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Microwaving skin sag off your face


It is a widely known fact of cosmetic life that effective methods of reversing facial sag are hard to come by. While sagging can be prevented or at least slowed down with proper care (such as topical DMAE, collagen synthesis activators, etc), once significant sag has occurred, the only consistently and markedly effective way to reverse it is a facelift. The problem is that facelift is costly, requires 2-4 weeks of downtime, and carries all the typical risks of surgery. In that context, it is not surprising that a new noninvasive method of skin tightening using a nonablative (nonstripping) radiofrequency device is generating both legitimate interest and excessive hype.

How it works

The method is based on the ability of radiowaves of certain frequency to penetrate and be absorbed by body tissues. The absorption of radiowaves causes tissue heating as well as some structural molecular changes. (An essentially similar effect is used in microwave ovens where high-frequency radiowaves heat and cook food.)

The skin is deep-treated with controlled doses of targeted radiowaves, while its surface layer (epidermis and upper dermis), is being cooled by a cryogenic spray to prevent open burns. The treatment produces localized heat injury of the dermis and subdermal layer as well as the collagen contraction leading to skin tightening. The subsequent healing of the microscopic dermal and subdermal lesions causes further skin tightening and also reduces the depth of wrinkles. Notably, since the skin surface is preserved, the downtime after the procedure is relatively short.

In theory, this approach makes good sense. First, most of the ideas behind it have been in practical use for years. Such well-established rejuvenation methods as laser skin resurfacing, dermabrasion and deep chemical peels, are partially based on skin remodeling following a controlled injury. Second, radiofrequency tissue tightening is being used with reasonable success in other areas of medicine. For instance, endoscopic radiofrequency devices are employed to tighten sphincters in the GI tract.


The first practical implemetation of radiofrequency skin tightening is a procedure called Thermage. It is performed with a patented radiofrequency device, ThermaCool, recently approved by the FDA. However, FDA approves medical devices based largely on safety (rather than both safety and effectiveness as for drugs). Therefore, we should not view the FDA approval of Thermage / ThermaCool as a guarantee that it does what it is purported to.

Unfortunately, relatively few clinical studies of Thermage have been performed so far. Most of them were sponsored by the manufacturer, which is not uncommon but does increase the potential for biased results. The studies were small or medium size and had only short-term follow-up. In one study, Drs Alster and Tanzi from Washington Institute of Dermatologic Laser Surgery at Georgetown University Medical Center treated 50 subjects with Thermage to improve cheek and neck laxity. The authors reported short-term effectiveness and relatively mild side effects:

"Significant improvement in cheek and neck skin laxity was observed in the majority of patients. Patient satisfaction scores paralleled the clinical improvements observed. Side effects were mild and limited to transient erythema (redness), edema (swelling), and rare dysesthesia (alteration of sensation). No scarring or pigmentary alteration was seen. ...
Although tightening continued to be evident 6 months after a single treatment, the longevity of clinical results has yet to be determined."

In a multicenter study, Dr Fitzpatrick et al investigated the effects of a single Thermage treatment in 86 subjects over the six months period. The results were analyzed using potentially inaccurate methods: photograph scoring and self-reports of the subjects. Fifty percent of the subjects reported being satisfied or very satisfied with wrinkle reduction in eye area. Photographic analysis showed that 61.5% of eyebrows were lifted by at least 0.5 mm. Typical side effects were redness and swelling, occurring in the minority of subjects; very rarely second degree burns (blisters) occurred. Three patients (4% of the subjects) had small areas of residual scarring at 6 months.

Based on these and other studies, it appears that only about 50-60% people experience clearly noticeable improvement with Thermage (at least with a single treatment). Even in responders the lifting effect is relatively modest: for example, brows are usually lifted by about 0.5-2 mm. This translates into a fresher, brighter look rather than dramatically younger appearance. However, since the healing response varies widely among people, there seems to be a minority, perhaps 10%, who experience substantial lifting and may look 10 years younger. On the other hand, up to a half of the people get no benefits at all.

Pros and cons

So, is Thermage worth having done? While there is no universal answer, here is a number of considerations to keep in mind.

Thermage is a midrange procedure -- between topical treatments on one end, and a facelift and ablative resurfacing on the other. Thermage reduces sag far less dramatically than a facelift and softens wrinkles less noticably than ablative laser. However, Thermage's risks, recovery time and side effect profile are significantly better.

Thermage costs about $1000-1500 for a single treatment and around $2000-$2,5000 for a set of two treatment, usually spaced 3-6 months apart. This is close to the cost of common laser treatments but about 5-10 times cheaper than a facelift.

Considering its relatively modest tightening effect, Thermage seems to best fit the people in their late thirties and forties who are only beginning to show facial sag.

Since Thermage is relatively new, many practitioners have limited experience. The lack of experience increases the risk of under- and overtreatment, leading to smaller improvements and greater side effects than reported in the clinical studies. If opting for Thermage, look for a practitioner who has been performing it on a daily or at least weekly basis for a minimum of 2 years, and has performed at least several dozen procedures.

The notion that Thermage requires no downtime is an exaggeration. While most people require a rather short downtime (from one to three days), some develop significant redness, swelling or even blisters and may need to stay out of public eye for a week or more. Also, the procedure itself may be rather painful. Some residual pain may linger for several days.

Many uncertainties remain. Do repeated Thermage treatments increase the positive and/or negative effects? Do benefits persist over the long term? Can radiofrequency injury, while tightening skin in the short term, reduce the skin's long-term viability and lead to faster aging down the road? How many people suffer long-term negative effects, such as worsening of skin texture, loss of subcutaneous fat, dryness, discoloration, or scarring? More studies are needed to address these questions. If history is any indicator, it will take another ten years or more before we know all that we need to know about this method.

In the meantime, the decisions to have Thermage will be based on limited knowledge, educated guesses and personal preferences. Search this site for user reviews of Thermage. You will find both positive and negative opinions. Keep in mind that user reviews are useful only as an adjunct to rigorous research and should never be the cornerstone of your decision to undergo a potentially harmful procedure.

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