What is monopolar radiofrequency?
Current passes from one electrode in the handpiece through the tissue to a return pad elsewhere on the body, and the tissue heats most under the handpiece, which is why every device cools the surface. The target is the dermis and the tissue beneath it. A 2004 laboratory study of an early Thermage system found altered collagen fibrils and more messenger RNA for type I collagen, and in people the visible change builds over weeks to months. A 2022 systematic review of 121 articles on radiofrequency for the face and neck found improved laxity and elasticity, with most studies reporting positive subjective ratings and higher satisfaction in people who wanted modest change.
How do Thermage, XERF and other monopolar devices differ?
Thermage, made by Solta Medical, has been in use since 2002, from the ThermaCool line to the CPT and the FLX, cleared by the United States FDA in September 2017. XERF, made by Cynosure Lutronic of Korea, was registered in Malaysia in May 2026. Volnewmer and Oligio, two other registered monopolar devices with published data, are included for context.
| Device | Frequency and delivery | Cooling | Tips and pulses in published protocols | On the MDA register |
|---|---|---|---|---|
| Thermage (CPT and FLX) | 6.78 MHz, one frequency, stamped pulses. The FLX adds automatic energy calibration and a vibrating handpiece. | Cryogen cooling before, during and after each pulse, as the register text for the CPT describes it. | Disposable tips: the FLX lists 4.0 and 3.0 cm2 Total Tips, a 0.25 cm2 eye tip and a 16.0 cm2 body tip. Studies report about 556 pulses (2007) and 900 (2026 trial). | Yes: FLX and CPT |
| XERF | 6.78 MHz and then 2 MHz within one pulse, as a train of sub-pulses. Stamped or glided across the skin. | Cryogen gas cooling in three levels. Output stops if the tip surface passes 43 degrees Celsius. | A large tip for the lower and middle face, smaller ones for the upper face. In one study, 150 shots per side for each area. | Yes: registered May 2026 |
| Volnewmer | 6.78 MHz in the published studies, continuous output, moved across the skin. | Continuous water cooling through a reusable tip | 300 shots per cheek in a 2025 trial. | Yes |
| Oligio | 6.78 MHz, each shot triggered by a hand switch. | Cooling gas at the tip | Disposable 4 cm2 tip. 412 shots on average in a Thai study. | Yes: Oligio and Oligio X |
A pulse count says little by itself, because tips differ in area and energy. The authors of one XERF study propose that its pulse train and cooling lower peak heating, and so the response of pain nerves; that is a hypothesis.
What do the studies show about results?
Thermage has a long file. In 2003, 86 people treated once around the eyes with an early system were followed for six months: on blinded photographs, wrinkle scores improved in 83% of treated areas and 61.5% of measured eyebrows lifted at least 0.5 mm, though the treating physicians saw improvement in 29% of areas and half the people were satisfied. Laxity improved in most of 50 people on masked assessment in 2004, and in 84% of 66 people on independent photographic review in 2007, though that study's objective measures faded with time. A 2021 open-label trial of the latest-generation device, which a later paper identifies as the FLX, rated 73% of 40 people improved at six months, each given an injected painkiller first. Most of these ratings are subjective.
XERF has a short, recent file. A 2026 prospective study at four United States sites treated 39 people twice, and the treating investigators, who were not blinded, rated 92% improved at 90 days. A 2026 retrospective study of 16 women treated once at one clinic in Israel measured brow elevation of about 1 mm at three months. Neither had a control group, and their authors call the findings preliminary. The maker supplied the device, research support and help with data management or statistics for the first, and filed the ethics application and ran the statistics for the second, whose lead author is its international trainer; both papers say it had no role in running the study or writing it up. A doctor's evidence review covers the rest of the file: laboratory work from the maker's team, a protocol note and a case report.
For context, a 22-woman split-face trial found Volnewmer and the Thermage FLX comparable for lifting, volume and wrinkles at eight weeks. A search of PubMed and ClinicalTrials.gov on 30 September 2026 found no trial comparing XERF with Thermage, and with three to six months of follow-up, none of these studies shows how long a result lasts.
