This article is the second part of the “100 Questions About Thermage,” continuing to introduce the core technology and principles of action behind Thermage.
13. The Reverse Thermal Gradient of Thermage
The “reverse thermal gradient” is a key mechanism that allows more radiofrequency (RF) current to penetrate deeper into the tissues during Thermage treatments. This reverse gradient is primarily achieved through epidermal cooling, but other factors also affect the depth of RF current penetration.
Factors influencing the RF current’s depth of action include:
- Epidermal cooling
- Skin tissue impedance
- For every 1°C increase in tissue temperature, skin impedance decreases by 2%, and conductivity increases. This means that as the RF current penetrates deeper into the skin, the temperature increases, and higher temperatures result in more RF current flowing, creating a positive feedback loop.
The significance of the “reverse thermal gradient” includes:
- Stimulating the entire dermal layer with RF current to regenerate collagen.
- Maximizing current flow in the fat layer, mainly acting on the fibrous septa, which results in the strongest fat compression effect.
- Protecting the epidermis from burns and reducing pain.
14. Treatment Head Sizes and Depth of Action
Thermage FLX
- Total Tip 4.0 cm²: This larger tip is used for facial treatments, allowing for faster heating and deeper penetration into the skin. It is effective for treating medium-sized areas like the face and neck, providing better facial contouring results by affecting the SMAS fascia layer.
- Eye Tip 0.25 cm²: Designed for precise treatment around the eyes, this tip has a penetration depth of about 1.1 mm. It is ideal for delicate skin areas, reducing the risk of adverse reactions.
- Body Tip 16 cm²: Used for larger body areas such as the abdomen, arms, and thighs, providing effective skin tightening and contouring.
Volnewmer
- I Tip 0.25 cm²: Similar to the Thermage FLX Eye Tip, it is used for treating areas around the eyes and mouth, requiring precise application due to the delicate nature of these areas.
- F Tip 3 cm²: Suitable for facial treatments, though smaller than the Thermage FLX Total Tip.
- V Tip 4 cm²: Comparable in size to the Thermage FLX Total Tip, used for facial treatments.
- S Tip 16 cm²: Designed for body treatments, similar to the Thermage FLX Body Tip.
Depth of Action
- Thermage FLX: The larger tip sizes allow for deeper penetration of RF energy, which is beneficial for affecting the SMAS fascia layer and providing better facial contouring results.
- Volnewmer: Specific details on the depth of action for Volnewmer probes are not provided in the available information.
Larger treatment heads offer two main advantages:
- Faster heating: A larger treatment head reaches the tissue degeneration temperature more quickly, and the temperature at which the tissue is affected is theoretically higher.
- Deeper penetration: The larger the treatment head, the deeper the penetration, leading to a stronger effect on the SMAS (superficial musculoaponeurotic system) fascia layer.
The eye area treatment head is specially designed due to the small area and very thin skin around the eyes. The treatment head’s area is set to 0.25 cm², allowing for more precise treatment. Its penetration depth is 1.1 mm, preventing excessive heat accumulation and minimizing the risk of adverse reactions.
15. Why Their Effects Last for a Year
The reason why Thermage and Volnewmer therapy have better efficacy than other radiofrequency treatments, and why their effects can last for a year, is as follows:
Thermage has high power, a strong effect, and provides full-layer heating, ensuring that the entire dermis is stimulated to regenerate collagen.
There are no contraindications for Thermage on the face, meaning all treated skin benefits from collagen renewal.
The reason Thermage’s effects can last for a year is that the collagen regenerated in the dermis layer retains its rigidity and strength for about a year. The so-called “rigidity” refers to the skin’s resilience.
Good skin resilience allows for normal protective functions, and the skin is less prone to sagging. After one year, the skin’s resilience decreases, requiring a repeat treatment to maintain the effect.
16. What is the principle behind Thermage’s vibration function for pain reduction?
The vibration function is designed to block pain signals from reaching the brain. According to Melzack’s Theory and Pain Control Theory, pain intensity is first adjusted at the spinal cord before being transmitted to the brain. Small nerve fibers carry pain signals, while large nerve fibers transmit non-painful sensations. Vibration continuously stimulates the large nerve fibers, promoting the transmission of non-pain signals, effectively controlling pain.
While vibration can theoretically reduce pain, the main source of discomfort comes from the high temperature. Therefore, using lower energy levels is key to reducing pain.
However, many patients do not prefer the sensation of vibration on their face, and some doctors feel that vibration may interfere with their technique. As a result, not many clinicians incorporate the vibration feature during treatment.
17. Why does Thermage use energy levels for adjustment instead of energy density?
In fact, energy levels 1-8 correspond to specific energy densities (J/cm²). So, why not directly use energy density to indicate the energy level?
