27. What Type of Energy Source Does Thermage Use?
Thermage is a non-invasive (non-surgical) skin tightening device that utilizes ραδιοσυχνότητα (RF) as its energy source—specifically, electric energy.
Radiofrequency refers to electromagnetic waves with frequencies typically ranging from 300 kHz to 3 MHz. In dermatology, RF technology is used not only for skin tightening and anti-aging treatments but also for procedures like electrocautery (e.g., high-frequency electrosurgical units).
Unlike most lasers that target specific chromophores, RF generates heat through the natural electrical resistance (impedance) of biological tissues to the flow of electrons within the radiofrequency field. This heating mechanism follows Ohm’s Law.
Ο resistance to the RF current, known as impedance, converts electrical energy into heat. The amount of heat produced is directly related to the strength of the current and the duration of exposure.
As a result, radiofrequency energy can be precisely delivered at controlled depths, affecting multiple tissue layers—including the epidermis, dermis, subcutaneous fat septa, and even the SAMS (Superficial Aponeurotic Muscular System) fascia layer—to achieve comprehensive skin tightening and remodeling.
28. What Is the Effective Temperature Range for Thermage to Achieve Skin Tightening?
Thermage delivers radiofrequency (RF) energy into the skin, where heat is generated due to tissue impedance. This process can produce temperatures of up to 65°C in targeted tissue layers.
The tightening effects of Thermage are twofold:
- Immediate tightening from the contraction of existing collagen fibers due to heat.
- Long-term rejuvenation through fibroblast stimulation, leading to new collagen synthesis in the dermis.
Ideal Temperature for Collagen Remodeling
Research shows that the optimal temperature range for collagen contraction is between 58°C and 65°C, με major collagen denaturation occurring around 65°C.
However, the effectiveness of collagen remodeling is not determined by temperature alone—it also depends on exposure time. For instance, for every 5°C decrease in temperature, the exposure time must increase tenfold to achieve similar collagen contraction results.
🔹 Important Notes:
- Sub-58°C temperatures can still induce collagen contraction—just to a lesser extent.
- Similarly, temperatures below 58°C can still stimulate collagen regeneration over time. For example, έντονο παλμικό φως (IPL) ή long-pulse 1064 nm lasers typically don’t reach the 65°C threshold, yet they can still promote collagen production through moderate thermal stimulation.
Does Thermage Always Reach 65°C?
Not necessarily. While Thermage is capable of generating temperatures up to 65°C, not every RF pulse delivers this level of heat. Instead, the device relies on a gradual, cumulative heating effect to achieve therapeutic temperatures over time.
Source: Dr. Wang Xiuhan, Taiwan
Αυτό cumulative heating strategy is implemented through a technique known as “super pass”—repeated passes over the treatment area using low to medium energy settings.
In practice, it may take dozens or even hundreds of pulses to reach the threshold for collagen denaturation. The exact number of pulses depends on factors such as:
- Energy level (higher settings like level 3–8 achieve results faster)
- Operator technique (e.g., aggressive passes vs. standard protocol)
For example, double-passing over the same grid zone after a template transfer can raise tissue temperature more rapidly—but it also increases the risk of burns.
🔸 Therefore, it’s recommended to follow the standardized super pass protocol endorsed by the manufacturer. Avoid rushing to reach higher temperatures too quickly, as controlled heating over time ensures both safety and efficacy.
29. Why Does Placing the Thermage Grounding Pad Lower on the Body Reduce Facial Pain?
Thermage uses a Μονοπολική ραδιοσυχνότητα (RF) system.
In this setup, the RF circuit is formed between the treatment tip (the positive electrode) και ο grounding pad (the negative electrode), which is typically attached to the patient’s body—commonly the waist or thigh.
How the Electrical Current Flows
When RF energy is delivered, the current flows from the treatment tip into the facial tissue, then through the body, and finally exits via the grounding pad.
- Επειδή το negative pad is placed far away from the treatment area, the current density in most of the body is very low—so patients do not feel any sensation elsewhere in the body, nor is there a risk of internal burns or electric shock.
Why Lower Placement = Less Pain on the Face
When the grounding pad is placed farther down, such as on the μηρούς, ο distance between the electrodes increases. This causes more of the electrical current to disperse through the body, και less current concentrates in the facial area.
✅ Αποτέλεσμα:
- Facial pain is reduced because less current density is concentrated in the treatment zone.
- ⚠* However, treatment efficacy may also decrease, since less energy is being delivered locally to the target tissue.
Above: Current pathway of monopolar RF energy during Thermage treatment
In summary, placing the grounding pad lower on the body can ease discomfort during facial Thermage, but it may also compromise the tightening effect due to reduced localized energy delivery.
