Today, we will introduce how Thermage and other radiofrequency (RF) devices achieve controlled thermal injury, and how Thermage produces excellent results without excessive damage to skin tissue (Thermage’s effective operating temperature).
45. How does Thermage achieve safe and effective results through controlled thermal injury?
Thermage is a monopolar RF system and was the first RF device used in aesthetic medicine. It works by creating controlled thermal injury—thermal denaturation without coagulation or necrosis—stimulating fibroblasts to regenerate and remodel collagen, elastin, and other extracellular matrix components, thus achieving non-invasive skin tightening and anti-aging effects.
The emphasis on controlled thermal injury highlights a critical and delicate balance in Thermage application.
- Too little heat may fail to induce a sufficient heat-shock response for meaningful collagen remodeling.
- Too much heat can cause excessive, irreversible tissue damage and scarring.
This balance makes precise device parameters and skilled clinical operation crucial for optimizing heat-shock protein (HSP)-mediated regeneration. The goal is to apply just enough thermal stress to trigger a strong heat-shock response and fibroblast activation—maximizing beneficial remodeling—without exceeding the cells’ recovery capacity.
Achieving this requires:
- Sophisticated device design (e.g., precise temperature monitoring, epidermal cooling, Comfort Pulse Technology).
- Professional expertise in setting the correct energy and treatment parameters.
The Science Behind Thermage: How Heat Shock Proteins Protect Your Skin
Heat shock proteins (HSPs) are the body’s natural defense system against heat damage. They act like little “bodyguards” inside our cells, protecting them when exposed to stress. In Thermage treatments, these proteins play a key role in ensuring that heat creates controlled, beneficial effects rather than harmful ones.
But here’s the catch: when the skin is overheated, HSPs lose their protective function. Instead of stimulating rejuvenation, excessive heat can damage cells, cause burns, and even lead to fat loss under the skin.
So how does Thermage manage to strike the perfect balance?
From High Heat to Controlled Heat
When Thermage first launched as the world’s first monopolar RF device, the original treatment method used high energy in a single pass. This raised skin temperatures to 65°C or above. While effective at tightening collagen, it also caused unwanted side effects—burns, scarring, and fat atrophy.
Clinicians quickly raised concerns, and the manufacturer, Solta Medical, listened. In 2007, they brought together experts to refine the technique.
The Breakthrough: Super Pass Technique
The solution was simple yet game-changing: switch from high energy, one-time passes ke medium-to-low energy with multiple passes (known today as the super pass method).
Instead of shocking the skin with extreme heat, this technique allows the temperature to build gradually, stabilizing around 50–60°C—the sweet spot where collagen contracts and regenerates, but without overwhelming the skin’s defenses.
Proven Safe and Effective
To back up this new method, Solta conducted a large, multicenter clinical study involving over 5,700 patients. The results confirmed what practitioners were seeing: safer treatments, fewer complications, and impressive skin-tightening results.
Clinical Evidence: Why the Super Pass Method Changed Thermage Forever
Back in 2007, Solta Medical organized a large multicenter study with 5,700 Thermage patients. The goal was to compare the traditional high-energy single-pass method with the new low-energy, multi-pass technique. The results were eye-opening:
| Observation | Traditional Method | Super Pass Method |
|---|---|---|
| Immediate skin tightening | 26% | 87% |
| Skin tightening after 6 months | 54% | 92% |
| Pain intolerable | 45% | 5% |
| Results met patient expectations | 68% | 94% |
What the Numbers Mean
- Immediate satisfaction skyrocketed: nearly 9 out of 10 patients saw visible tightening right after treatment with the super pass method, compared to only 1 in 4 with the old method.
- Long-term results were stronger: after 6 months, over 90% reported tighter, firmer skin with the new technique.
- Pain levels dropped dramatically: only 5% found treatment intolerable with the super pass method, versus 45% under the traditional approach.
- Patient satisfaction soared: almost all patients (94%) felt results matched their expectations.
Validated by Experience: Safer—and Even More Effective
The results were compelling: burns, necrosis, and lipo-atrophy essentially disappeared, while skin-tightening outcomes actually surpassed those achieved with the old high-energy, single-pass approach.
In 2007, this refined protocol—medium-to-low energy with multiple passes (the “super pass” technique)—was published as an expert consensus and has remained the global standard ever since. Unlike other energy-based anti-aging modalities (e.g., focused ultrasound and lasers) that continue to experiment with technique variations, Thermage practitioners worldwide have largely converged on the super pass method and kept validating it in daily practice.