The reason is that different areas of the skin have varying thicknesses and fat layer depths, which lead to different local impedances. The energy density released by Thermage with each pulse is closely related to the skin tissue impedance. Since impedance varies, the actual energy received by the skin per unit area also varies.
This is why Thermage does not directly use energy density to indicate RF energy emission. At the same energy level, the impedance of different areas of the skin varies, meaning the energy density applied will also differ.
18. Treatment Protocal for Volnewmer
18. Heat Feedback or Pain Feedback?
Official standardized training emphasizes adjusting energy levels during the treatment based on the client’s heat feedback. This is done to avoid burns while trying to make the treatment as comfortable as possible. Thermage generates heat through tissue impedance, and both the sensation of heat and pain arise from high temperatures.
According to Thermage’s principles, without considering comfort, the higher the energy level, the better the results. However, a higher energy level doesn’t just lead to a heat sensation but can also result in significant, even intolerable, pain.
Official guidelines recommend aiming for a “heat” sensation, not pain, and avoiding “burning.” However, this is open to debate. On the one hand, blindly pursuing high energy levels can cause unbearable pain and a high risk of burns. On the other hand, using lower energy levels will inevitably reduce effectiveness.
Additionally, we must consider individual pain thresholds. Some people can tolerate pain, while others cannot. Some people may tolerate pain but are sensitive to heat, meaning they can endure discomfort but not the high temperatures that cause a burning sensation. I believe both extremes — blindly pursuing high energy or prioritizing comfort — are not ideal.
It’s important to distinguish between severe pain that is hard to endure and moderate pain that is easier to tolerate. The difference lies in the intensity of the pain and the individual’s pain tolerance. Therefore, the ideal discomfort is mild tingling rather than just heat without pain.
In pain management, a crucial step is to clearly inform clients about potential heat sensations and tingling feelings. It’s also essential to communicate with clients to assess their pain tolerance and comfort level requirements.
Special attention should be given to sensitive areas that often cause noticeable pain. For example, the jawline area, where there is a shallow mandibular nerve, will typically cause noticeable pain for nearly all clients. Other sensitive areas may vary from person to person.
19. Is Heat Feedback Sufficient to Avoid Burns?
As mentioned earlier, individuals have varying pain tolerance levels, meaning that even with higher energy levels, some patients may find it tolerable. This can cause a disconnect between pain sensation and the skin’s actual response. Therefore, to avoid burns, it is crucial to closely monitor the skin’s reaction during the treatment.
If a client isn’t experiencing significant pain but there is noticeable redness and swelling on the skin, it is important to promptly cool the skin down. Experienced practitioners can usually assess when redness and swelling reach a level that indicates the treatment is approaching the threshold for a burn.
It is worth noting that while rosacea is not a contraindication for Thermage, it is a chronic inflammatory condition with significant vascular dilation and dry skin, which means patients with rosacea have a lower tolerance to heat. In other words, rosacea patients are more susceptible to burns from Thermage.
For rosacea patients, it is especially important to continually observe their skin’s reaction and adjust the energy level as necessary to prevent adverse effects.
20. Can Pregnant Women Undergo Thermage Treatment?
Thermage has several contraindications, and pregnancy is one of them. There are several reasons for this:
- Lack of Clinical Research: Thermage has not conducted clinical studies on pregnant women, so its safety during pregnancy is not established.
- Potential for Pain Impacting Uterine Contractions: The discomfort or pain from Thermage could potentially trigger uterine contractions, which may pose risks to both the mother and the baby.
- Psychological Concerns: Even if Thermage is not officially listed as contraindicated for pregnant women, many expectant mothers may worry about the treatments they have undergone or medications they have taken during pregnancy. This concern could lead to psychological stress or anxiety regarding the safety of the procedure.
From the perspective of Thermage’s underlying principles, using a lower energy level on the face is unlikely to have any negative impact on pregnancy. However, the official Thermage documentation explicitly lists pregnancy as a contraindication, and this instruction carries legal weight.
Therefore, even if a pregnant woman requests the treatment, it is advised not to perform Thermage on them, in order to adhere to safety guidelines and legal standards.
21. Considerations for performing Thermage on male clients
Here are the precautions for performing Thermage on male clients:
- Men generally have a lower pain tolerance than women
When performing Thermage, it’s important to recognize that men often have a lower pain threshold than women. Therefore, it’s essential to monitor their feedback closely and adjust the energy levels to avoid excessive discomfort. - Understand the male client’s profession and expectations
It’s important to communicate with male clients to understand their profession and aesthetic expectations. For male clients who may have on-camera requirements, make sure to clearly explain the expected results of Thermage and manage their expectations to avoid any potential disputes. - Beard considerations
For male clients with coarse beards, ensure thorough shaving before the treatment. It’s crucial to remove all stubble as well. If the beard is not properly shaved, the coarse hairs can puncture the treatment head’s membrane, causing damage. This could result in a failure of the capacitive coupling and significantly increase the risk of burns.
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