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Nonsurgical Skin Tightening With Three Heat-Producing Devices: Thermage, Exilis, and Ulthera

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Jill K. Jones, RN, CPSN

Jill K. Jones, RN, CPSN, completed her nursing education in 1986 from DeKalb School of Nursing in Clarkston, GA. The initial 13 years of her nursing career were focused on plastic surgical nursing as she worked alongside a plastic surgeon providing every aspect of perioperative patient care and practice management as well as providing nonsurgical aesthetic services to the practice’s patient base. In 1993, Ms. Jones earned her certification as a Certified Plastic Surgical Nurse (CPSN) through the American Society of Plastic Surgical Nurses, Inc. (ASPSN), and has maintained her CPSN status since. She has served on the National Board of Directors for the ASPSN and continues to be an active member of the society as well as serving in leadership roles.

The author reports no conflicts of interest.

Address correspondence to Jill K. Jones, RN, CPSN, Aesthetic Advancements Institute, 2789 Hidden Falls, Buford, GA 30519 (e-mail:jjones@aestheticadvancements.com).

DOI: 10.1097/PSN.0b013e3182a5766e

Aesthetic medicine is an ever-evolving field of medicine. The past decade has delivered dramatic growth and development in surgical and nonsurgical modalities of treatment alike. However, this is particularly apparent in the development of approaches to nonsurgical modalities of treatment. This exists because of the great patient demand to either reduce or remove the visible effects of aging on the face (skin laxity, sagging tissue, and lines and wrinkles), without resorting to surgery.

For many years the use of dermal fillers has been a treatment of choice for the loss of facial volume, lines and wrinkles, and a sagging of the facial features. Neuromodulators are a mainstay treatment to reduce the creasing of the skin caused by repeated muscle contraction, as well as a method to achieve a degree of “lifting” effect to certain facial features. Light-based devices and chemical peeling assist with exfoliating the skin and providing a smoother, more even complexion.

However, even with these existing very effective nonsurgical aesthetic treatments, there remained a void in providing a true nonsurgical “tightening” effect to early loosening of skin seen in the aging face. The Holy Grail of aesthetic medicine would be the ability to provide patients with an appreciable tightening and lifting of the face with no downtime and in a cost-effective way.

To reach this end, research and development have led to technological progress resulting in sophisticated electromagnetic systems. Today, there are many devices currently on the U.S. market to treat skin laxity. These range from broadband infrared to laser, electrostimulation, radio frequency, and ultrasound.

There exist three devices cleared by the Food and Drug Administration in the United States for the noninvasive tightening of the skin utilizing either radio frequency or ultrasound technology (Table 1).

TABLE 1.FDA Cleared Indications of Devices.

ultherapy vs thermage

Thermage and Exilis utilizeradio frequency and Ulthera utilizes focused ultrasound technology. Thermage was the first on the market and for 10 years was the only real viable option for nonsurgical skin tightening. Exilis entered the market in early 2013 and has steadily gained in popularity. The ultrasound technology used for skin tightening, as used in Ulthera, is much newer and entered the market in 2009. Although all three devices are similar, there are differences (Table 2).

TABLE 2. Overview of Radio Frequency Versus Ultrasound.

ultherapy vs thermage


Both radio frequency and ultra- sound devices produce heat, although by different methods. The heat produced by the devices increases collagen production in the deep layers of the skin by causing a thermal injury, thus causing a compensatory tightening of the skin.

The heating that occurs with radio frequency and ultrasound is not based on Fitzpatrick skin type or dependent upon selective photothermolysis, but rather the heating of water. In the dermis, which is composed of collagen, elastin, and ground substances, exposure to this degree of heat results in an immediate and temporary change in the collagen. The heat produced is believed to elicit a micro-inflammatory stimulation of fibroblasts, which then stimulates the production of new collagen.

All three of the devices are used to tighten early skin looseness, which may provide substantial results and completely satisfy patients, or can delay the need for surgery for others.

