Elsevier

Clinics in Dermatology

Volume 26, Issue 6, November–December 2008, Pages 602-607
Clinics in Dermatology

Thermage: the nonablative radiofrequency for rejuvenation

https://doi.org/10.1016/j.clindermatol.2007.09.007Get rights and content

Abstract

Thermage is a noninvasive nonablative device that uses monopolar radiofrequency energy to bulk heat underlying skin while protecting the epidermis to produce skin tightening. It is used for the treatment of rhytids on the face including the periorbital region and lower face, and more recently, for off-face applications. Studies have shown that it can impart mild tightening of periorbital mid, and lower facial laxity. Other radiofrequency devices have also shown objective improvements in cellulite of the buttocks and thigh regions. Thermage is an efficacious and safe nonsurgical alternative for treating mild skin laxity.

Introduction

Photodamage is manifest in a number of ways on the aging face. Fine lines and dynamic rhytids are earlier manifestations that give way, as the process continues, to deeper, more static rhytids especially around the eyes, forehead, glabella, and in the lower jaw around the lower mouth. In more sebaceous areas of the face, enlargement of pores also occur. As the support system wanes, deeper nasolabial folds develop. Laxity of the jowls occurs later and tends to be more severe in individuals endowed with additional subcutaneous facial adipose tissue. Dyschromia, as a result of telangiectasias, erythema and solar lentigines, also reflects photodamage to skin.

The challenge faced by any one photorejuvenation method is to improve the appearance of any or all of the above in a safe manner. Although older ablative methods of photorejuvenation predictably produced improvement in photodamage, the demands of today's cosmetic patient with busy work and social schedules require techniques where downtime and potential for adverse outcomes are limited. Noninvasive procedures with little downtime and favorable side-effect profiles are thus advantageous.

Thermacool TC (Thermage, Hayward, Calif) is a noninvasive nonablative radiofrequency (RF) device that delivers monopolar RF energy in the form of an electrical current that generates heat through the inherent electrical resistance of dermal and subcutaneous tissue. The generated heat produces subtle damage to collagen, and in combination with the following inflammatory cascade induced by heating, a tightening effect is realized. Through this controlled volumetric heating of the dermis, the device is especially efficacious for the treatment of moderate laxity of the lower face. The optimal candidate is a patient most commonly in the mid-thirties to mid-sixties with some sagging of the jowls but lacks the need for a surgical lifting procedure. Other applications where the tightening effect is beneficial is in the treatment of the periorbital and supraorbital/forehead areas where a degree of brow and forehead lifting can be achieved. Buttocks and thighs are newer applications that show varying degrees of efficacy depending on patient baseline characteristics. The device initially received Food and Drug Administration clearance for treatment of periorbital rhytids and subsequently for treatment of rhytids of the lower face. The Food and Drug Administration granted regulatory clearance in January 2006 for the use of the device in off-face noninvasive treatment of wrinkles that allowed for use of the device on nonfacial skin including abdomens, thighs, and buttocks.

Section snippets

Device properties

Volumetric heating is the principle on which the tightening effect of RF treatment is based. Tissue resistance to the flow of electrical current within an electric field causes the generation of heat. The 3-dimensional unit of epidermis and dermis is heated uniformly while contact and air cooling is used to protect the epidermis, producing a subtle degree of damage to collagen fibrils. An immediate tightening effect is observed because of shortening of collagen bundles, and a later effect

Treatment protocol

All patients should have carefully taken preoperative and postoperative photographs. Ideally, standardized photography in the same room with the same lighting and in the same positions should be obtained. Investment in a high-quality standardized photography system is useful for this application so that an appropriate evaluation of improvement can be demonstrated. We have found it useful to have patient photographs taken from the front, from both sides, and at a 3-quarter turn. These

Histologic and ultrastructural changes

Zelickson et al2 histologically evaluated abdominal human skin in 2 patients up to 8 weeks after treatment, using energies from 104 to 181 J. Examination of an immediate post-treatment biopsy revealed only a mild perivascular and perifollicular infiltrate that was not seen on either the 3- or 8-week follow-up biopsy. Electron microscopic evaluation of the post-treatment biopsies at 0, 3, and 8 weeks post-treatment demonstrated increased diameter of collagen fibrils and decreased distinction of

Appropriate candidates

From our studies, as well as those of others, we have found that the device is of negligible benefit to obese patients and patients with extreme skin redundancy. It can be used safely on patients who have had prior cosmetic procedures, including rhytidectomy, laser surgery, fillers (excepting possibly silicone; see below), and botulinum toxin. Recently, safety has been demonstrated with treatments over tissue previously injected with medium-term soft tissue fillers.9 For those patients who have

