A before and after of Thermage on the face. Photo source: Thermage.com

About The Author:  FutureDerm is pleased to welcome dermatologist Dr. Hanan Taha, M.D. to our staff as a Contributing Writer. For a complete bio please visit our About page.

Most of us already have heard of Thermage. It obtained FDA approval for treatment of wrinkles around the eyes in 2002, facial wrinkles in 2004, and all body laxity and cellulite in 2005. But does it work?  How does it work?  And what should you expect?  We will cover all of these answers here…

The Science

How Thermage Works. Source: Thermage.com

Thermage does indeed work!  Technically speaking, Thermage uses monopolar radiofrequency energy to deliver an electrical current that generates heat through the inherent electrical resistance of dermal and subcutaneous tissue.

Wait… what?!

To simplify the physics of the process, Thermage directs an electrical current to the skin. This electrical energy is met by the cells in these areas. Their resistance converts the radiofrequency (RF) energy into heat energy. (To understand this further, read into electromagnetic energy and Ohm’s law.)

This heat denatures collagen in the lower skin layers, causing two things:

Collagen changes form easily, just like eggs do. When exposed to heat, as in Thermage, old collagen will become much smaller and thicker, and hence leave the body. This will also signal new collagen to be developed.

• In the short term: Heating collagen breaks down hydrogen bonds in its chains, causing its structure to shorten and thicken.  So immediately after the procedure and for a few weeks, this shortening will lead to a visible tightening effect. Think of how eggs look like when you scramble them: Collagen, like eggs, is a protein that is affected drastically by heat. However, as your body clears out the damaged collagen, this initial effect does not last.
• In the long term: Denaturing collagen signals skin fibroblasts to produce new, healthy collagen, leading to the tightening seen after a few months of the procedure. Also the heat stimulates blood flow, leading to an increase in the metabolism of the fatty layer.

Thermage radiofrequency is monopolar, as opposed to bipolar, meaning that the current travels from the handpiece into the body but does not return to the handpiece, and thus needs a grounding electrode, called a “return pad” placed elsewhere on the body.

Thermage handpiece.

On the other hand, bipolar radiofrequency travels from one pole on the hand piece to another. The advantage of monopolar radiofrequency is that it penetrates deeper than bipolar radiofrequency, reaching the deepest skin layer.

Thermage is non ablative, meaning its effects happen under the skin, leaving the skin surface intact. This translates into much shorter downtime.

Each pulse is accompanied by cooling before, during, and after pulse delivery. This prevents damage to the skin, limiting all the effects of Thermage to deeper tissue.

How Hot?

The skin is maintained around 104 degrees Fahrenheit (40 degrees Celsius). The deeper tissue is about 140-167 degrees Fahrenheit. Safety measures are taken to reduce the risk of burning.

Skin surface: maintained around 40 degrees Celsius (104 degrees Fahrenheit).

Deeper tissue: collagen denaturation occurs is between 65-75 degrees Celsius (149 to 167 degrees Fahrenheit).

The Procedure

After your dermatologists declares you are a suitable candidate for the procedure and obtains consent, the following happens:

• Photographs are taken of the area to be treated for before and after comparison.
• All metal jewelry in area treated should be removed.
• The return pad is placed on your back.
• The area to be treated is cleaned thoroughly with alcohol so that no makeup, cream, or any dirt is left. This is to prevent anything from interfering with the delivery of the radiofrequency.
• While the skin is still wet from the alcohol, a temporary grid is applied on the skin. It is pre-drawn on a sheet, and the physician applies the sheet onto the skin, uses a piece of cotton soaked with alcohol to smooth it on, and when it is removed, the grid has transferred onto your skin. The grid provided by Thermage is the only one to be used, as it is specially formulated so as not to interfere with the radiofrequency. It has circles and squares and is useful as a guide so that the physician does not overlap pulses.
• If the eyelid is to be treated, a special plastic eye shield provided by Thermage is placed into the eye, as you would a lens, beforehand.
• The doctor does a test pulse and asks you if the heat is acceptable or not on a scale of 0 to 4, the aim being 2 to 3 (painful but tolerable). He can adjust the machine accordingly. He then goes to work using the grid as a guide. A coupling fluid is constantly reapplied to improve the delivery of the radiofrequency.
• There is a predetermined number of pulses, depending on the disposable tip being, and the doctor works to distribute these pulses evenly throughout the area being treated using various techniques, and then he concentrates on areas he feels require more attention. The face Thermatip has 600-900 pulses, the body Thermatip has 900-1200 pulses.
• One session lasts between 45 and 120 minutes, depending on the area treated. Multiple areas can be spread out on separate days.
• Each pulse is accompanied by cooling, but you will mostly feel a drilling like sensation. This will be more pronounced on bony areas. There is also heat that should be a bit painful but still tolerable.
• There is NO anesthesia, as the physician will want constant feedback from you on the heat level. Also, anesthesia in the area treated might alter the heat resistance of the tissue, making the heating unpredictable.
• Afterwards the grid and skin are cleaned using alcohol.

