34. Origin and Reliability of the Standardized Thermage Operation Protocol
Thermage was approved by the U.S. FDA in 2003. However, its initial treatment protocol followed a “high energy, single-pass” approach, which unfortunately led to a significant number of adverse effects such as burns and unintended fat loss.
In response to these complications, Solta Medical, in collaboration with clinical experts, revised the treatment method. A new protocol was developed and validated through a large-scale clinical observation involving multiple hospitals. This research culminated in an expert consensus published in 2007, which officially established the current “medium-to-low energy, multiple-pass” technique, also referred to as the “Super Pass” method in today’s standardized training programs.
There are two key points to understand:
① Reliability through large sample size:
To ensure the reliability of the new protocol, the clinical study observed 5,700 aesthetic patients across multiple hospitals. This significantly reduces the margin of error that often plagues smaller-scale studies. By contrast, many beauty institutions today rely on protocols based on “test runs” involving only 10 cases or so, which leaves a large margin for error. Similarly, some doctors claim to use “new techniques” based on personal experience, but such methods often lack rigorous scientific summary or theoretical backing.
② Lack of further published innovation due to maturity of the protocol:
Since the 2007 consensus, Thermage has been widely used across the globe. Yet no new scientific paper has been published proposing a different operational protocol. A doctor from Taiwan once explored a lower-energy protocol a few years ago, but their article appeared in a commercial magazine rather than a peer-reviewed medical journal, and it was not indexed in any recognized medical databases. Therefore, it was viewed as a speculative exploration rather than an academically validated method, and it gained no substantial recognition among dermatologists worldwide.
Why has no one developed a new standardized Thermage technique since 2007?
Simply put, the “medium-to-low energy, multiple-pass” method is already well-established and effective. It reliably delivers anti-aging results while minimizing adverse effects such as burns or fat atrophy. Globally, there may be variations in pain management strategies, but when it comes to the core operational technique, doctors across the world continue to follow the same standardized approach—the one validated and finalized in 2007.
35. Does Thermage Carry a Risk of Fat Atrophy (Fat Melting)?
The short answer is: Yes, theoretically Thermage can cause fat atrophy, although the risk is greatly reduced with standardized protocols.
When Thermage was first launched, it employed a high-energy, single-pass technique. This led to a significant number of cases involving fat atrophy—a clear indication that, from a technical and mechanistic perspective, Thermage has the potential to affect subcutaneous fat.
However, in 2007, a new standardized protocol was introduced:
Medium-to-low energy, multiple-pass coverage, also known as the “Super Pass” method.
Under this approach, the risk of fat atrophy has dropped substantially. In fact, there have been no internationally published clinical reports of fat atrophy caused by Thermage since this new method was implemented. Still, from a theoretical standpoint, the possibility remains.
Evidence from Thermal Imaging:
Thermal imaging of Thermage treatment reveals that the fat layer exhibits the highest temperatures (represented in orange), often in a grid-like or branching pattern. This suggests that:
- The hottest zones are within the fibrous septa (connective tissue partitions) inside the fat layer.
- While these fibrous structures are the main targets, adjacent fat lobules are inevitably exposed to elevated temperatures, especially those close to the fibrous walls.
Why Fat Atrophy Might Still Occur:
- Thermage can penetrate deep enough to reach the fat layer.
- The system uses a “reverse thermal gradient”—meaning deeper tissues reach higher temperatures, with the fat layer being the hottest.
- Though fat tissue has high impedance, RF energy still flows through the fibrous septa within the fat, and a small amount may enter fat lobules.
- Even minimal current in fat can lead to damage if surrounding fibrous tissues reach high temperatures—especially at higher energy levels. This may lead to localized fat atrophy near these fibrous zones.
How to Prevent Thermage-Related Fat Loss:
✅ Avoid using high energy settings.
Even if the epidermis is protected from burns, excessively high energy increases the risk of fat melting.
✅ Strictly follow standardized treatment protocols.
Do not re-treat the same area without at least five pulses of spacing in between.
✅ Be cautious in areas with thin fat layers or volume loss.
Używać lower energy settings in such zones to minimize risk.
Thermage’s Volumetric Heating and Depth of Action
(Refers to the illustration showing Thermage’s volumetric heating pattern, where the RF energy disperses into deeper layers including dermis and subcutaneous fat, with peak heat concentrations at fibrous septa.)