Periorbital rhytids

An RF device was Food and Drug Administration–cleared in November 2002 for the treatment of periorbital rhytids. Subsequently, the device was cleared for treatment of facial laxity. Fitzpatrick et al6 treated 86 patients with periorbital rhytids and followed them up for 6 months in a blinded, multicenter prospective study. Patients received treatment in the lateral canthal and forehead areas. A single pass was performed using energies ranging from 52 to 220 J, depending on location and skin

Side effects

Most patients experience only temporary and mild erythema and edema after the procedure. One patient developed transient crusting, which rapidly resolved, and another developed a transient depression, which spontaneously resolved in 3 weeks. A variety of other, mostly mild, side effects have also been reported. During early trials with the device, erosions, vesiculation, and subsequent crusting were seen, but this has become much less common with further development of the device (Thermage,

Other applications/future directions

Recent applications where RF has shown promise has been in the treatment of rosacea,22 acne scarring,23, 24 hypertrophic scars, and keloids,25 and studies have demonstrated efficacy and safety in darker skin types.26

Studies are currently under way at many facilities to establish the potential usefulness of the Thermacool TC device to treat laxity of the arms, legs, abdomen, and buttocks. Early anecdotal reports suggest that treatment of the superior half of the buttocks can provide a lift to

Conclusions

Radiofrequency technology provides a viable, noninvasive treatment alternative for mild tissue laxity of the periorbital region, nasolabial folds, jowls, and marionette lines, as well as the possibility of tightening on the abdomen, buttocks, and thighs. In addition, it may improve the appearance of acne scars and improve acne.23, 24

Although RF does not improve laxity to the same degree as surgery, it does have the advantage of avoiding surgery-associated recovery time and potential

References (30)

  • B.A. Bassichis et al.

    Use of a nonablative radiofrequency device to rejuvenate the upper one-third of the face

    Otolaryngol Head Neck Surg.

    (2004)
  • C.F. Wahlgren et al.

    Depth of cutaneous analgesia after application of a eutectic mixture of the local anesthetics lidocaine and prilocaine (EMLA cream)

    J Am Acad Dermatol

    (2000)
  • E.B. Lack et al.

    Relationship of energy settings and impedance in different anatomic areas using a radiofrequency device

    Dermatol Surg

    (2005)
  • B. Zelickson et al.

    Histological and ultrastructural evaluation of the effects of a radiofrequency-based non-ablative dermal remodeling device, a pilot study

    Arch Dermatol

    (2004)
  • W. Nahm et al.

    Objective changes in brow position, superior palpebral crease, peak angle of the eyebrow, and jowl surface area after volumetric radiofrequency treatments to half of the face

    Dermatol Surg

    (2004)
  • T.S. Alster et al.

    Improvement of neck and cheek laxity with a non-ablative radiofrequency device, a lifting experience

    Dermatol Surg

    (2004)
  • J. Ruiz-Esparza et al.

    The medical face lift, a non-invasive, non-surgical approach to tissue tightening in facial skin using non-ablative radiofrequency

    Dermatol Surg

    (2003)
  • R. Fitzpatrick et al.

    Multicenter study of noninvasive radiofrequency for periorbital tissue tightening

    Lasers Surg Med

    (2003)
  • S.P. Arnoczky et al.

    Thermal modification of connective tissues: basic science considerations and clinical implications

    J Am Acad Orthop Surg

    (2000)
  • M. Alam et al.

    Safety of radiofrequency treatment over human skin previously injected with medium-term injectable soft-tissue augmentation materials: a controlled pilot trial

    Lasers Surg Med

    (2006)
  • W.K. Nahm et al.

    Objective changes in brow position, superior palpebral crease, peak angle of the eyebrow, and jowl surface area after volumetric radiofrequency treatments to half of the face

    Dermatol Surg

    (2004)
  • L.G. Jacobson et al.

    Treatment of nasolabial folds and jowls with a noninvasive radiofrequency device

    Arch Dermatol

    (2003)
  • D.J. Narins et al.

    Non-surgical radiofrequency facelift

    J Drugs Dermatol

    (2003)
  • T.S. Hsu et al.

    The use of nonablative radiofrequency technology to tighten the lower face and neck

    Semin Cutan Med Surg

    (2003)
  • M. Fritz et al.

    Radiofrequency treatment for middle and lower face laxity

    Arch Facial Plast Surg

    (2004)
  • Cited by (64)

    View all citing articles on Scopus
    View full text