Bottom line: Meticulous training and standardized operation using the super pass protocol are the keys to achieving controlled thermal injury—and delivering safe, predictable, and impressive tightening results.
How the “Super Pass” Multi-Pass Coverage Works
To achieve both safety and effectiveness, Thermage practitioners use the Super Pass technique. This involves layering energy in a controlled way, rather than relying on a single, high-energy pass.
Key Principles of the Super Pass Method
- Alternating coverage: First complete a row of squares, then a row of circles (alternating patterns ensure even energy distribution).
- Pulse spacing: Before applying the next pulse on the same spot, wait at least the time of five pulses (or move across five treatment spots) to prevent overheating.
- Temperature sensing: Use your hand to check skin temperature. If an area feels warmer, move to another zone before returning, allowing time for the skin to cool.
Treatment Pattern
- Work in rows of squares and circles
- Move from inside to outside
- Progress from top to bottom
This systematic approach ensures the skin warms gradually and evenly, keeping tissue in the optimal range (50–60°C) for collagen tightening without risking burns or fat loss.
46. Optimal Thermage Temperature and Its Effect on Fibroblasts
Research has shown that the way fibroblasts (the skin’s collagen-producing cells) respond to treatment is closely linked to the temperature reached during radiofrequency heating.
When RF energy generates heat in the skin, it stimulates fibroblasts to produce heat shock proteins (HSPs). This triggers the expression of TGF-β1, which then induces HSP-47 Dan HSP-70, ultimately encouraging fibroblasts to produce more kolagen.
This mechanism—stimulating fibroblasts to synthesize more collagen, elastin, and extracellular matrix—is the foundation of nearly all anti-aging therapies, including those based on retinoic acid and other active ingredients. Radiofrequency devices achieve this effect by delivering controlled heat into the deeper skin layers, tightening existing collagen and promoting regeneration.
Temperature Ranges in RF Aesthetics
- Low range (40–45°C): Gentle heating, usually limited to the skin surface. Improves blood circulation, enhances absorption of skincare products, and can trigger mild cellular activity. Most home-use RF devices operate in this range.
- Medium range (45–60°C): The “sweet spot” for non-invasive professional RF treatments. This is where fibroblast activation and collagen stimulation are most effective, making it the target zone for Thermage and other clinical devices.
- High range (60–75°C): If Thermage is operated improperly (e.g., excessive stacking of pulses), local tissue temperature can exceed 60°C. While higher temperatures may intensify collagen contraction, they also carry a much greater risk of burns, fat atrophy, and scarring.
- Fractional RF microneedling (58–85°C): Devices like golden microneedling RF operate at even higher temperatures, intentionally creating controlled coagulative necrosis within the dermis. This more aggressive approach stimulates stronger collagen remodeling but requires downtime.
Effects of Different Temperatures on Fibroblasts
Fibroblasts in the skin are key cells responsible for producing collagen, elastin, and extracellular matrix (ECM), playing a central role in maintaining skin structural integrity, elasticity, and repair. RF-based cosmetic treatments, such as Thermage, stimulate fibroblasts through heat, inducing the production of new collagen.
Mild Heating (40–45°C):
- Effect on cells: At this temperature, fibroblasts experience mild heat stress, which can induce the expression of heat shock proteins (HSPs), particularly HSP70. This supports cellular self-protection and proper protein folding.
- Outcome: Studies suggest that mild heat stimulation at 40–42°C can promote collagen synthesis through upregulation of HSP47, improving wrinkles and skin laxity. However, the lower the temperature, the weaker the fibroblast activation and the fewer new collagen fibers are produced. At this range, collagen fibers do not undergo “thermal contraction,” so immediate tightening effects are limited.
Moderate Heating (50–60°C):
- Effect on cells: This is the optimal or advantageous temperature range for stimulating fibroblast activity and new collagen production. Fibroblasts are sufficiently stimulated without suffering severe irreversible damage.
- Collagen denaturation and remodeling: Temperatures of 50–60°C can cause mild denaturation and contraction of existing collagen fibers, producing some immediate tightening effects. Importantly, this mild denaturation acts as a damage signal, strongly activating fibroblast proliferation and migration.
