XERF vs Ultherapy vs Thermage

XERF, Ultherapy, and Thermage are the three most established non-surgical skin tightening treatments available today.

All three stimulate collagen and address skin laxity without surgery or downtime. But they use different technologies, reach different tissue depths, feel very different during treatment, and suit different patients and concerns.

If you are trying to decide between them, here is a clear breakdown of how they differ and what each one is best suited to.

XERF uses dual-frequency monopolar radiofrequency energy at two frequencies simultaneously: 6.78 MHz and 2 MHz. These two frequencies reach different tissue depths in the same session, from the superficial dermis through to the deep SMAS fascia, the structural layer addressed in a surgical facelift. Integrated cryogen cooling is delivered with every shot, protecting the skin surface while the RF energy works below it. No numbing cream is required.

Ultherapy uses high-intensity focused ultrasound (HIFU) rather than radiofrequency. Ultrasound energy is delivered to precise focal points in the skin, creating thermal injury at defined depths, most notably at the SMAS layer at 4.5mm depth. The energy is concentrated and targeted rather than distributed across a range of depths. It is the established gold standard for SMAS lifting but is associated with meaningful procedural discomfort, often requiring numbing cream or pain relief.

Thermage uses single-frequency monopolar radiofrequency at 6.78 MHz. It heats the mid-to-deep dermis broadly and thoroughly, making it effective for skin texture, fine lines, and overall skin firmness across larger areas. It does not reach the SMAS layer and does not have the same structural lifting capacity as XERF or Ultherapy. Pain levels are moderate to high and numbing cream is standard.

Here is what those differences mean in practice.

1. Tissue depth.

Thermage heats the dermis broadly but does not reach the SMAS layer. Ultherapy targets the SMAS with high precision through focused ultrasound, but concentrates energy at specific focal points rather than across a range of depths.

XERF addresses the superficial dermis, mid-dermis, and SMAS fascia simultaneously in a single session through dual-frequency RF at 6.78 MHz and 2 MHz. For patients who previously needed both Thermage and Ultherapy to address the full range of tissue depths, XERF achieves this with one device.

2. Comfort.

Ultherapy’s focused ultrasound creates thermal injury at discrete points, which many patients find sharp or burning. Pain relief or numbing cream is routinely offered.

Thermage generates significant heat across the dermis, and numbing cream is standard in most protocols.

XERF delivers integrated cryogen cooling with every shot, allowing the RF energy to work at depth without numbing cream or pain relief for most patients. Patients who have found Ultherapy or Thermage difficult to tolerate often report XERF as considerably more comfortable.

3. Evidence base.

Thermage has been established for over two decades and carries the most extensive published literature. Ultherapy has been widely used for over a decade with a substantial evidence base and FDA clearance for brow lifting.

XERF is newer, developed by Lutronic in South Korea in partnership with Cynosure. It has a growing clinical evidence base including histological studies confirming collagen remodelling and SMAS tightening at multiple tissue depths. As with any newer technology, the long-term published evidence continues to accumulate.

4. Treatment focus.

Thermage excels at broad skin texture improvement, fine line reduction, and large-area firming where coverage matters more than depth.

Ultherapy is the established choice for precise structural SMAS lifting, particularly brow elevation and sharply defined jawline correction.

XERF addresses both dermis-level skin quality and SMAS-level structural tightening simultaneously, making it well suited to patients with combined concerns across multiple tissue depths.

Below is an example of patient before and after the XERF laser treatment.

Choose XERF if:

• You have mild to moderate skin laxity in the face, jaw, or neck
• You want to address both skin quality and structural laxity in a single session
• Comfort during treatment is important to you and you want to avoid numbing cream
• You have found Ultherapy or Thermage too uncomfortable in the past
• You want no downtime and to return to normal activity immediately
• You are looking for progressive, natural-looking results that build over several months

At Dr Hass Clinic, the XERF laser treatment is what we tend to recommend most to patients.

Consider Ultherapy if:

• Your primary concern is focused structural SMAS lifting, particularly brow lifting or very defined jawline correction
• You are comfortable with higher procedural discomfort in exchange for precise depth targeting
• You have used Ultherapy previously and responded well to it

Consider Thermage if:

• Your primary concern is overall skin texture, fine lines, and broad-area firming rather than structural lifting
• You are treating a very large body area where broad thermal coverage is more relevant than depth precision

For patients with combined concerns across skin quality, jowling, and neck laxity, XERF addresses multiple tissue depths in a single session. For patients with a very specific structural lifting goal, Ultherapy remains a well-evidenced option. For patients focused primarily on skin texture across a large area, Thermage may be the most targeted choice.

Yes. XERF pairs well with injectables, dermal filler, polynucleotides, and medical-grade skincare as part of a personalised rejuvenation plan. Where XERF tightens the structural foundation of the skin, filler can restore lost volume, and injectables can address dynamic lines. Dr Hasaneen will discuss whether a combination approach is appropriate at consultation.

At Dr Hass Clinic, we offer XERF as our non-surgical skin tightening treatment, performed exclusively by Dr Hasaneen Al-Janabi, a GMC-registered surgeon and Member of the Royal College of Surgeons with advanced training in energy-based devices. The clinic uses the authentic FDA-cleared XERF system by Cynosure Lutronic.

Dr Hasaneen chose XERF after reviewing the available evidence and clinical outcomes across non-surgical tightening devices. We do not currently offer Ultherapy or Thermage. Every treatment plan is bespoke, mapped to your individual anatomy, skin quality, and goals. If XERF is not the most appropriate option for your concern, we will tell you at consultation.

To understand whether XERF is appropriate for your concerns and what results you could expect, read our guide on XERF results and how long they last, or find out more about whether you are a good candidate for XERF.