30. What Are the Common Contraindications for Thermage Treatment?
Thermage, as a radiofrequency (RF) device, has several contraindications—particularly those related to electrical current interactions. These must be carefully considered to ensure patient safety.
(1) Contraindications Related to Electrical Current
① Implanted Electronic Devices
Thermage must not be used on patients with active implanted medical devices such as:
- Cardiac pacemakers
- Implantable cardioverter defibrillators (ICDs)
- Electronic drug infusion pumps
⚠️ The RF field or current may interfere with the normal function of these devices, posing serious health risks.
② Metal Dental Work
Thermage should not be applied directly over metal dental components, especially metal braces—most notably those made from stainless steel.
🔥 RF energy can cause metal to heat up, potentially leading to:
- Skin burns
- Tooth pain
- Damage to dental materials
Exception – Small-Scale Metal Dental Work
In cases of minor dental metal components, precautions can be taken:
- Insert a piece of dry, absorbent cotton roll ή dry, sterile medical gauze between the skin and the crown area.
- This barrier reduces the risk of metal heating and protects the tissue.
⚠️ It’s important to note that the risk varies depending on the type of metal used in dental restorations. Different metals (e.g., stainless steel vs. ceramic-coated alloys) have different electrical conductivities and impedance levels, which affect how they interact with RF energy.
A more detailed analysis of these different metal materials and their compatibility with RF treatments will be addressed separately.
(2) Contraindications Related to Wound Healing Response
Thermage works by generating high temperatures that cause collagen denaturation, thereby triggering a controlled wound-healing response that stimulates new collagen production. This process naturally includes an inflammatory phase.
However, in patients who are on long-term anti-inflammatory medications, the healing process may be impaired:
- Non-steroidal anti-inflammatory drugs (NSAIDs) όπως ibuprofen και indomethacin
- Corticosteroids (glucocorticoids)
❗ These medications suppress the inflammatory response, which in turn reduces collagen regeneration and interferes with the skin’s ability to repair post-treatment micro-injuries.
Additionally, certain medical conditions associated with poor wound healing are considered relative contraindications for Thermage (not absolute, meaning treatment may still be possible with caution):
- Systemic lupus erythematosus (SLE) – an autoimmune disease
- Diabetes mellitus – due to impaired microcirculation and slower healing
(3) Special Populations
To date, there are no established clinical studies evaluating the safety or efficacy of Thermage in the following groups:
- Έγκυες γυναίκες
- Breastfeeding women
- Children
⚠️ Therefore, Thermage treatment should be avoided in these special populations as a precaution.
Σημείωμα:
This is only a categorized summary of Thermage contraindications and does not represent a complete list. A full medical assessment should always be conducted before treatment.
31. Can Thermage Be Performed on Patients with Titanium Screws or Porcelain Crowns in the Face?
This question primarily concerns the electrical conductivity and impedance of different metals.
⚙️ Titanium Implants (Screws, Plates, etc.)
Based on materials science data:
- Titanium has very low electrical conductivity compared to common conductive metals like copper or aluminum.
- Titanium’s resistance is about 25 times higher than copper και 16 times higher than aluminum—even higher than iron.
- This means titanium is a poor conductor and does not easily carry electrical current.
✅ Κλινική Ενόραση:
In real-world clinical settings, no burn injuries have been reported as a result of RF current interacting with titanium implants during Thermage treatment.
Σύναψη:
Thermage is considered safe for patients with titanium screws or implants in the facial area.
🦷 Porcelain Crowns (Ceramic Dental Restorations)
Porcelain crowns come in different types:
1. All-Ceramic (Full Porcelain) Crowns
- Contain no metal.
- Are completely non-conductive.
✅ Thermage can be safely performed without any additional precautions.
2. Porcelain-Fused-to-Metal (PFM) Crowns
- These have a metal core covered by a porcelain outer layer.
- When the porcelain coating is intact, salivary ions cannot penetrate to the metal base, preventing electrical conduction and current flow.
⚠️ However, since it’s difficult to confirm the condition of the porcelain layer clinically, precautionary steps are recommended.
✅ Clinical Recommendation:
For patients with PFM crowns, place a piece of dry sterile gauze ή cotton between the crown and the skin during treatment. This acts as an insulator to prevent any risk of heat conduction.
