics, I find that many articles and research articles show unrealistic positive reviews because of commercial influence.

By providing critical reviews and various alternatives, my aim is to provide the most objective medical evidence and educate patients on the safest and most appropriate options.

References:

1. Key DY et al. Single-Treatment Skin Tightening By Radiofrequency and Long-Pulsed, 1064-nm Nd: YAG Laser Compared. Lasers in Surgery and Medicine 39:169–175 (2007)
2. Flor A. Mayoral MD et al. Multiple Facial Burns With the New Thermage CPT System; J Drugs Dermatol. 2011;10(11):1320-1321.
3. (Updated Sept 2019)  Matjaz Lukac, Zdenko Vizintin, Samo Pirnat, Karolj Nemes; New Skin Treatment Possibilities with PIANO Mode on an Nd:YAG Laser; Journal of the Laser and Health Academy Vol. 2011, No.1
4. Angélica Rodrigues de Araújo et al; Radiofrequency for the treatment of skin laxity: myth or truth; An Bras Dermatol. 2015 Sep-Oct; 90(5): 707–721