The treatments have been reported to provide satisfactory result in the lifting of the eyebrows by treating the forehead skin, reducing loose skin around the eyes by treating the periocular area, reducing the early signs of jowls and tightening the jawline by treating the cheeks, jawline, and the neck. It may take up to 3–6 months to see full results. A repeat treatment every 1–2 years is usually required to maintain optimal results.



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The early Thermage procedures were considered to be very slow and uncomfortable to the point of being painful. The newest version, the Thermage CPT, provides treatments that have greatly reduced the discomfort due to the addition of a type of vibration delivered by the Comfort Pulse technology and using bursts of cryogen spray to cool the skin surface. Many patients still request some method of pain relief, such as an antianxiety medication or an anti-inflammatory injection. The typical treatment length is 60 min.

There is not a real downtime, but skin will be red and swollen after the treatment.

Depending on the severity of the laxity, one to two treatments may be necessary to achieve results. A second treatment may be suggested at 3 months. Results may be seen for up to 2 years.


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Although Thermage and Exilis utilize radio frequency to produce an electrical current to heat the deeper layers of the skin, Exilis utilizes a monopolar radio frequency, which allows the waves to go deeper and exert more energy.

Exilis utilizes a dual pulse to deliver a controlled energy. Exilis’ hand piece has a cooling system to counteract the heat and Energy Flow Control technology controls the heat delivery. Patients report feeling a little warmth, but no pain as long as the hand piece is moved around the treatment area. Most patients do not request medication or numbing cream. A typical treatment takes 20 min.

There is no real downtime, but skin may be a little pink for 15–30min posttreatment.

A series of four to six treatments may be recommended, one every 2 weeks, to achieve results. Results typically last 6 months to 2 years.


Ulthera delivers focused ultra-sound energy below the surface of the skin and can focus energy to a depth of 4.5 mm, targeting the foundational SMAS layer.

Ulthera tends to be the most painful, and pain medications and antianxiety medications are usually required. A typical treatment takes 60 min.

There is no true downtime; however, swelling and redness may be visible for several hours and some patients develop bruising and some have numbness that may last for several weeks posttreatment.

One treatment may be all that is necessary, depending on the laxity of the skin; however, an evaluation after 3 months is suggested to see if an additional treatment is indicated. Results are typically seen for up to 2 years.


Whether utilizing a radio frequency or ultrasound-emitting device, the result is a deep heating of the tissues beneath the surface of the skin, which creates a thermal injury and a resulting neocollagenesis. The desired effect is a “tightening” and “lifting” of the skin and underlying structures. All three of the devices described earlier have been used successfully in the properly trained, skilled practitioner hands and on properly selected patients. All results do require repeat treatment protocol every year or two to maintain optimal results.


Alam, M. (2010). Ultrasound tightening of facial and neck skin: A rater- blinded prospective cohort study. Journal of American Academy of Dermatology, 62(2), 262–269.

Kaufman, J. (2012).Cosmetic dermatology(2nd ed., pp. 219–220). New York, NY: McGraw Hill.

Duncan, D., Key, D., Samlaska, C., Sasaki, G., Van Natta, B., & Werschler, P. (2011). Anti-aging face treatment: “What’s the difference between Thermage and Ulthera. Increased Density Advisory Group. Retrieved from http://beautyeditoroncall.com/2012/01/19/anti-aging-face-treatments-whats-the-diffrence-between-thermage-and-ulthera/


Kronemyer,B. (2013, February). New Exilis Elite delivers advanced RF, the science for better body shaping and skin tightening. The Aesthetic Guide, pp. 2–9.

Sasaki, G.,& Tevez, A. (2012). Clinical efficacy and safety of focused-image ultrasonography: a 2-year experience. Aesthetic Surgery Journal, 32, 1–12.

Weiss, R. A., & Weiss, M. A. Dynamic monopolar radiofrequency for successful non-invasive treatment of skin and body contouring (ClinicalReport). Retrieved from http://westcoastlaser.com/files/exilis/DrWeiss_Whitepaper.pdf