Can radiofrequency treatments cause indentations or divits?

Dear Dr. Irwin, I had a Thermage treatment on my face 10 days ago and now I’m left with noticeable pitting and indentations, especially on my cheeks and around my temples. To say the least, it is very distressing. I’ve reported it to my clinician who plans to report it to the Solta clinical team. Is this common protocol? What is my best option for fixing my skin? And help is greatly appreciated. Sincerely, C. Taylor

Radiofrequency is a useful tool in the anti-aging world of dermatology. For those of you who have not experienced a radiofrequency treatment, it uses sound energy to heat the dermis, which is where the collagen, collagen making cells and elastic fibers are. That heat has to be very accurate, which is heating the dermis to 42-44 degrees Centigrade (about 107-111 degrees Fahrenheit). If the heat is lower, there is no effect, and if the heat is too high you might get burned… or it could melt fat in a small area.   This exact range of heat then tightens the existing collagen (a little), but more importantly it makes cells produce more collagen. This new collagen grows, which takes about 3 months, and is why it tightens your skin a little. Also, it produces a “glow.”

The companies that make this equipment like Thermage, Exilis, Ultherapy, Thermismooth have well worked out protocols and guidelines for clinicians/providers to follow. Here’s the problem: The doctors/nurses, aestheticians are not required to follow them and sometimes don’t. This can be a good thing, because with a very experienced providers you may get even better results (customization). The bad part comes possibly when less experienced or less careful providers make an error and a complication occurs.

Here’s what to watch out for:

  • Is your provider (doctor/nurse/aesthetician, etc.) very experienced?  This is hard to tell and assume honesty.  Sometimes it’s good to ask “How long has your office had Thermage?” for example.
  • Another way is to ask fairly technical questions and see if your provider can answer them. You can do a little homework on the web first.
  • The best way, in my opinion, to control the heat is feedback from YOU the patient. It should feel hot, but not too hot. If it feels like it’s burning then it may be. Don’t be stoic!! Have them stop or turn it down.
  • Some systems like Thermage have built in cooling so you won’t feel the heat. Then the provider just needs to stay in the company’s guidelines and not press too hard. If fat melting is ocurring, then either it’s turned up too high, the wrong tip is used, equipment malfunction, or too much pressure. More is NOT necessarily better. Don’t be stoic!!
  • Some systems have a real time temperature monitor that’s digital. These are the most accurate but not perfect. The quick “temp” with a hand held device taken on the skin is NOT very accurate.

How prepare for a successful RF treatment:

  • Do your due diligence on the office and provider.
  • If you have metal in your body make sure they know. You CAN’T have metal between the treatment site and the grounding pad placement.
  • Never use RF over permanent fillers like Artefill, Belafill or silicone. (And these aren’t recommended ever)
  • Pregancy is a contraindication because there are no studies on safety.
  • Get the consent and pre procedure information ahead of time. Make sure your questions are answered.
  • Do NOT use drugs or anesthesia because you want your pain sensors to work and give feedback to your provider. It should be very warm, but comfortable.
  • Generally there is no discomfort afterwards and no sun restriction.

Hope this helps,  Dr. I

*Note to writer of question. If the indentations remain after 6 months, and don’t self correct, then your options are small volume fat transplantation, hyaluronic acid fillers, and/or Sculptra. Experts only please!



Dr. Brandith Irwin, MD

Ask me your skincare question!

Hi, I’m Dr. Irwin. I believe that consumers deserve a medically trained and unbiased skin care advocate.

  • All our content is written and researched by myself.
  • My medical office in Seattle has treated thousands of patients for 15+ years.
  • This site is not affiliated or financially tied to any product, treatment or device.
Ask Me Something
SkinTour Skincare
One of the best investments in your skin is your daily skincare. Why? Because you can prevent many problems with blotchy skin color, lack of glow, texture, some types of acne, and fine lines with good skincare products. You can also correct some of these problems with effective skincare products. Great skincare is often more expensive because quality ingredients are expensive. Some companies spend on research/development which benefits all of us and adds to the cost. Are they worth it? In general - yes! I have handpicked some of what I consider to be the best skin care products, and offer them for sale on SkinTour's shop. This is based on my team and I's testing and research at our clinic. Many of the products are in my own regimen. What could be better than using skin care products a dermatologist uses?!