36. Can Thermage Treat Cellulite?
In Chiny, Thermage is not officially indicated for the treatment of cellulit.
However, according to the U.S. FDA, cellulite is an approved indication for Thermage—with specific conditions.
FDA-Approved Indications (U.S.)
Z vibration mode activated, Thermage is approved in the U.S. for the temporary improvement of:
- The appearance of cellulit
- Mild muscle soreness relief
- Muscle spasm relief
- Localized blood circulation enhancement
The simultaneous application of radiofrequency energy and skinvibration by the Thermage FLX System are indicated for use in:Dermatologic and general surgical procedures forelectrocoagulation and hemostasis;
Non-invasive treatment of periorbital wrinkles and rhytids;Non-invasive treatment of wrinkles and rhytids,Temporary improvement in the appearance ofcellulite,;Relief of minor muscle aches and pains,Relief of muscle spasms,
Temporary improvement of local circulation (i.e., bloodcirculation)
Skuteczność kliniczna
Cellulite is notoriously difficult to treat. That’s why the FDA only approved Thermage for temporary improvement of cellulite—not permanent reduction. This distinction is important.
While practitioners in China may experiment with Thermage for cellulite, the results are usually modest, I not as effective as treatments specifically designed to target fat lobules and fibrous septa (e.g., acoustic wave therapy, subcision, or specialized cellulite devices).
37. Why Is Thermage FLX Called the 5th Generation in China but the 4th Generation Internationally?
Thermage has undergone several major upgrades since its initial launch, and naming conventions vary between countries.
International Version (Outside China)
According to the international classification:
- 1. pokolenie – Original Thermage
- 2. pokolenie – Thermage NXT
- 3rd Generation – Thermage CPT (launched in 2009)
- Introduced Comfort Pulse Technology
- 4th Generation – Thermage FLX (launched in 2017)
- Added AccuREP™ auto-tuning impedance technology
- Introduced a larger 4.0 cm² treatment tip
- Offered faster and more precise treatment
The 2013 update to Thermage CPT, which included a gold treatment tip, was considered a minor upgrade and not counted as a new generation.
Chinese Version (Mainland China)
In Chiny, the classification is slightly different:
- 1st to 3rd Generations – Same as international
- 4th Generation – 2013 CPT with the gold treatment tip
- 5th Generation – Thermage FLX (2017)
In other words, China counts the 2013 CPT update as a full generation, making Thermage FLX the 5th generation locally.
Why This Matters
The generation label isn’t as important as understanding the technological upgrades. Thermage FLX offers significant improvements over previous versions, including:
- Real-time energy adjustment (AccuREP™)
- Faster treatment speed
- Enhanced comfort
- Improved efficacy
So regardless of whether it’s called the 4th or 5th generation, Thermage FLX is a major leap forward in RF skin tightening technology.
38. For clients with high pain tolerance, can higher energy levels be used to enhance the efficacy?
Pain tolerance varies greatly among individuals—some people are highly sensitive to pain, while others can endure it well. However, it’s important to understand that pain in treatments like Thermage comes primarily from heat. In areas with superficial nerves, even moderate heat can cause discomfort.
For Thermage, which is a high-temperature procedure, high pain tolerance does not mean you can arbitrarily increase the energy level. Higher energy levels generate more heat in the tissue, which significantly increases the risk of burns and unwanted fat melting.
Therefore, even for those with high pain tolerance, energy levels should not be excessively high (typically not exceeding level 5). Likewise, for clients with low pain tolerance, energy levels should not be too low at the expense of treatment efficacy.
When using relatively high energy levels, it’s crucial to closely observe the skin’s reaction. Normally, mild redness and swelling are expected. However, if the skin turns deep red or becomes severely swollen, it indicates the energy level is too high and should be reduced accordingly.
39. The Importance of the Transfer Grid
Thermage’s official guidelines repeatedly emphasize the importance of using the transfer grid during standardized treatment procedures.
In clinical practice, many practitioners in China, after gaining experience, begin to feel that applying the grid is not strictly necessary and that good results can still be achieved without it. While occasionally skipping the grid may not cause major issues on an individual basis, this approach should never be generalized or promoted.
The transfer grid plays a critical role in standardized Thermage treatments.
