Exchanging Clinical Information and Treatment Protocols about Thermage.

Comments on Thermage's support?
What are "the right patients"?
Comments?

Overall I found their support to be overall better than most other companies.
The right patients: those with reasonable expectations, less than 60 or less than 10 years post-menopause if not on HRT's, with more of"skin laxity" appearance than "fatty weight" as being the "droopiness cause"

Eyelids with Thermage Conversation which evolved into a conversation about how to use Thermage on The Eyelids, Around the Eyes and the Face. Please read and comment!

Mark: Amen to that. PMDOC has a ton of experience with Thermage and I would have to say that Thermage is one of the most clinician dependant services anyone offers. For example, we have had next to zero results doing eye lids. And we have done as much as 225 shots per eye.

Kevin: I complained to Thermage people a year ago about how "weak" their eye tips were. I still use the regular face tips for the eyes but my patients are mostly Asian (thicker skin). For the Caucasian population, you are better of using the LIP tips. They are "programmed" to generate more fluency and you get MORE band for the buck since the tips are 1.5cm2 instead of 0.25cm2. Try it and you will be much more impressed with results

Thermage: Interesting I have heard this before, we do have a new larger eye tip and as you know we have been getting great results. We have two really strong doctors in the Northeast that do nothing but eyes. I will get Dan tied in with these offices and start the communications on our product.
N: Just so you know, I don't do Thermage eyes as an independent treatment. Inserting the eye shields worries me. I do, however, get good results while doing full, or upper face treatments by gently pulling the skin both above and below the eye over the bone. I do a total of 8 passes over these areas. However, to avoid bulk heating I will initially only do 4 passes. It is essential to continually feel the temperature of the skin with your wrist or hand. As the heating occurs deep it takes a little while for the surface temperature to really reflect what is happening below. Once I am comfortable that the temperature is not too high, I will come back and complete my last 4 passes. If the temperature is marginally high you can always turn your power down a little bit. The real trick with eyes is to get that skin over bone, and don't let the color the skin turns stop you from finishing all the passes.
One other thing to consider is that it is the rare patient who really only needs their eyes done. Keep in mind that nothing can be pulled up from below. Quite aside from my lack of comfort about inserting eye shields, a full eye treatment really should include a brow lift, and this tanslates into an upper face treatment.
Kevin: checked on the thermage site. There is no such new larger eye tips. Besides, it would not make much difference to my last comment anyway since the depth is the same for both tips. With the lip tips, you can do both the eyes and lips. The keys to good resutls would be to stretch the skin so you can get as much depth of penetration as possible. Use a Q-tip and place it just above the eyebrow and stretch the skin upward to expose the skin under the eyebrow. Doing this will:
1) Avoid treating over layers of skin folds thus failing to get to the dermal layer
2) Allow for sufficient skin surface area for the 1.5 cm tip. Press the skin toward the orbital rim thus no pressure on the eyeball
3) Use the same Q-tip to stretch downward on the skin of the lower lid to expose as much skin hidden under the lid as possible. In general, with the ground pad on the FOREARM, you should be able to use from 44-61 Joules/cm2 level for the upper eye and 38-50 Joules on lower lids. Doing 6 passes should be enough, thus for a total of about 60 pulses (2 on top, 2 under and one on lateral canthus each side each pass) . No need for the grids ( BTW, I NEVER use grids for anything, I find them COUNTER-PRODUCTIVE)
4) Using the larger tip will result in better cummulative tightening effect since there is less chance of "untreated gaps" seen more often with the 0.25 tip
Kevin: One more thing, to get better "lifting effect" to the eyes, you must treat the forehead also. With the leftover amount on the lip tips, you can treat the forehead. Again with the pad on the FOREARM area, you can apply about 56-61 Joules on the midline and over the medial aspect of eyebrow. Go LOWER on fluency as go go superiorly (toward the hairline) and laterally down to 44-50joules around the temporal areas. NO need to treat too strong on the temporal area anyway since we don't want it to be anymore sunken than already is.
N: I am happy to share my techniques. Describing them online is, however, a bit difficult. Some of the most important components are:
1. Do NOT grid. It only obscures the natural topography of the face, and makes contouring virtually impossible.
2. Really LOOK at the patient. All the technology in the world won't do a thing if you can't figure out where to apply it.
3. NEVER try to tighten and lift from below the affected area.
4. Keep working towards the desired clinical endpoint.
Well performed Thermage is really the artistic application of technology. I sure don't want to sound as though I've got all the answers, but here's what I know: If you only follow the grid as the reps teach, you will get disappointing results every time.
Wouldn't you prefer to ask questions rather than have me go on and on?