How painful is each one? What the studies report
Pain scores are hard to compare between studies, because scales, numbing, energy settings, patients and the moment of scoring all differ.
| Study | Device | People | Numbing | Average pain, 0 to 10 |
|---|---|---|---|---|
| Edwards, 2013 survey | Thermage with a new vibration handpiece (named CPT in a 2026 paper) | 64 | Not stated in the abstract | 6.06, recalled 1 to 10 months later; 9% found it too painful |
| Wang, 2026 randomised trial | Thermage CPT, the control arm in a trial of another device | 105 | 5% lidocaine cream | Rated just after, in bands: none 6.7%, mild (1 to 3) 45.7%, moderate (4 to 6) 41.0%, severe (7 to 10) 6.7% |
| Wang, 2026 | Thermage FLX | 46 | 2% lidocaine cream | 6.6 (right side) and 7.1 (left side), within 5 minutes of each side |
| Roh, 2025 split-face trial | Thermage FLX | 22 women | Topical anaesthetic | 5.8, 7.4 and 8.4 at 100, 200 and 300 shots |
| Weiss, 2026 | XERF | 39 | None | 4.2, during treatment |
| Erlich, 2026 | XERF | 16 women | Cream only on request (4 of 16) | 4.3 just after, range 2 to 8; 2 of 16 scored 7 or 8 |
| Roh, 2025 split-face trial | Volnewmer, on the other cheek of the same women | 22 women | Topical anaesthetic | 3.1, 3.8 and 4.5 at 100, 200 and 300 shots |
| Wanitphakdeedecha, 2022 | Oligio | 30 Thai adults | Lidocaine-prilocaine cream for 1 hour | 3.1 during treatment, range 0 to 6 |
Technique changed early on. In a 2007 survey of 5,700 monopolar radiofrequency treatments by 14 physicians, 45% of patients found the original high-energy single pass too painful, against 5% with a lower-energy, multiple-pass method. In 84 Japanese women, numbing cream lowered the pain of an early Thermage system without changing the result.
The FLX's maker describes its vibrating handpiece as an aid to comfort, and its safety information lists mild-to-moderate pain. Whether the FLX hurts less than the CPT is unsettled: in a 2020 survey of Korean dermatologists (52 surveys analysed), 25.5% rated it more painful, while 57.4% rated it more effective. In a randomised trial using the CPT as a control, 52% of patients rated the pain none or mild and 48% moderate or severe.
In both XERF studies the energy was set to what each patient could tolerate, which partly shapes their scores, and 2 of 16 women in the smaller study still scored 7 or 8.
In most of these studies, reported scores for Thermage are higher than those for XERF. Whether that reflects the device, the settings, the patients or the study design is unknown, because no study has put the two on the same face.
What is the downtime, and who is it not for?
Recovery is short in these reports, usually redness and mild swelling. In more than 600 Thermage treatments these usually cleared within 24 hours, though six patients had swelling for up to a week, and 2.7% of treatments had any temporary side effect. In the XERF studies, three of 16 women had redness for one or two days, with no thermal injury in that study and no lasting adverse events in the other. Burns do happen: in an early Thermage study, second-degree burns followed 0.36% of 5,858 applications and three people had small residual scars at six months, and the maker lists blisters, burns, altered sensation, lumps and pigment change among reported reactions. In darker skin, a review of 35 studies of radiofrequency and radiofrequency microneedling found temporary darkening in seven, prolonged mild darkening in one and lasting scarring in one, judged the risk low and noted that many studies were weak. A 2022 review also lists reduced facial fat volume, which matters on a face with little fat to spare.
The Thermage maker lists an implanted pacemaker, defibrillator or other implanted electrical device as a contraindication, and says it has not studied the system over skin fillers, in pregnancy or breastfeeding, in people with diabetes, an autoimmune disease, cold sores or epilepsy, over tattoos or tattooed make-up, or in children. The XERF studies excluded implanted electronic devices, metal implants, fillers that do not dissolve, pregnancy and breastfeeding, active skin infection, uncontrolled systemic disease and active malignancy in the treated area. Radiofrequency tightens skin. It does not restore volume or remove excess skin, so a hollow face or advanced laxity is not what it is for.
Before any radiofrequency treatment, ask which device and generation will be used, what settings and numbing to expect, whether the device is on the Medical Device Authority register, and who will treat you. How to check an aesthetic doctor in Malaysia covers the registers, and why the same treatment name can mean two different machines explains why the generation matters.
Thermage or Ultherapy?
Radiofrequency heats a volume of tissue; focused ultrasound heats small points at set depths. Two randomised trials of 20 people each, one on the neck and one split-face, found no statistically significant difference in laxity between monopolar radiofrequency and micro-focused ultrasound at six months, and the neck trial found more procedural pain with the ultrasound. Neither abstract names the radiofrequency device, and trials this small cannot show two treatments are equal. XERF vs Ultherapy vs HIFU vs microneedle RF sets out which layer each reaches.
Why this clinic runs XERF
This clinic runs XERF and does not offer Thermage. My reason is comfort: Thermage has a reputation for pain, and that reputation is what kept me from having it myself or offering it here. I have had XERF on my own face, and what that felt like is written up in does XERF actually work.
This is not a claim that any other device gives worse results, which the evidence above would not support, or that XERF is free of discomfort: its published scores are moderate for many people, and the studies behind them are small and involved its maker.
