Is it worth adding Thermage to my Medical spa? Does it work with the new Thermage treatment protocol - multiple passes on low fluence until you see an end point?

Thermage is much debated. I've seen what appear to be excellent results and I've heard docs swear it's a sham. As for myself, the cost of tips is so high (you have to order six at a time) and the company so difficult to work with, that I've decided to hold off for the time being. I don't need another peice of technology taking up space and not providing any income.

I have had an RN that has done Thermage for 4 years do 3 patients this summer. She used the new protocols. Don't let anyone fool you that it is not painful. It is!!!
Now for the bad news..........
I am considering giving all 3 patients their money back due to complete (and I mean complete) lack of results. The photos do not lie. There is absolutely not change. We are approaching the 6th month and I fully expect to have to refund the full amount. And yes they signed a consent but because these are very loyal patients I cannot feel good about their results and if it were me, I would be upset as well. Consider long and hard before adding Thermage.

Would you ever reconsider giving them their money back and perhaps do their treatment over again for free? Many of our patients absolutely love their Thermage results and we offer discounts on repeat treatments. Some patients aren't as impressed with their results, but we find that it looks better on the second try.

When I am doing the consultation for Thermage I really try to show patients our stellar results, the ok results, and the ones that aren't so hot. They see the full spectrum and understand how some people benefit from just one treatment, but others need a series. Keep in mind that Botox and Restylane can also work in concert with Thermage and really optimize the results.

Aesthetic MD,
I would if I could but my situation is with the RN that owns the machine and will still charge me the pre-determined $ to repeat the treatment. I am scared that I will then be out 2 treatments and still have an unhappy patient. I worked in a practice that offered Thermage for about 2 years. We saw some good results but had a fair share of "non-responders". I agree that some people just don't get the results that they expect even though you thoroughly review this with them at the consultation. I still find myself being very honest with these patients that really need a surgical procedure.

What is the % of nonresponders in your clinic with Thermage patients? 50%?30%?20%?

