Thermage is internationally recognized as the gold standard for non-invasive skin tightening. Its unique ability to target multiple layers of skin with minimal downtime and low risk of complications makes it an essential anti-aging treatment. However, because skin aging is multi-factorial, combining Thermage with other aesthetic modalities such as Ultherapy (HIFU), botulinum toxin, and dermal fillers can optimize outcomes.
This article provides a comprehensive guide on how to safely and effectively combine Thermage with these treatments based on anatomical layers, energy interaction, and treatment timing.
1. Thermage + Ultherapy (HIFU): Strategic Layer-Based Combination
Thermage offers non-invasive skin tightening with minimal damage and no risk of irreversible injury or scarring. It’s the only FDA-cleared device of its class with clinical results lasting up to one year. Unlike other RF devices, Thermage can treat the entire face — including the orbital rim — using a specialized eye tip. It works across several skin layers: epidermis, dermis, subcutaneous fat fibrous septae, and even the superficial muscular aponeurotic system (SMAS), though the effect on SMAS is limited due to energy attenuation at 4.3mm depth.
Ultherapy (or similar ultrasound-based devices), uses focused ultrasound to target the dermis, fat layers, and SMAS with superior lifting results, especially in patients with visible skin laxity or facial sagging.
Combination Strategy & Principles
- Indication:
- Mild skin laxity: Thermage alone may suffice.
- Pronounced sagging (e.g., jowls, flattened midface): Combine Thermage with Ultherapy.
- Important Considerations:
- Do not perform both treatments on the same day unless absolutely necessary.
- Both devices generate heat in overlapping skin layers.
- Same-day treatment significantly increases the risk of thermal overload, burns, or subcutaneous scarring.
- If same-day treatment is chosen:
- Perform Thermage first, using energy levels based on thermal feedback (don’t push high energy beyond pain tolerance).
- After Thermage, apply a soothing mask for 30–60 minutes.
- Evaluate redness and edema:
- Minimal reaction: Ultherapy can be done with slightly reduced energy.
- Significant redness/swelling: Reduce Ultherapy energy further.
- Limit total shot count for Ultherapy to avoid excessive overlap in thermal coagulation zones.
- Do not perform both treatments on the same day unless absolutely necessary.
- Treatment Order When Not Same Day:
- Either order is acceptable if spaced correctly.
- Recommended interval: 1–4 weeks.
- Optimal synergy occurs during the wound-healing (inflammatory) window.
- Avoid exceeding 4 weeks between treatments.
2. Thermage Eye + Face Tip Combination: Targeted Periorbital Rejuvenation
Thermage Eye Tip is FDA-approved and uniquely designed for use inside the orbital rim — an area prone to early aging due to thinner skin. However, many patients opt for facial Thermage first due to wider marketing appeal and visible lifting.
Combination Strategy
- Eye tips typically have fewer pulses, limiting standalone efficacy.
- Combine facial and eye tip treatments for enhanced results:
- Upper and lower eyelid tightening
- Reduction of eye puffiness
- Improvement of brow ptosis
- Particularly effective for true lower eyelid wrinkles, where deeper tissue support is needed
Targeted Zones for Eye + Face Tip Synergy
- Lower eyelid: Eye tip addresses fine wrinkles; face tip targets periocular ligaments.
- Infraorbital ligament: Improves skin tension and reduces laxity.
- Zygomatic ligament: Addresses under-eye bags and midface support.
- Supratrochlear and supraorbital ligaments: Enhances brow lift effect.
3. Thermage + Botulinum Toxin: Dual-Level Anti-Aging
While Thermage targets skin layers and connective tissues, botulinum toxin works by relaxing overactive facial muscles that contribute to wrinkles and tissue descent.
Dual Approach
- Thermage: Improves skin texture, tightens loose tissues.
- Botulinum toxin: Smooths dynamic wrinkles and reduces downward muscle pull.
Treatment Timing
- Thermage first: Wait for redness to subside before injecting toxin.
- Toxin first: Wait 7 days for full effect before performing Thermage (RF energy won’t compromise toxin effect once it’s bound).
Specific Indications
Nasolabial Folds & Marionette Lines
These are not true wrinkles but grooves caused by:
- Fat pad descent
- Downward muscle pull
Thermage + Toxin is more effective than Thermage + Ultherapy here, as Ultherapy does not act on muscles.
Target Muscles for Toxin
- For nasolabial folds:
- Depressor anguli oris (DAO): Pulls mouth corner down.
- Depressor labii inferioris (DLI): Pulls lower lip down.
- Platysma (upper fibers): May contribute to jawline sagging.
- For marionette lines:
- DAO
- Platysma (inner band)
- DLI injection should be conservative to avoid side effects like lip eversion or speech issues.
Dosing and Injection Technique
- DAO: 2–3 units per side (max 4U); total ≤ 8U.
- DLI: 1–2 units per side; inject cautiously.
- Platysma (upper fibers): 2–3 units per point; max 10U per side.
- Injection should be ≥1cm lateral to DAO to avoid diffusion into smile muscles.
- Avoid orbicularis oris.
General Tips:
- Use deep injection technique.
- Always start with conservative doses.
- Reassess after 2 weeks and adjust if necessary.
- Ensure symmetry and preserve natural expression.
4. Thermage + Dermal Fillers: Structure Meets Refinement
Thermage provides broad tissue tightening, while fillers restore volume in specific areas. These two approaches are complementary, not interchangeable.
Strategy Overview
- Thermage: Overall lift and ligament tightening — “global anti-aging”.
- Fillers: Focal volume restoration — “facial sculpting”.
For patients unsatisfied with nasolabial or marionette line improvement after Thermage, filler supplementation can significantly enhance results.
Notes:
- Injection technique depends on filler material, anatomical target, and desired outcome.
- Because filler strategy is highly individualized and experience-based, this article does not cover detailed protocols.
Conclusion: Smart Combination, Maximum Results
- Thermage is a foundational treatment for non-invasive facial rejuvenation, with unique advantages in full-face treatment and long-lasting results.
- Most patients benefit from combination therapy — because aging is complex, no single device or technique can address all signs.
- Combination protocols must be customized, with careful attention to:
- Treatment timing
- Energy layering
- Dose control
- Anatomical precision
- The goal is to enhance efficacy without increasing risk. Incorrect combinations can cause excessive thermal injury or underwhelming results.
- Always perform a thorough pre-treatment evaluation and tailor the plan to the patient’s anatomy, aging pattern, and goals.
Combining Thermage with Ultherapy, botulinum toxin, and dermal fillers is not just additive — it’s strategic. When done right, the synergy delivers results far beyond what each treatment can achieve alone.