J: Q&A is a great idea. Once all the Q&A is done, we can archive it for future reference. I am also interested in getting comments from the other experienced users about your technique (and these pictures). I bet, by putting your techniques together, we can come up with an even better technique.

Kevin: I agreed with what Naomi said except for #3 (partially). In some instances, such as the lower third of face or the bottom part of the abdomen, I still try to work on tightening them no mater what since I feel that I must overcome the "gravitational pull" on the skin anywhere I see it and have to address it as much as possible.

J: I guess if you tighten from below, you get a shrink wrap type effect rather than a lift?

N: The more profound answer to this is that when you evaluate the skin you need to clearly define which areas need lifting, tightening, or both. Tightening an area can cause the adjacent skin to appear loose, saggy, or when applied correctly, plump. This is the true sculpting, or contouring of Thermage. All over tightening may be fine for your 25-35 y.o. crowd, but those patients who are older need tightening and contouring.
Although I understand that nationwide the median age for aesthetics is getting lower, the only 20 something patients I see for Thermage are acne sufferers. These patients fall into a different treatment model. For all others contouring, sculpting, or whatever you want to call the precise application of Thermage RF energy is an essential component in obtaining a high degree of patient satisfaction. If you can't show them specifically where you contoured their skin when they come in for follow-up, they will tell you they got no result at all!
I believe contouring is high up on the list of differences between disappointing results and great results. Any thoughts???
D: We thermafrax someone who could benefit from skin tightening and contouring (thermage) and resurfacing (fraxel). We give them one thermage then 4 fraxel treatments afterwards. Depending on their skin type and what their concerns are will determine our fraxel settings and how far apart they are spaced.
D: Kevin, how long have you been thermafraxing faces? We are still playing around with our treatments to see which would work better thermage first, or fraxel first. We have done some patients with fraxel first but overall we have not hit our 6 month period to see the results for our thermage. we got fraxel about 5 onths ago.

Let's keep this conversation going!
What is your Thermage Techique? Do you agree with N's Technique?
Is there a better Eyelid Tip available? Thermage says, Yes, but we have not seen it?
How do you do the Eyelids? Do you need the special tip or can you do it Kevin's way?
Do you need to do the Eyelids or can you just do around the eyes like N?
Any and all opinions are welcome.
Let's figure out how to get the best results!!!

Just finished Thermage Eyes on a client using Kevin's procedure with the lip tip and pad on forearm. Interesting enough we were able to get up to 75 Joules with minimum discomfort. Since this was a redo (we did the standard .25 eye tip six minths ago with minimum reults) it was encouraging to see the client react comfortably to the higher energy. We will see at the three month follow up.
Jeff, the "new" eye tip that Thermage refers to is simply the .25 tip increased in shot count to 450.
By the way did Thermage V.P. ever connect with the Dr.'s in the Northeast has he stated he would?

Regards,
Mark
P.S. Thanks again Kevin for the eye technique.

Don't treat only 'problem areas' with radiofrequency tissue tightening

SAN FRANCISCO -- Radiofrequency tissue tightening is showing impressive results in treatment of flaccid skin that occurs with everything from aging to weight loss, pregnancy or liposuction. But some key pearls on technique should be considered for the best chances of a successful outcome, said Flor Mayoral, M.D., at the annual meeting of the American Academy of Dermatology.

Treatment pearls:

Whether it's abdomen, thighs or buttocks, don’t treat only the “problem areas” or “vectors.” Instead, make a grid that covers the entire area to be treated and provide a minimum of two passes to all areas before concentrating on the problem areas.

