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You are here: Anti-Aging Skin Treatments > Noninvasive Methods >

Monopolar Radiofrequency skin tightening/tissue lift (Thermage/Thermacool)

Generic name: Monopolar Radiofrequency

Brand(s): Thermage/Thermacool

Maker / Website: Solta Medical, Inc (,

Cost: About $1,500-2,000 for a single treatment and around $2,500-3,000 for a set of two treatments

Function / Purpose:
Monopolar radiofrequency devices are used primarily for tissue tightening. In cosmetic rejuvenation, this includes skin tightening / reduction of sag (most commonly of the face and neck but sometimes elsewhere). Since monopolar radiofrequency penetrates relatively deeply (up to 20 mm) and can affect subcutaneous fat, it has some potential for body sculpting and cellulite treatment.

Monopolar radiofrequency is one of the modes in which radiofrequency can be used in medicine and cosmetics. (See our overview of radiofrequency treatments). Monopolar delivery of radiofrequency for cosmetic rejuvenation is based on applying a single electrode to the treated area whereas the opposing electrode is relatively far removed so that the current goes deeply through the body. As a result, the tissue in the treated area is heated rather deeply (usually up to 20 mm) and intensely, which arguably increases both the potential benefits and risks. Monopolar radiofrequency is typically used to treat skin laxity and sag, usually of the face and neck but also elsewhere. It also has some potential to treat cellulite and perform body sculpting.

The first practical application of radiofrequency for skin tightening was the procedure called Thermage. As of the time of this writing, Thermage remains the most widely used cosmetic procedure based on radiofrequency. It is performed with a patented FDA-approved radiofrequency device Thermacool. However, FDA approves medical devices based largely on safety (rather than both safety and effectiveness as for drugs). Therefore, we should not view the FDA approval of Thermage / ThermaCool as a guarantee that it does all that it is purported to.

Unfortunately, relatively few clinical studies of Thermage have been performed so far. Most of them were sponsored by the manufacturer, which is not uncommon but does increase the potential for biased results. The studies were small or medium size and had only short-term follow-up. In one study, Drs Alster and Tanzi from Washington Institute of Dermatologic Laser Surgery at Georgetown University Medical Center treated 50 subjects with Thermage to improve cheek and neck laxity. The authors reported short-term effectiveness and relatively mild side effects:

"Significant improvement in cheek and neck skin laxity was observed in the majority of patients. Patient satisfaction scores paralleled the clinical improvements observed. Side effects were mild and limited to transient erythema (redness), edema (swelling), and rare dysesthesia (alteration of sensation). No scarring or pigmentary alteration was seen. ...

Although tightening continued to be evident 6 months after a single treatment, the longevity of clinical results has yet to be determined."

In a 2003 multicenter study, Dr Fitzpatrick et al investigated the effects of a single Thermage treatment in 86 subjects over the six months period. The results were analyzed using potentially inaccurate methods: photograph scoring and self-reports of the subjects. Fifty percent of the subjects reported being satisfied or very satisfied with wrinkle reduction in eye area. Photographic analysis showed that 61.5% of eyebrows were lifted by at least 0.5 mm. Typical side effects were redness and swelling, occurring in the minority of subjects; very rarely second degree burns (blisters) occurred. Three patients (4% of the subjects) had small areas of residual scarring at 6 months.

In a more recent publication (2006), Dr Weiss and co-workers from Johns Hopkins University School of Medicine, presented a retroospective analysis of 600 cases of Thermage treatment. The authors concluded that Thermage was "a very safe procedure" and the side-effects were "infrequent, self-limited, and minor, comparing favorably to other nonablative devices utilized for facial rejuvenation." They noted that the "treatment algorithm and tips have evolved over several years leading to increased safety and efficacy".

Based on these and other studies, it appears that only about 50-60% of the subjects experience clearly noticeable improvement with Thermage (at least with a single treatment). Even in responders the lifting effect is relatively modest: for example, brows are usually lifted by about 0.5-2 mm. This translates into a fresher, brighter look rather than dramatically younger appearance. However, since the healing response varies widely among people, there seems to be a minority, perhaps 10%, who experience substantial lifting and may look 10 years younger. On the other hand, up to a half of the people get no benefits at all.

It is important to note that Thermage has evolved since its initial introduction. The manufacturer has improved the equipment, including the control unit and hand-piece, at least twice, making it [allegedly] more safe and effective. Improved practices of use have been worked out. As a result, the risk/benefit profile of Thermage today (assuming new equipment and experienced practitioner) is likely to be better than in the early days of the procedure.

So, is Thermage worth having done? While there is no universal answer, here is a number of considerations to keep in mind.

Thermage is a midrange procedure -- between topical treatments on one end, and a facelift and ablative resurfacing on the other. Thermage reduces sag far less dramatically than a facelift and softens wrinkles less noticeably than ablative laser. However, Thermage's risks, recovery time and side effect profile are significantly better, especially with the latest version of equipment and an experienced provider.

Thermage costs about $1,500-2,000 for a single treatment and around $2,500-3,000 for a set of two treatments, usually spaced 3-6 months apart. (Some practitioners perform a larger series of treatments using lower setting and adjust costs accordingly.) Overall, the cost is close to that of common laser treatments but about 5-10 times cheaper than a facelift.

Considering its relatively modest tightening effect, Thermage seems to best fit the people in their late thirties and forties who are only beginning to show facial sag.

Since Thermage is still relatively new, some practitioners have limited experience. The lack of experience increases the risk of under- and overtreatment, leading to smaller improvements and greater side effects than reported in the clinical studies. If opting for Thermage, look for a practitioner who has been performing it on a daily or at least weekly basis for a minimum of 2 years, and has performed at least several dozen procedures. Also, make sure that she/he uses the latest version of Thermacool equipment.

The notion that Thermage requires no downtime is an exaggeration. While most people require a rather short downtime (from one to three days), some develop significant redness, swelling or even blisters and may need to stay out of public eye for a week or more. Also, the procedure itself may be rather painful. Some residual pain may linger for several days. Notably, the recovery may, on average, be easier and smoother with the later versions of Thermacool equipment and more experienced practitioners.

Many uncertainties remain. Do repeated Thermage treatments increase the positive and/or negative effects? Do benefits persist over the long term? Can radiofrequency injury, while tightening skin in the short term, reduce the skin's long-term viability and lead to faster aging down the road? How many people suffer long-term negative effects, such as worsening of skin texture, loss of subcutaneous fat, dryness, discoloration, or scarring? With new equipment and more experience, the side effects of Thermage seem to have decreased. Nonetheless, more studies are still needed to address the above questions. If history is any indicator, it may take another ten years before we know all that we need to know about this method.

In the meantime, the decisions to have Thermage will be based on limited knowledge, educated guesses and personal preferences. Search this site for user reviews of Thermage. You will find both positive and negative opinions. Keep in mind that user reviews are useful only as an adjunct to rigorous research and should never be the cornerstone of your decision to undergo a potentially harmful procedure.

Related Links
Overview of radiofrequency and combination treatments
User reviews of Thermage/Thermacool
Index of noninvasive and minimally invasive methods/procedures
Forum discussions of noninvasive procedures
eMedicine: Nonablative Facial Skin Tightening


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