Thermage, yes indeed. I've been doing it or about 5 years now. The technology when first introduced was not ready for prime time since in spite of the company's claims of a 90% satisfaction rate, back in those days it was closer to 30%. And for those who do have improvement the changes are subtle and slowly developing over 6 months. Unless you take good crisp pictures with proper lighting you may not see the changes that you need to document an effect. The early problem with fat depressions happened because of the total lack of help from the company regarding improving results so practitioners experimented with increasing pulses and sometimes even stacking pulses. The increasing number of pulses seemed to work best but the stacking of pulses caused the dimpling effect that was sometimes observed. The real source of aggravation was when it became obvious that the number of pulses needed to increase the company would charge for all the extra pulses requiring practitioners to spend progressively more and more for those treatment tips that didn't cost the company a dime more to program for extra pulses and the cost is such that you can't pass on the extra cost to the patient. So each year the number of pulses would increase. So now with the 3cm tip it is recommended to use 900 pulses for a full face. But I have decided to use 1200 to increase the odds of a good result. And yes I am treating to an end point which for me is not just some evidence of tightening but also some skin edema and erythema as well. The erythema lasts for only a half hour and the minor edema may last only until the next day. As far as the pain is concerned, they understand that it is supposed to be uncomfortable but if they have to clench their teeth or fist or curl their toes then the energy levels are turned down. In addition, I load everybody up on 150-200mg demerol to minimize the pain and also alleviate some of the anxiety. And that way I can increase the energy settings somewhat as well. My success rates are in excess of 80% now but these are in carefully selected patients who are taught about the subtle changes to look for as well as getting good crisp before and after pictures. I also teach them how to position their facial muscles to avoid the muscle droop that contributes to the skin droop. And I teach them good facial skin massage that doesn't stretch the skin to help in the progressive improvement of skin circulation the absence of which caused much of the problem in the first place. And now as to the refurbished tips. This is a creation of Thermage's absolute greed and arrogance. Thermage has been referred to as having a predatory attitude toward their practitioners trying to squeeze as much profit out of each procedure as possible by forcing them to pay for additional pulses that don't cost the company any more to produce per tip. Since the current protocol calls for treating to an effective end point as earlier referenced, such an end point varies between patients and if I need to go beyond the current standard of 900 which I do routinely I very much resent having to pay the damn company more when I am willing to spend the extra time and it doesn't cost them any more to do the procedure. And as to whether the refurbished tips work. Yep they do. They work just fine, not just from my experience but from that of several other practitioners as well. I have yet to hear of any burns or other complications from such tips. And understand that all these companies do is they bypass the internal ROM chip that is inside the tip with an external identical chip. The tip itself is left unaltered. I would love to buy all my tips directly from Thermage but not as long as I have to keep using these excessive number of pulses or which Thermage insists on raping me further for them. Oh and one last thought. For those who might consider the purchase of a Thermage unit I would do so only if Thermage would be willing to allow up to 1800 pulses per tip without charging any more than their current 900 standard. They have a timer on the chip anyway so that after say 3 hours the chip is timed out any way and can't be used or another procedure later in the day or beyond to protect the company's interest in that regard. Thermage would also demand that you sign a binding agreement that is totally self serving. Without getting into the details absolutely refuse to sign the agreement. Too many gotchas. My attorney told me that if I signed it he would discharge me immediately from his practice because of total and utter stupidity on my part after having been warned. And lastly demand a copy of the service manual to allow your local biomedical company to trouble shoot problems if you wish rather than having to depend on Thermage in case they chose to screw you regarding service as well. And they will in an effort to increase their profit as shown by the example of them screwing their docs with the progressively more costly treatment tips as well. Why would anyone not think they would apply that same attitude toward service issues. Although my results are reasonable given my current practices and in properly selected patients I have had to go through some considerable aggravation in the pursuit of a better result with nothing but lip service from the company. My recommendation overall for prospective new users is to boycott the technology until Thermage changes their 'business plan' along the lines of what I have suggested. They are just cooking their own goose by creating an extreme amount of public anymosity otherwise. Any other experiences out there would be interesting.

Anti-Ager Doc:
It is funny that you had this post. By the way, Thermage recently launched this program of selling you ANY tips (DC body contouring and CL cellulite tips included) of any pulse amount at around $500 with supply included. However, you have to buy them at a minimal monthly amount for at least 6 months. Any thoughts on this???

pmdoc,
this is your problem: you think you know it all and you don't. please site your references, not just claiming subjective facts.
recent article now published: Titan heating depth 2ickx CC. The 2-4 mm in depth NOT 1-2 as you claim. reference: Dierickx CC. The role of deep heating for noninvasive skin refuvenation. Laser Surg Med 2006; 38:799-807. Recent article published in ASLMS 40:146-152 (2008) re: titan studies. SO....... again is thermage incredibly superior to titan ; can you actually see a noticeably difference??? probably not. pmdoc , i am wondering why the hell you spend so much time on these blogs , looks like you have too much time on your hands and not enough patients. this blog really may not have too much to offer for specialist, more like a blog for primary care guys talking unintelligible information amonst each other.

Photo:
I am sure why you took this matter that personally. My statement on titan IR's depth of penetration is strictly quoted from Cutera's leading dermatologists (Drs. Taub, Roy,Battle, Fincher, Nikolaidis, Zelickson, Ross, Spooner, Ruiz-Esparza). Go to www.cutera.com, log in under usename: guestvip, password: wendy. I did NOT invent those statistics. If there is something new as of 2008 as you stated then it is not my problem. By the way, the spelling is: REJUVENATION.

PS: I checked out the ASLMS article. Let me summarize: the MD's are from China, in their abstract (as per circa late 2007): "..RECENTLY, an infrared device with contact cooling has been shown to be effective in the treatment of skin laxity.." Should I go on????

