# Chapter 3.2 Thermage: Mechanism, Indications, Protocols --- ## 1. Mechanism of Thermage ### **Principle** - Thermage is a **monopolar radiofrequency (RF) device**. - Current flows from an active tip on the skin → through dermis/subcutis → to a grounding pad. - This configuration allows **deep, uniform tissue heating** (up to ~4–6 mm). ### **Physics** - RF energy generates **Joule heating** in tissue. - Dermal temperatures reach ~55–65 °C → collagen denaturation & fibril contraction. - Simultaneous **cryogen spray cooling** protects epidermis (keeps surface ≤ 40 °C). ### **Biological Response** 1. **Immediate**: - Collagen fibrils shrink ~1/3 of original length. - Dermis contracts → subtle tightening effect. 2. **Delayed**: - Heat Shock Protein (HSP) induction (HSP47, HSP70). - Fibroblast proliferation, neocollagenesis, elastogenesis, angiogenesis. - Peak effect 3–6 months after treatment. 3. **Long-term**: - Remodeling continues for up to 12–18 months. --- ## 2. Indications of Thermage ### **Facial** - Mild-to-moderate skin laxity (jawline, nasolabial folds, marionette lines). - Eyelid skin tightening (Thermage Eyes tip, FDA-approved). - Non-surgical brow lift. - Periorbital wrinkles, crow’s feet. ### **Neck** - Submental laxity, platysmal band softening. - Early “turkey neck” appearance. ### **Body** - Abdomen (postpartum skin laxity). - Upper arms (bat wings). - Thighs, buttocks (skin texture & cellulite improvement). - Knees (lax, crepey skin). --- ## 3. Patient Selection - Best suited for **ages 30–55** with mild-to-moderate laxity. - Works well in patients with **thin-to-medium skin thickness**. - Less effective in severe laxity or heavy subcutaneous fat → surgical lift may be needed. - Safe across **all Fitzpatrick skin types** (color-blind technology). --- ## 4. Treatment Protocols ### **Preparation** - Pre-procedure photography and consent. - Skin cleansing, marking treatment zones. - Grounding pad placement (thigh or back). - Coupling gel + return electrode check. ### **Energy Delivery** - **Tips**: - CPT (Comfort Pulse Technology) tips (e.g., 3.0 cm² face tip, 0.25 cm² eye tip). - Single-use disposable tips with limited pulses (e.g., 600–1200 shots). - **Settings**: - Typical energy range: 120–200 Joules per pulse (depends on region). - Pulse duration: ~1–2 sec with cooling spray before and after. - **Technique**: - Overlapping stamping technique (no linear dragging). - Multiple passes (2–4 passes common). - Higher density in laxity-prone areas (jawline, periorbital). ### **Pain Control** - Moderate discomfort → oral NSAIDs, anxiolytics, or topical anesthetic. - Some clinics use nerve blocks (supraorbital/infraorbital/mental). ### **Duration** - Face: 45–90 minutes. - Body: 60–120 minutes depending on area size. --- ## 5. Post-Treatment Care - Minimal downtime: mild erythema/edema resolving in hours. - Avoid excessive sun exposure for several days. - Moisturizers and sunscreen recommended. - Results develop gradually → patient counseling essential to set expectations. --- ## 6. Clinical Efficacy - Studies show significant tightening lasting **1–2 years**. - Improvement rate: 70–90% patient satisfaction in well-selected cases. - Best outcomes: jawline definition, periorbital tightening, forehead lifting. - Less dramatic for heavy jowls or advanced laxity. --- ## 7. Safety Profile - **Common transient effects**: erythema, edema, tingling. - **Rare complications**: - Subcutaneous fat atrophy (usually from overtreatment). - Surface burns (if poor coupling or improper technique). - Neuropathic pain (very rare). - Overall considered **very safe** when performed properly. ---