- Fibroblast proliferation and activation: In this range, fibroblast proliferation and ECM synthesis (collagen, elastin, etc.) are effectively stimulated.
High Heating (>60°C, e.g., 65–75°C):
- Effect on cells: At these temperatures, collagen fibers undergo more dramatic immediate contraction, leading to pronounced immediate tightening.
- Risks and precautions: While the immediate effects are stronger, higher temperatures carry an increased risk of thermal injury, which may cause excessive fibroblast damage or even cell death, impairing subsequent collagen production. Therefore, high-temperature RF treatments require precise temperature control and robust epidermal cooling to protect the skin and superficial tissues from burns.
Advantages of the 50–60°C Temperature Range:
Research indicates that maintaining dermal temperatures precisely within 50–60°C offers significant advantages in RF cosmetic treatments:
- Optimal balance between collagen stimulation and tissue damage:
- Effective activation: 50–60°C provides sufficient heat stress to activate fibroblast proliferation and the synthesis of collagen (especially type I and III).
- Avoidance of over-damage: Within this range, cells avoid irreversible severe damage, ensuring fibroblast survival and long-term functionality. Higher temperatures may cause fibroblast death, limiting new collagen formation.
- Ideal collagen remodeling: 50–60°C is considered the ideal range for collagen remodeling, inducing collagen contraction while stimulating subsequent new collagen synthesis, all while minimizing thermal injury risk.
- Effective induction of heat shock proteins: As mentioned, this temperature range effectively stimulates the expression of HSP47 and HSP70. HSP47 is crucial for the proper folding of newly synthesized collagen, while HSP70 protects fibroblasts from stress-induced damage, ensuring they can continue functioning efficiently over time.
- Higher safety and comfort: Compared with higher temperatures (e.g., 65–75°C), 50–60°C causes less epidermal heating. When combined with Thermage’s epidermal cooling technology, the risk of burns is minimal. For patients, this temperature range is generally better tolerated, resulting in greater comfort and improved treatment compliance.
- Support for long-term effects: The goal of RF treatments is to stimulate sustained collagen production and remodeling. Temperatures of 50–60°C effectively initiate long-term fibroblast activation and collagen synthesis pathways, rather than relying solely on immediate collagen contraction. The proper activation of these biological processes is key to achieving lasting skin tightening effects.
- In summary, maintaining dermal temperatures within the 50–60°C range is considered ideal in RF aesthetic treatments for promoting collagen remodeling and fibroblast activation. It strikes a crucial balance between efficacy and safety.
Comparison of the Effects of Different RF Temperature Ranges on Skin Fibroblasts and Tissue
| Dermal Temperature / RF Technology | 50°C | 50–60°C | >60 ° C. |
|---|---|---|---|
| RF Device Types | Monopolar RF circuits | Various RF devices with moderate energy accumulation | Various RF devices with high energy stacking |
| Research Model / Subjects | In vitro fibroblasts | Ex vivo skin / human dermis / porcine models | In vitro cells / ex vivo skin / human dermis / porcine models |
| Key Biological Effects / Histological Changes | Fibroblast activation; type I collagen synthesis without cellular damage | Fibroblast activation and proliferation; increased collagen density and dermal thickness; HSP70 positive; no necrotic damage | Cell damage in vitro; increased risk of fibroblast necrosis and tissue damage; initial cell injury and coagulative necrosis in ex vivo skin |
| Clinical Outcomes | Limited stimulation of new collagen; minimal immediate tightening | Improved skin tightening, elasticity, and wrinkle reduction; effective collagen remodeling | Potential severe complications such as burns, fat atrophy, and scarring |
Efficacy and Tissue Damage of Anti-Aging Devices: Effects of Treatment Temperature
| Perangkat | Suhu | Type of Tissue Damage | Mode of Action |
|---|---|---|---|
| terapi panas | 50–60°C | Denaturation | Volumetric heating with reverse thermal gradient |
| Ultherapy (US version) | 65–70°C | Coagulative necrosis | Fractional point-mode delivery |
| Ulthera handpiece | ~65°C | Coagulative necrosis | Fractional point-mode delivery |
| Golden Microneedling | 60–65°C | Coagulative necrosis | Fractional point-mode delivery |
47. Factors Affecting the Treatment Temperature of High-Temperature Anti-Aging Devices
Several factors influence the actual tissue temperature achieved during high-temperature anti-aging treatments:
- Device type and working principle – e.g., monopolar, bipolar RF, or fractional RF.
