XERF, Thermage and Ulthera: What Is the Difference?

XERF, Thermage and Ulthera: what kind of treatments are they?

XERF lifting, Thermage and Ulthera are non-surgical lifting treatments that deliver energy into the skin to improve elasticity and sagging. They differ, however, in the energy they use and in the way heat is delivered to the tissue.

XERF and Thermage use radiofrequency (RF), while Ulthera uses microfocused ultrasound (MFU-V). A distinguishing feature of XERF is that it uses two frequencies, whereas Thermage manages skin elasticity with monopolar RF. Ulthera delivers energy to a target depth while the skin layers are checked on an ultrasound image.

How does XERF lifting work?

XERF is a monopolar radiofrequency lifting device that uses two frequencies, 6.78 MHz and 2 MHz. It delivers RF energy into the tissue, generates heat, and induces collagen remodelling and tissue tightening. Using two frequencies allows both layers close to the skin surface and deeper tissue to be considered together. It can be used when loss of elasticity makes the facial line look blurred, or when looseness around the jawline and mid-cheek is the main concern.

XERF focuses on managing skin elasticity and facial contour together. When planning treatment, the energy and the treatment area are set with reference to the face's fat distribution, skin thickness and the location of sagging.

In a 39-patient multicentre study of dual-frequency monopolar radiofrequency devices such as XERF, the improvement rate rose from 84.6% at day 30 to 92.3% at day 90.^[1]

What skin concerns is Thermage used for?

Thermage FLX is a treatment that delivers heat to skin tissue using monopolar radiofrequency. Heat stimulation induces contraction and remodelling of existing collagen fibres, which is used to improve skin elasticity and wrinkles. It can be considered when the skin looks generally loose, or when fine lines and reduced surface elasticity are the concern. As well as the whole face, dedicated tips are used on areas such as around the eyes, where the skin is thin and fine lines are prominent.

Thermage delivers RF energy through the surface of the tip that contacts the skin. Unlike methods that concentrate ultrasound energy at a specific depth, it delivers heat across a broad area of tissue, which is characteristic of its overall tightening effect.

How does Ulthera act on deeper layers?

Ulthera is a lifting device that uses microfocused ultrasound together with imaging. It concentrates ultrasound energy at a target depth beneath the skin to create small thermal coagulation points, and collagen remodelling follows during the tissue's recovery process. Because the structures beneath the skin can be seen on ultrasound during treatment, energy is delivered while the target layer is checked. It is used not only for surface elasticity but also for concerns such as sagging around the jawline and cheeks that makes the facial contour look collapsed.

The depth to which Ulthera delivers energy depends on the tip used. The treatment area is therefore designed after considering which part of the face has sagged and at what depth treatment is needed.

A systematic review of high-intensity focused ultrasound studies of the face and neck, such as Ulthera, reported improvement in skin laxity along with mostly mild and temporary side effects.^[2]

What is different between the three?

All three can induce collagen remodelling, but because the way energy is delivered differs they cannot be regarded as the same treatment. XERF and Thermage both belong to the RF family, yet XERF uses two frequencies, while Ulthera is distinguished by concentrating ultrasound at a target depth.

Read alsoFor a wider comparison of ultrasound, radiofrequency and thread lifting, see “Ultrasound, radiofrequency and thread lifting compared” (Korean).

Sagging or skin texture: which is your concern?

If reduced surface elasticity and fine lines are the main concern, the RF treatments XERF or Thermage can be considered. If, on the other hand, the jawline and cheeks have sagged downwards and the facial contour looks blurred, Ulthera, which uses ultrasound, is also an option.

XERF can be considered when elasticity and the facial line are both concerns, since it is an RF treatment that takes shallow and deep layers into account together. Thermage is best understood as centring on overall tightening and fine lines, and Ulthera on lifting by delivering ultrasound energy at a target depth.

No single one of the three is more suitable for every face. It is important to choose on the basis of skin thickness, fat volume and the location and degree of sagging. In a face with little fat, excessive energy or a wide treatment area can affect facial volume, so careful planning is needed.

What should be checked before treatment?

Before deciding on treatment, it is worth confirming the exact model of the device, whether genuine tips are used, the treatment area, the energy settings and the expected recovery process. Even with the same device, the way treatment is performed can differ according to the practitioner's anatomical understanding and energy delivery plan.

Temporary redness, swelling or tenderness may occur after treatment, and problems such as burns or sensory changes can occur rarely. It is advisable to tell the medical team about your skin condition, previous treatments and any medication you take before planning treatment.

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