Don’t walk away without seeing tissue contractions

Make sure to prescribe a compression garment, such as support pantyhose for the legs, or underwear for the buttocks, and make sure the garment provides even pressure, and doesn’t leave any skin marks or indentations

Always pre-position the skin before firing

Treat from distal to proximal

Most importantly – don’t over-promise results

We are looking to add Thermage to our practice. We also treat patients with laser resurfacing -Candela Smooth Beam. What are your indications for Thermage use? We are considering adding VelaSmooth treatments for cellulite. Is Thermage a good alternative for cellulite treatments?

David:
Thermage is primarily indicated for skin tightening, treatment of rhytids/wrinkles. Recently the new tips can do "decent body contouring", not b/c it can "melt fat" but b/c in the body or people with thicker skin, it can penetrate deep into the dermal layer for much more bulk heating thus tightening effects.
I am not sure if there is any truly effective cellulite treatment on the market currently. I have used thermage new cellulite tips but not been impressed with. Velasmooth has been around for 4-5 years now but physicians have not rushed to use it at all. Syneron then recently tweaked it a bit with the new Velashape but I am not sure of it neither.
About the Smooth Beam/VBeam/Candela Perfecta, I definitely would not look at it as a skin resurfacing platform. I am very experienced with it. Pulse Dye Laser is mostly attracted to "red blood cells", thus a gold standard for postop scars, rosecea, inflammatory acne, angioma, telengectasia, portwine stain, possibly stria.

As you know, we get very nice results with our Thermage eyes. This is our protocol, and I am sure its a bit different from everyone elses...

Majority of our clients are younger (under 50), for those, we use the 225 eye tip with a 200 STC tip. For one eye, we pulse 112 pulses of the eye tip mostly on the upper lid and right below the lower lash line. Since the upper and lower lids have a very small surface area, we keep repeating the rows. Keeping the eye sheild in place, we then go and do another 100 pulses with the STC tip (not directly over the upper lid). The STC will help give a nice brow lift (and we keep pulsing until we have that lift), this tip will also help with the fat pad under their eyes. Of course it is a case by case for each patient. If their primary concern is their upper lid, we concentrate most of the pulses on the upper lid smoothening out the creepiness and the folds and concentrating on lifting that brow. If their primary concern is their lower lid, we concentrate on the lower lid, especially with the STC and try to break down that fat pad. We usually finish off with Juvederm and fill in the trough line (if its still there). The return pad is on the lower back. Most clients can take a setting of 363-365. If we have a much older client (in their 50s and up), and depending on their hooding and creepiness, we may use the 450 eye tip instead of the 250.

Thinking about adding Thermage.

In general terms, personal experience/opinion on;

ROI?

Results?

Patient satisfaction?

I paid mine off in 90 days. It is not perfect but fills a void. Some pts want tightening without multiple treatments and also no incisions.

The big thing is be picky about who you choose and do not over promise. I get tired of seeing people advertise it as a non-surgical facelift.

I tell every patient the biggest risk they have with any of the skin tightening systems is to their pocket book. I absolutely do not want them thinking they are going to get the equivalent of a surgical facelift.

LH

Thanks for a realistic view. Do you find any advantage used with re:store, or just a good marketing term?

There should be a synergistic effect but very expensive. I have not combined them as most of my patients have an issue with the price.

We are thinking about combining Thermage with Sciton ST and calling it Thermage Plus - One Thermage and 3 STs. Any thoughts about efficacy? Good Idea, bad idea? Can you do Thermage and ST in the same setting?

This is in response to the Thermage Handout which shows vectors of treatment.

I've seen the handout from Thermage to which you are referring. You're right, it's a nice handout. However, as with most of the things we do, it outlines only the most basic treatment techniques. To really get the WOW results we all want there is much, much more involved. Patient selection; setting realistic patient expectations; eliminating the use of any anti-inflammatory medications long enough prior to, and after treatment; patient education regarding what to expect during treatment; are all essential components to this end. Understanding skin as well as what it is that RF energy is really doing are also necessary. However, these are only the rudiments required to acheive the true tightening, contouring, and sculpting that Thermage can really produce.

