Energy Devices · A Physician's Perspective
Why we chose XERF over Thermage.
And why we still use Ultherapy.
Every few years, a new skin tightening device enters the market promising better lifting, firmer skin, and more collagen. After nearly two decades in aesthetic medicine, I have learned to be skeptical of marketing claims. Devices come and go, but the underlying physics of energy delivery stays the same.
When we recently added XERF to Skin Trek, many patients naturally asked the same question: why XERF instead of Thermage? It is a fair question, and rather than telling you one technology is simply better, I would like to share how I evaluated the options and why we ultimately made the decision we did.
My history with Thermage
Before discussing XERF, it helps to understand where I am coming from. I have performed more than ten thousand Thermage treatments over nearly twenty years, and I served as a Thermage Clinical Trainer in Canada, teaching physicians and nurses how to treat safely and effectively.
Thermage has earned its place in aesthetic medicine. It pioneered monopolar radiofrequency skin tightening and has helped countless patients achieve meaningful improvement without surgery. I have tremendous respect for what it has contributed to the field. This article is not written by someone abandoning a technology out of novelty. It is written by someone who knows it intimately.
Why we started Skin Trek with Ultherapy instead
When Skin Trek first opened, we did not purchase Thermage. We chose Ultherapy. The reason comes down to one feature that has always stood out to me: real-time ultrasound imaging.
Unlike most skin tightening devices, Ultherapy lets us visualize the tissue layers while treating. That means we can see the treatment depth in real time, identify the SMAS layer, avoid important anatomical structures, and adjust based on each patient's individual anatomy. For certain lifting indications, that level of precision is genuinely valuable. Even today, I consider ultrasound visualization one of the most important innovations in non-invasive lifting.
You can read more about how it compares to other lifting devices in our guide on Ultherapy vs. Thermage vs. Sofwave.
But we always planned to add monopolar RF
Although Ultherapy is excellent, it was never meant to replace monopolar radiofrequency. The two technologies work differently. Ultherapy delivers focused ultrasound energy into specific tissue planes, which makes it particularly useful when structural lifting and precise targeting matter. Monopolar radiofrequency creates volumetric heating throughout the dermis and fibroseptal network, stimulating collagen remodeling across a broader area.
I have always believed a comprehensive clinic should eventually have both. The only real question was which monopolar RF platform to invest in.
Then came XERF
When XERF launched in 2025, I became interested almost immediately. Not because it was new, but because of the engineering. Several design choices genuinely caught my attention.
Dual-frequency energy delivery
Traditional monopolar RF systems operate at 6.78 MHz. XERF combines 6.78 MHz and 2 MHz. Rather than thinking of this simply as going deeper, it is more accurate to say the system delivers energy across multiple tissue depths, creating more balanced volumetric heating throughout the treatment zone. Heat distribution matters. Collagen remodeling depends not only on reaching therapeutic temperatures but on heating tissue consistently throughout the target volume. From an engineering standpoint, I found the concept elegant.
Simplified illustration. The second frequency extends balanced heating into the deeper fibroseptal network rather than concentrating it in the dermis alone.
The Wave Fit pulse
This may be the feature that impressed me most. Instead of repeatedly delivering identical pulses, XERF gradually raises tissue temperature before transitioning into a maintenance phase. Think about heating a cast iron pan. You do not repeatedly blast it with maximum heat. You bring it up to temperature, then hold it there. From a thermal engineering perspective, this makes a great deal of sense, because collagen remodeling depends not only on reaching a therapeutic temperature but on maintaining it consistently throughout treatment.
Simplified illustration of the concept. During the heat phase, more RF energy is delivered to bring tissue up to therapeutic temperature. Once reached, the system drops into a hold phase, delivering just enough energy to maintain that temperature rather than overshooting it. Pulse count, peak power, and duration adjust automatically to the depth and energy settings.
Simplified illustration of the concept. Cooling pulses are paired with RF delivery throughout both phases, protecting the epidermis while the deeper tissue is heated. RF energy is higher during the heat phase to reach target temperature, then settles into a steady maintenance level during the hold phase.
Integrated cooling, a different philosophy
Both Thermage and XERF use cryogen cooling to protect the epidermis. The difference is in how that cooling is controlled. Thermage determines the amount of cryogen automatically. XERF's Integrated Cryogen Delivery also protects the surface, but lets the operator select different cooling levels depending on treatment area, skin thickness, patient comfort, and clinical objective. In my experience, that flexibility lets treatment be tailored more precisely to each patient rather than relying entirely on automatic adjustment.
There is also a comfort difference. Thermage combines cooling with vibration as part of its pain management. After thousands of treatments, I have found vibration polarizing. Some patients appreciate it, others tell me it feels more distracting than comforting. XERF relies on its pulse design and cooling to improve comfort without vibration. I prefer that approach.
A smarter treatment tip
One of the most overlooked aspects of any monopolar RF system is the treatment tip itself, and this is where some of XERF's most meaningful improvements sit. Compared with previous-generation systems, XERF uses a more sophisticated sensor array that continuously monitors treatment conditions during energy delivery. Combined with a larger 6 cm² face tip compared with Thermage's 4 cm² face tip, the system gathers more feedback while covering more area with each pulse. No energy device is completely risk-free, but thoughtful engineering like this has the potential to improve both efficiency and safety.