- Tingkat energi – high, medium, or low.
- Operational technique – for example, the Thermage “super pass” technique.
- Pulse parameters – including total pulse width, number of sub-pulses, and pulse duration.
Example: Thermage (representative of 50–60°C)
As mentioned above, earlier high-energy single-pass methods produced strong immediate collagen contraction and triggered collagen regeneration through wound-healing responses. However, these techniques generated temperatures ≥65°C in tissue, which led to significant burns, fat atrophy, and even scarring in clinical practice. Early literature and reviews often cited 65°C as Thermage’s “optimal denaturation temperature,” but clinical experience did not fully support this theoretical value.
In fact, with the current globally adopted approach of medium-to-low energy with multiple passes, the actual tissue temperature produced by Thermage has been reduced to 50–60°C. The advantages of this temperature range have been discussed in detail above.
Example: Golden Microneedling (representative of 60–65°C)
The technical term for Golden Microneedling is “fractional RF microneedling,” which comes in insulated Dan non-insulated needle types. Because non-insulated needles produce milder effects, the mainstream devices today are insulated microneedles.
Fractional RF microneedling follows a “fractional pattern” principle: each thermal injury point creates significant local damage, so adequate surrounding healthy skin must remain to repair the treated area. Different brands of Golden Microneedling devices achieve different peak temperatures at the thermal injury points, depending on device frequency, power, energy, and pulse width (i.e., RF application time).
Although the treatment temperature is the key factor determining both efficacy and risk of adverse effects, most brands do not disclose these data. In clinical practice, the majority of Golden Microneedling devices operate around 60–65°C. For example, the pioneering US ProFound device initially proposed an optimal temperature of 67°C, but this level of tissue injury was excessive and the device was not globally promoted.
For Golden Microneedling, the thermal injury zones actually represent nekrosis koagulatif. To avoid excessive tissue damage, fibroblast death, or tissue necrosis, it is critical to use appropriate energy levels and shorter pulse durations. Practitioners should prioritize safety over maximal efficacy, rather than blindly pursuing stronger effects.
Summary: Effects of Treatment Temperature in High-Temperature Anti-Aging Devices
- Temperature Determines Tissue Damage:
For high-temperature anti-aging devices, the treatment temperature directly affects the degree of skin tissue damage. While higher temperatures theoretically stimulate more collagen regeneration through the “damage–repair” mechanism, excessive heat can lead to fibroblast death or apoptosis and render heat shock proteins ineffective in protecting against thermal injury. - Evolution of Thermage Operation Techniques:
At its launch, Thermage was applied using a high-energy, single-pass method, generating very high tissue temperatures that caused severe adverse effects such as burns, fat atrophy, and scarring. In 2007, after multicenter clinical verification involving 5,700 cases, the standardized medium-to-low energy, multiple-pass coverage technique was adopted. This method allows controlled thermal injury, is effective, safe, and minimizes damage to skin tissue. - Optimal Temperature Range (50–60°C):
Using the standardized medium-to-low energy, multiple-pass approach, Thermage produces dermal temperatures of approximately 50–60°C. This temperature range is considered ideal for RF aesthetic treatments, as it:- Induces collagen contraction and stimulates new collagen synthesis.
- Activates fibroblasts without causing cell death.
- Avoids coagulative necrosis and excessive tissue damage.
- Risks of Temperatures Above 60°C:
Temperatures exceeding 60°C, particularly ≥65°C, greatly increase the risk of tissue injury, causing fibroblast death and coagulative necrosis. This may result in burns, subcutaneous scarring, and skin hardening. - Principles for Non-Invasive Anti-Aging Treatments:
Non-invasive anti-aging procedures are maintenance and enhancement treatments, rather than aggressive therapeutic interventions. Their goal is to achieve optimal aesthetic results with minimal or no adverse effects. Excessive temperature risks defeating this purpose.
Kesimpulan:
The current Thermage standardized method—medium-to-low energy with multiple passes—achieves an ideal dermal temperature of 50–60°C, producing controlled thermal effects such as collagen denaturation and contraction without causing tissue coagulation or cell death. Medical aesthetics practitioners should understand the device’s mechanism and temperature effects and operate according to standardized protocols. Safety and effective results are the expectations of patients, and they are the professional responsibility of the clinician.