Thermage’s standardized method is known as the Super Pass technique, which involves treating one row of grid squares (in a stamping pattern), followed by targeting the intersections of the next row of squares.
This structured approach ensures uniform coverage, consistent energy delivery, and maximized treatment efficacy while minimizing risks such as overlaps, missed areas, or burns.
The advantage of this technique is that it avoids being too aggressive—such as treating the same row of grid squares twice—which would increase the risk of adverse reactions. At the same time, it also avoids being too conservative—like completing all the grid squares on half of the face before treating the intersections—which could compromise the treatment’s effectiveness.
Facial Grid Patterning (Super Pass Method)
- Draw a grid pattern
- One row of circular shots at a time
- From inside to outside
- From top to bottom
If you don’t print the treatment grid, can you really remember the exact position of each square and the intersection points?
If you accidentally overlap too many shots in one area, burns can occur very easily.
By transferring the treatment grid onto the skin and following the standardized Super Pass technique, practitioners around the world are able to ensure both safety and efficacy.
Doctors in China are advised not to try to be clever or improvise.
Below comes from training materials used in Taiwan.
Staggered Treatment Method
First, treat one square grid, then treat one circle grid.
Each pulse overlaps 25–50% of the previous treatment area, allowing for faster energy accumulation.
This results in quicker treatment speed and improved effectiveness.
40. In what situations should gentle energy levels and techniques be used?
Different individuals have varying skin conditions, so it is essential to consider and evaluate each patient’s specific skin status before any aesthetic procedure.
For Thermage treatments, the following factors need to be assessed:
- Epidermal hydration level (degree of skin dryness)
- Presence of obvious inflammation (including chronic inflammation)
- Presence of diffuse erythema (redness)
When the skin is dry:
We know that Thermage radiofrequency (RF) current mainly relies on the impedance of the tissue it passes through. The higher the impedance, the higher the temperature generated. Lower conductivity means the current has more difficulty penetrating into deeper skin layers.
There is a significant difference in impedance and conductivity between dry skin and well-hydrated skin.
electrical conductivity of human tissues at room temperature under 1 MHz current:
| Tissue Type | Conductivity (siemens/m) |
|---|---|
| Bone | 0.02 |
| Fat | 0.03 |
| Sucha skóra | 0.03 |
| Nerve | 0.13 |
| Cartilage | 0.23 |
| Moist Skin | 0.22 |
| Mięsień | 0.50 |
| Thyroid | 0.60 |
When the skin is dry (mainly the epidermis), the radiofrequency (RF) current conductivity is very low, causing the RF energy emitted from the treatment tip to concentrate mostly in the epidermis and superficial dermis.
At this time, high temperatures can easily cause burns or excessive skin reactions, and the treatment will also be more painful.
Therefore, if during the consultation phase the patient’s skin is assessed as very dry (for example, during winter in northern regions), it is advisable to apply a medical-grade facial mask (with device registration) for 10–15 minutes before treatment. This can quickly increase the epidermal hydration level (through an occlusive effect).
If this step is skipped, energy levels need to be lowered and treatment techniques adjusted to reduce pain and avoid burns.
When the skin has diffuse erythema:
Diffuse erythema without inflammation is less concerning—for example, redness caused by photodamage.
However, for conditions like rosacea, which involve obvious inflammation with diffuse erythema, extra caution is required during Thermage treatment.
The international Thermage consensus specifically emphasizes that treatment should not be performed on visibly red and swollen skin.
Rosacea with inflammation and barrier damage has a significantly reduced heat tolerance, making gentle treatment appropriate. Otherwise, the risk of burns is very high.
Treatment strategies for sensitive or intolerant patients:
- Lower the energy level
- Perform two consecutive rows of grid treatment before treating the crossing points
- Avoid treating patients in the acute exacerbation phase of rosacea
- Continuously observe skin reactions; if reactions are severe, promptly cool the skin with blowing cold air or similar methods
- Pre-treatment facial mask application to rapidly increase epidermal hydration
- Continuously apply coupling gel during treatment to ensure a thick layer remains on the skin surface (very important)
Finally, I want to say that Thermage is considered a relatively simple aesthetic procedure, but “relatively simple” does not mean risk-free.
We need to understand its working principles and the risks of burns and fat dissolution.
Knowing how to prevent complications and especially the importance of standardized operation is essential.
More questions about Thermage will continue—stay tuned!