Dear Photo, Dean and other Titan loyalists:
I am not here argue with you directly. There are professionals here who wish to know in details about skin tightening in principles and detailed info about some of the available technologies. Here are the bottom lines:
1) The collagen has to be heated up to 59-65C for collagen to denature. Thus there is truely NO such thing as painless collagen heating non-ablatively speaking as of present time.
2) It takes 1.5 mm to get to the upper layer of dermis called papillary dermis, The much deeper layer, reticular dermis, is below.

If you, Titan loyalists, are true BELIEVERS in facts and science then help Cutera with before and after photos to get FDA aprroval once and for all. Don't get angry at me for merely stating scientific facts

Photo:
By the way, I am actually a specialist. There are probably many FP's,IM's and OB/GYN's here who might felt hurt by your comment

photo,

Article in Lasers in Surgery and Medicine february issue showed only 41% of individuals (asian females) showed OBJECTIVE improvement 3 months after a second Titan treatment. This is the article you referenced and it appears as though you may not have read all of it. You must always read the entire article and look at the authors conclusions. The author continues to offer monopolar radiofrequency for treatment of skin laxity of the face. It appears that Dr. Chan feels the monopolar radiofrequency is the better choice. Nice thing about this article is that it was not company sposered.

You also make the assuption that this article supports that there is no difference between monopolar radiofrequency and Titan. You absolutely can not reach that assumption from this article. The only way you would be able to make this claim is to do a split face study using monopolar RF on one side and IR on the other. I have not seen a study with direct comparison of the 2 energies at this time. So it appears that you are making statements or assumptions that you can not back up.

By the way I am a specialist in family medicine. Yes, we actually do know how to read journals. Apparently, you are too busy to actually read the entire articles you have received from Cutera. I do not appreciate your tone about primary care. I guarantee we know a lot more about the human condition than you will ever know. So either be part of the constructive portion of this blog or go away. We can all learn from each other. I bet you could even learn from a primary care doc if you listen.

LH:

Thanks for your follow-up to Photo. By the way, I must share something with you, Jeff Barson and others on this site. After posts from Photo and Dean accusing me of “fabricating information about IR’s depth of penetration and that I was a thermage pimp and that I was one of those primary doctors with nothing else to do but sharing "unintelligible information" here on medicalspamd site” I received a somewhat suspicious email from a poyopaya@yahoo.com with a Japanese name inquiring about having a thermage by me, asking me for my office location and website. I became quite suspicious and did not respond since when you responded to an email it revealed your registered name. I hoped I was wrong on this count and asked if this person could identify herself on this site so I could be sure that the intention was genuine. If my suspicion was correct then I must warn you all here of potential harms to our very pure intentions to participate on this wonderful blog, MOSTLY for professionals to share information but also for non-professionals to seek free advices. I am aware that there are manufacturers’ reps here who might have felt their employment and reputation negatively affected because of us, professionals, sharing our experiences good AND bad here. However, when comments or intents went beyond civilized and respectful but rather venomous and then possibly militant (by disguise) then I feared we lost our sense of humanity and self-respect. Again, I really hope to be wrong about this and ask whoever with the above yahoo address to identify you here. Otherwise, “USERS BEWARE”.

pmdoc

Ive often thought about your concerns. You should start a hotmail acct its free. You can put a fictitious name on the registration then its pretty hard to get any personal info. Use this to have pictures sent or correspondence with unknowns.

Its unfortunate but you need protection from ill intent on this
discussion/learning blog

Florida PA:
I appreciate your suggestion. I accidentally left my email address here for Jennifer who wished to share some info with me about Fraxel and thermage combo. I regretted doing with my normal email address.

Hello,

I'm an U.S seller and I have a large amount of Thermage CPT tips, liposonix transducers, and ultherapy tranducers for sale. They are brand new. I can have them shipped directly to you. Please email me for more information at tracey2609@gmail.com.

All the best
Tracey N.