It is essential to really study the face of the your Thermage patient. This doesn't have to take much time, but from the first word out of your mouth regarding the treatment, you should be privately analyzing the face of the person you're looking at. As I do my Thermage consults I am already working out my plan for how I will use my vectors to lift and tighten the skin optimally. I find it very helpful to give my patients a mirror, ask them what they don't like about their own faces/bodies, and then show them what the Thermage is likely to do for them. By doing this I help determine what points my patients care most about, but equally importantly it helps me figure out what skin needs to be tightened in which directions. By the time I am done my consult I know what I am going to do during the treatment.

I think one of the biggest problems we have to overcome is the fear of turning the power up. Thermage is an interactive experience between provider and patient. Once you establish this "partnership" you can guide your patient through the difficult. areas. Be honest, supportive, and counsel them through. I often guide my patients with deep breathing techniques to get past the most painful spots. Sometimes I'll tell them how many more painful pulses I need to make and count them down with the patient. There are a million methods that can be utilized, but remember, you are the professional and must guide your patient through the treatment at levels which are appropriate. Help them get through what is necessary for the best result...which is what they want! Keeping track of skin temperature is obviously essential, but as long as you continuously check this, you will prevent bulk heating while delivering the most effective treatment.

In case you're wondering, I have never had a patient get off the table because the treatment has been too painful. To the contrary. For the most part they do not want me to turn the power down, even when it hurts, because they understand that this is part of what is required for a good result. In fact, it is the rare patient that doesn't ask how soon they can have the treatment repeated so they can "keep up" the tightening.

I find it very difficult to explain the additional aspect of what, for lack of a better term, I call the "artistry" of Thermage. There is "artistry" both in the application of the pulses, and patient management. The more at ease you are with your technology, the more at ease your patient will be with you. The more at ease your patient is with you, the better you can utilize your technology. It goes hand in hand.

I hope some of this is helpful for some of you.

Could anyone with experience kindly comment on the differences if any between the Accent and Thermage pls. Is the accent as painful? As effective? Any User issues such as reliability, repair and the big one which is the best value for the money.

Thanks David

We are planning to promote Cellulite treatments with Thermage. We have not done that many for cellulite.

How is it working for Cellulite? What tip do you use? What technique do you use?

Are your results good, very good or great?

How do you set patient's expectations and do you usually meet or surpass their expectations?

Thanks.

I just read in the new MedEsthetics about larger size Thermage body tips. I had heard they were working on them. We were in the "Partnership Program" over the last year and just stopped because we are now overstocked with tips. (The Thermage business has really slowed for us). Sadly, we have a terrible rep (the rep that sold us the machine subsequently became our Botox rep then her territory changed!). We've had no contact from the company about these new tips. I'm doubly upset because now I have a box of the "old" body tips when I'd rather have the new, larger ones. Thermage has a "no return" or "trade in" policy but in the past (when they changed the recommended pulse counts) I did get them to swap out my low count tips for different ones.

Has anyone used the newer, larger tips?

I have heard mixed results about Thermage - does it work? Better/worse than Syneron's skin tightening?

LH and others,

What % improvement are you promising patients? Also, how does this work in the Jawls region?

RealSelf.com has lot of patient reviews about how Thermage does not work.......Our rep is telling us that they have mand a lot of changes to make the treatment less painful, more effective, yada yada....he's a rep after all.

What is everyone's experience out there?

Thank you all for sharing the useful information on Thermage. The more I read, the more I am troubled by where to find good doctors like you guys who actually care about and strike at getting the best result instead of having a clinician do the standard protocol and simply making a sale. I had Thermage done twice. The results were not impressive. I am willing to give it another try if I could locate a good doctor. To start off, how do I find out who in our area (DC, Maryland, VA) has the CPT machine and is willing to work with a patient to customize the treatment?

Where can we have such a market place where potential doctors and patients can be matched up?

Thank you Jeff. That would be great!

I was able to find which clinic has the CPT machine using the Find a Doctor feature on the Thermage site.

Hi Jeff, Is it possible to include the year in your date field so we can easily tell how current the information is?