Electrical conduction in dental materials is minimal to none. Metal-fused porcelain crowns (PFM) have an internal conductive metal core, but if the porcelain layer is intact, no current can pass through due to insulation. Even if the metal is exposed, any resulting current (e.g., from biting foil) is extremely weak and harmless. All-ceramic crowns are fully non-conductive and pose zero risk. Therefore, both crown types are generally safe for RF treatments, with insulation recommended for PFM if integrity is uncertain.
Περίληψη:
| Material Type | Conductivity | Thermage Safety |
|---|---|---|
| Titanium (e.g., facial screws) | Very Low | ✅ Safe – No insulation needed |
| All-ceramic crowns | Κανένας | ✅ Safe – No insulation needed |
| Porcelain-fused-to-metal | Potential (if exposed) | ⚠️ Safe with gauze insulation |
Always assess each case individually and follow standard safety protocols during Thermage treatment.
32. Can Thermage Cause Nerve Damage Due to High Temperatures?
According to the official Thermage user manual, treatment in areas containing superficial or facial nerves may be more sensitive and at higher risk of irritation or injury. Practitioners are advised to closely monitor patient heat feedback και consider lowering energy settings when treating such areas.
In comparison, microfocused ultrasound (e.g., Ultherapy) can reach temperatures around 70°C at its focal point, which poses a higher risk of nerve damage—particularly in areas like the mandibular nerve zone, which is considered a no-treatment zone for that reason.
Thermage, on the other hand, uses volumetric heating με ένα gradual temperature buildup, and typically does not reach 70°C. The thermal effect is distributed more evenly across skin layers rather than concentrated at a focal point.
When treating areas such as the γνάθο, patients may experience sharp discomfort due to nerve sensitivity, especially if the mandibular nerve is stimulated by the heat. However, current best practice with Thermage emphasizes adjusting energy settings based on patient feedback, rather than encouraging patients to endure pain.
✅ Σύναψη:
Thermage is unlikely to cause nerve damage when used properly. There have been no clinical reports of nerve injury caused by Thermage to date, and the treatment’s design and protocol prioritize safety through controlled, patient-guided energy delivery.
33. Precautions for Thermage Treatment Around the Eyes
Thermage offers a specialized eye treatment tip, which provides distinct advantages when addressing periorbital concerns. One key safety measure is the use of a protective eye shield, placed beneath the upper eyelid to safeguard the eyeball during treatment inside the orbital rim. This allows for safe and effective RF application within the eye socket area.
Key Design Adaptations for the Eye Area:
- Tip Size:
The eye tip is significantly smaller—only 0.25 cm²—compared to the standard 4.0 cm² tip used for the face. This enables precise treatment in the delicate and narrow eye region. - Treatment Depth:
The energy penetration is shallower, at just 1.1 mm, versus 4.3 mm for facial tips, making it safer for the thin and sensitive skin around the eyes.
When performing Thermage treatment around the eyes, the following precautions must be taken:
① Use of Eye Shields
- Eye shields must be worn during periorbital Thermage to protect the eyeball.
- They are available in small, medium, and large sizes, and should be selected based on the patient’s palpebral fissure (eye opening).
- Eye shields come in plastic and metal materials. ⚠️ Metal eye shields must NOT be used during Thermage, due to the risk of electrical conduction with radiofrequency energy.
How to Properly Insert the Eye Shield
- To ensure comfortable insertion, apply 1–2 drops of topical anesthetic eye drops before placing the shield.
- More importantly, always apply a growth factor-based ophthalmic gel inside the eye before inserting the shield.
❗ This gel is not just for lubrication.
Its primary function is to protect the cornea, which may be accidentally scratched during shield insertion.
Κάνω not assume the gel is only a comfort aid—it is a critical safety measure.
② Starting Energy Level
- For periorbital treatment, the officially recommended starting energy level is 2.0.
- The practitioner should adjust the energy based on patient heat feedback και ο degree of redness or swelling στην περιοχή που υποβλήθηκε σε επεξεργασία.
③ Vibration Mode: Disabled
- Do not use the vibration function during eye-area treatment.
- Vibration may cause the eye shield to shift, increasing the risk of:
- Corneal abrasion
- Ocular injury
④ Post-Treatment Eye Care
- Do not wear contact lenses for at least 24 ώρες after the eye treatment.
- Avoid rubbing the eyes για at least 2 hours post-procedure to prevent corneal trauma.
Summary of Today’s Key Points
Today’s discussion focused on essential safety measures during Thermage eye-area treatments and, most importantly, provided an evidence-based analysis of the electrical conductivity and resistance of different metals—objectively addressing the question of whether patients with facial titanium implants or porcelain-fused metal crowns can safely undergo Thermage.
✅ With proper precautions, both scenarios are manageable, and Thermage remains a safe, effective treatment.
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