A better approach to blister prevention
Any clinician who has performed a large number of monopolar RF treatments has encountered the occasional superficial blister or focal epidermal injury. These events are uncommon, but they are recognized complications across all platforms. What impressed me about XERF was how much attention went into redesigning the tip and improving energy monitoring to reduce localized hot spots. I would never claim any device eliminates adverse events entirely. But I appreciate seeing a manufacturer keep refining rather than assuming the original design was already perfect.
The feature that really won me over
Ironically, the biggest reason I chose XERF was not the hardware. It was the treatment philosophy. XERF actively teaches a combination of stamping and controlled sliding techniques, and that caught my attention immediately, because I have quietly been using both approaches with Thermage for years.
Experienced RF physicians understand that different anatomical regions behave differently. Some areas benefit from stationary pulses. Others benefit from controlled movement to distribute thermal energy more evenly. Successful monopolar RF is not about rigidly following one technique. It is about understanding heat generation, heat transfer, tissue thickness, thermal accumulation, and energy distribution, then adjusting accordingly.
"Historically, sliding techniques were often discouraged in Thermage education. Seeing a major manufacturer openly embrace the approach honestly felt like vindication. It aligned with what years of clinical experience had already taught me."
Does this mean XERF is better?
Not necessarily. Thermage is an excellent technology. XERF is also an excellent technology. This is not an Apple versus Android debate. Both devices are capable of producing excellent clinical outcomes. The differences are in the engineering details, the treatment philosophy, and how each platform approaches energy delivery. Every clinic has different priorities, and every physician has different preferences. This article simply explains why our clinic chose XERF.
Are we retiring Ultherapy?
Absolutely not. In fact, I believe these technologies complement one another exceptionally well. Ultherapy remains my preferred choice whenever precise anatomical targeting matters, largely because of its real-time visualization. XERF excels at delivering controlled volumetric heating over larger areas, which makes it an outstanding tool for collagen remodeling and overall tightening.
Increasingly I find myself thinking less about Ultherapy versus XERF, and more about Ultherapy plus XERF. For many patients, combining targeted ultrasound lifting with comprehensive monopolar RF collagen stimulation may offer the best of both worlds. I suspect that combination will become our go-to non-invasive lifting protocol for patients seeking maximum improvement without surgery.
Side-by-side comparison
| XERF | Thermage FLX | Ultherapy PRIME | |
|---|---|---|---|
| Technology | Dual-frequency monopolar RF | Monopolar RF | Microfocused ultrasound with visualization |
| Energy | 6.78 MHz + 2 MHz | 6.78 MHz | Focused ultrasound |
| Primary target | Dermis & fibroseptal network | Dermis & fibroseptal network | Deep dermis, SMAS & fascia |
| Real-time imaging | No | No | Yes |
| Epidermal protection | Adjustable ICD cryogen | Automatic cryogen | Ultrasound gel coupling |
| Comfort strategy | Wave Fit pulse + adjustable cooling | Cryogen + vibration | Visualization & energy selection |
| Face tip size | 6 cm² | 4 cm² | Multiple transducers |
| Technique | Stamping + controlled sliding | Stamping | Line-by-line delivery |
| Typical downtime | Minimal | Minimal | Minimal |
Final thoughts
After nearly twenty years with Thermage, changing platforms was not a decision I took lightly. Thermage played an important role in my career and I continue to have tremendous respect for what it has contributed to aesthetic medicine. But technology evolves, and our responsibility as clinicians is to keep evaluating new innovations with an open mind. Not because they are new, but because thoughtful engineering can translate into a better experience for our patients.
For Skin Trek, XERF's dual-frequency design, its pulse structure, adjustable cooling, redesigned tip, and treatment philosophy aligned closely with how I already think about monopolar radiofrequency. That is why we chose it. Not because Thermage stopped being a great technology, but because, after carefully evaluating both, XERF best matched the direction we believe non-invasive skin tightening is heading.
Common questions
Is XERF better than Thermage?
Neither is objectively better. Both produce excellent results. XERF's dual-frequency energy, adjustable cooling, larger treatment tip, and pulse design aligned with how I already approach monopolar RF, which is why we chose it. Thermage has decades of published clinical data behind it and remains an excellent platform. The right choice depends on the clinic and the physician.
If you trained on Thermage, why switch?
Precisely because I know monopolar RF so well, I could evaluate XERF on its engineering rather than its marketing. The features that matter to me, dual-frequency heating, a gradual heat-and-hold pulse, adjustable cooling, and a technique philosophy that embraces both stamping and sliding, are things years of Thermage experience taught me to value. XERF reflected them.
Do you still offer Ultherapy?
Yes. Ultherapy remains our tool of choice for precise structural lifting because of its real-time ultrasound visualization. Increasingly we think in terms of Ultherapy plus XERF rather than one versus the other, combining targeted ultrasound lifting with broad RF collagen stimulation for patients who want maximum improvement without surgery.
Is XERF safe for all skin types?
Yes. Radiofrequency energy is not absorbed by melanin, so XERF does not carry the pigmentation risks associated with some laser treatments in darker skin types. It is safe and effective across all Fitzpatrick skin types, which makes it a strong option for our East Asian and South Asian patients.
Curious whether XERF, Ultherapy, or a combination is right for you? A free consultation is the honest starting point.
Book a Free Consultation About XERF at Skin Trek