The End Result

Before and 10 months after a single Thermage treatments on the stomach area. Note the increase in stomach tightness! Image source: Thermage.com

• Immediately afterwards, there is visible tightening and edema. It is a required endpoint and its presence indicates the treatment level was satisfactory and that results are more likely to be achieved. There is also transient erythema.
• Edema and erythema will disappear by the next day.
• Improvement continues for 6 months post Thermage. Depending on the area treated, results include:
  • Improved complexion.
  • Tighter, more contoured skin.
  • Eyebrow lift.
  • Correction of hooding of the eyelids.
  • Correction of wrinkles around the eyes.
  • Improved laxity of the jawline and neck.
  • Improved nasolabial folds.
  • Improved acne scars.
  • Tightening of skin of the abdomen, arms, thighs, and buttocks.
  • Improved cellulite.

Is Thermage Safe?

Thermage is safe when conducted by an experienced, licensed practitioner.  However, care must be taken to avoid hurting the patient or burning the skin. Safety measures include:

• The pad placed on the back grounds the current.
• If the entire Thermatip is not in full contact with the skin, the Thermage machine gives a beep and an error message, and it does not work again until the machine is reset and the head is placed properly on the skin.
• The coupling fluid provides optimal pulse delivery.
• Removal of all makeup and any kind of residue on the skin ensures no interference with the RF.
• The doctor wears gloves so that no part of his skin touches yours during delivery of the pulse.
• All jewelry is removed from area treated.
• The cooling before, during, and after delivery of the electrical current prevents overheating of the skin.
• The grid provided by Thermage prevents overlapping pulses, which means more even distribution of pulses and less chance of overheating. Of course, after finishing an area the physician can pass over it again. This is not considered overlapping. Multiple passes ensure the desired temperature is reached.
• Constant feedback keeps the doctor informed of the patient’s comfort level.

Are There Possible Side Effects?

Since its FDA approval in 2002, Thermage has produced multiple generations of the device: ThermaCool TC, ThermaCool TC-3, ThermaCool NXT, and finally Thermage CPT. With each new device, the side effects have occurred less and less, and they include:

• Crusting of the skin (scabbing). Transient.
• Acne. Treatable.
• Herpes eruption. Treatable.
• Pigmentary changes. Treatable.
• Skin depression: usually transient (months). In the meantime it can be corrected by fillers if needed.
• Transient tenderness or dysesthesia (abnormal sensation) or anesthesia (loss of sensation).

How Much Does Thermage Cost?

Depending on the area being treated and where you are, a Thermage session can cost between $1000 and $4,500. Ask the clinic if they offer a discount if you schedule your next appointment (for 1.5 years later) right away!

One of the reasons why this procedure is very costly is that the tips used are disposable to maintain sterility and quality. There are also many consumable parts (the coolant, the coupling fluid, the grid, the return pad, etc).

How Many Sessions Are Needed?

Only one. If you like the results you can have another one usually after 1.5 to 2 years, since the effects of ageing and gravity do not stop!

Can I have Thermage if I already had a cosmetic procedure done on me?

Yes, studies have shown that Thermage can be used safely in patients who have had plastic surgery, laser therapy, Botox or fillers (with the possible exception of silicone fillers).

Who is a Good Candidate?

• Ages 30 to 60, with mild to moderate skin laxity.
• All skin types can use Thermage safely.
• Patients with realistic expectations.
• Patients who have had a surgical face lift a few years back and are starting to experience sagging again.

Who must not use Thermage?

• Severely obese patients will not see good results.
• Same thing with extreme skin redundancy seen in severely photodamged, aged skin.
• Thermage is contraindicated in patients who have a pacemaker or defibrillator implant.
• Patients who have metal implants of any kinds should not have Thermage done on these areas.
• Patients who have habits or conditions that impair wound healing, as the aim of this procedure is wounding (damaging) collagen and counting on the healing process to create new healthy collagen. These patients include smokers, patients with an autoimmune disease, or patients on long term corticosteroids.
• For the eye area: patients who have had corneal surgery or Lasik should wait a few months to allow for healing before using Thermage.

Bottom Line

Thermage works, and the beauty is that there is no downtime. Get up and get back to your normal activities right away!

Realistic expectations are crucial. This is in no way a substitute for a surgical facelift. The improvements can be measured in mere millimeters, so it’s more appropriate for someone on the early road of skin ageing. More progressed cases might need surgery, but talk to your doctor to find out if it will work for you.

You should not be disappointed if you do not see results right away. As mentioned earlier, results take time. Your doctor will want you back for photographic documentation to measure progress at 3 and 6 months. Many patients return for a second treatment after a year or two as they like the results so much.

Thanks for reading! Remember, stop by my blog, elbashra.com, or tell your friends if interested in reading about skin care in Arabic!

Sources:

SA. Sukal, RG. Geronemus. Thermage: The Non- Ablative Radiofrequency for Rejuvenation. Clinics in Dermatology 2008; 26 (6): 602-7.

DJ. Hodgkinson. Clinical Applications of Radiofrequency: Non Surgical Skin Tightening (Thermage). Clinics in Plastic Surgery 2009; 36 (2): 261-8.

KD. Polder, S Bruce. Radiofrequency: Thermage. Facial Plastic Surgery Clinics of North America 2011; 19 (2): 347-59.