[Dr. Bellevue Column 88.] A Comparison of RF, Ultrasound, and Microwave Lifting

Hello.

Bellevue Clinic, where everyone’s beauty comes first,

Dr. Bellevue here,

and I’m glad to greet you again today.

The core of modern aesthetic medicine lies in how precisely we can suppress the mechanisms of aging through a noninvasive approach. For this purpose, dermatology uses three different physical energies: radio frequency (RF), high-intensity focused ultrasound (HIFU), and microwave (MW). Of course, the titanium three-wavelength laser is also used, but today, from a medical professional’s perspective, I’ll take a deep dive into the engineering principles, interactions within biological tissue, and mechanisms of pain for these three types of energy: RF, ultrasound, and microwave.

1. Radio Frequency (RF)

Lifting through volumetric heating of the dermis and collagen denaturation - Thermage, Oligio, etc.

[1] The physical mechanism of RF

Radio-frequency lifting, represented by Thermage introduced in 2003, uses the principle of dielectric heating, in which electromagnetic waves cause ions and molecules in tissue to vibrate. High-frequency current flowing through the electrodes meets the tissue’s electrical resistance and generates heat. The goal is usually to deliver heat uniformly throughout the dermis at temperatures above about 40–55°C.

[2] The biological effects of RF

Collagen fibers exposed to heat immediately contract, and afterward fibroblasts are activated and go through a remodeling process in which new collagen and elastin are synthesized.

[3] The reality of RF pain

There is a stinging sensation caused by resistance on the skin surface, but the key issue is stimulation of nerve endings by deep heat. When energy is concentrated in the lower dermis and subcutaneous tissue, the heat irritates the areas around nerves and blood vessels, producing a heavy, throbbing pain. The longer the procedure takes, the more painful it inevitably becomes, because heat builds up.

2. High-Intensity Focused Ultrasound (HIFU)

Lifting by forming thermal coagulation points in the fascial layer - Ultherapy, Shurink, etc.

HIFU lifting, represented by Ultherapy, works by concentrating sound energy at a single point to generate powerful heat.

[1] The physical mechanism of HIFU

Ultrasound generated through piezoelectric elements is focused like a magnifying glass onto a single focal point. The temperature at this focal point rapidly rises to 60–70°C.

[2] The biological effects of HIFU

It creates tiny thermal coagulation points (TCPs) in the SMAS (superficial musculoaponeurotic system), located deep within the skin. As damaged tissue heals, strong contraction occurs, producing a lifting effect that pulls sagging tissue upward.

[3] The reality of HIFU pain

The pain mainly comes from ultrasound energy reaching the periosteum, the membrane covering the bone, or from heat conduction. This is why patients often describe it as “the bone feels cold” or “it throbs like a toothache.” For especially sensitive patients, the procedure is sometimes performed under sleep anesthesia.

3. Microwave (MW)

Lifting that maximizes selective targeting and energy efficiency - ONDA

[1] The physical mechanism of microwaves

Microwave technology, represented by ONDA lifting, is the most recently introduced intelligent energy. It uses a special frequency of 2.45 GHz. At this frequency, energy loss at the skin surface is very low, under about 20%, and more than 80% of the energy is delivered directly to the lower dermis and fat layer with strong straight-line penetration. Very efficient, right?

[2] The biological effects of microwaves

It uses frictional heat generated by rotating molecules inside fat cells 2.45 billion times per second. This induces apoptosis of unnecessary fat cells, helping refine the contours while also supporting collagen remodeling in the dermis. For that reason, it can also be effective for body lifting and fat reduction.

[3] Why is microwave pain minimal?

Why can ONDA be performed without anesthesia? The device passes through without stimulating pain receptors in the epidermis, and a powerful contact cooling system protects the skin surface at 15°C. As a result, it has an innovative mechanism that greatly reduces the pain the patient feels while delivering strong heat to the deeper layers. Instead, you need to keep moving the handpiece continuously so the inside does not get too hot. It’s like a microwave turning around in circles. In fact, when you remove the cooling handpiece from the skin, you may feel the heat. That’s why it is very comfortable even without anesthesia during the procedure. Microwave treatment is performed with oil rather than gel.

This machine costs a whopping 130 million won....ㅠㅠ

Comparison of the technical characteristics of each lifting energy

Comparison item	Radio Frequency (RF)	Ultrasound (HIFU)	Microwave (MW)
Energy characteristics	Electromagnetic current	Sound waves (vibration)	Special-frequency electromagnetic waves
Main target	Entire dermis (volumetric heating)	Fascial layer (SMAS)	Lower dermis & fat layer
Generated temperature	40–55	60–70	50–55 (focused deep within)
Mechanism of pain	Deep heat and nerve stimulation	Periosteal stimulation and coagulation point formation	Avoidance of nerve stimulation through cooling
Clinical strengths	Skin adhesion and tightening	Upward lifting of sagging tissue	Refining fullness and shaping the contours

Each energy source is complementary

Rather than concluding that one energy is superior, it is important to have the insight to choose the right energy according to the patient’s stage of aging and anatomical structure. If the skin is thin and fine wrinkles are the concern, RF is appropriate. If contouring fat under the jowls or a double chin is the priority, microwave is a suitable option. If overall sagging is severe, ultrasound becomes the proper alternative.

As you may have felt after looking through the history of lifting from Thermage (2003) to ONDA (2022), the evolution of energy has always moved in three directions: “deeper, more precise, and less painful.” Considering the pace of scientific and technological progress, future lifting is likely to evolve beyond simply applying strong heat into forms that “mimic biological signals” or “directly control the cellular level.”

If we try to predict the next-generation lifting energy candidates that may appear in the future...

The first is cold plasma. Plasma devices are already used today to disinfect the skin surface or improve absorption, but in the future, plasma for deep regeneration may become a major player in lifting. Rather than destroying or contracting tissue with heat, reactive species generated by plasma directly stimulate the cell’s self-regeneration signals. It is a method that does not force collagen production, but instead makes cells decide on their own to “become young again!” The second is muscle lifting through magnetic fields and electrical stimulation (EMS & Magnetic Field). Until now, lifting has focused on the skin (dermis), fat, and fascia (SMAS), but in the future it will directly target the “muscles” beneath them. Through high-intensity magnetic fields or special electrical signals, facial muscles can be retrained to restore the tone of facial muscles weakened by aging, tightening the skin from within. Rather than pulling the outside, this method strengthens the internal structure itself, making the most natural lifting possible. In addition, although there are already devices that deliver multiple energies from a single handpiece, future technology will likely make it possible to alternate energies at the nanosecond level. For example, microwave loosens the fat, RF causes contraction, and then ultrasound immediately stabilizes the fascia. Different physical energies will not collide but instead complement one another and create synergy. In other words, it would combine “the comfort of ONDA + the depth of Ultherapy + the tightening of Thermage” in a single shot. We do not yet know when a device like this will be developed, but because technological progress is so rapid, I think we may encounter it sooner than expected...

Or, the evolution of software rather than hardware (energy source) may change the lifting paradigm. The treatment device could scan the thickness of the skin layer, hydration level, and nerve locations in real time with precision far beyond ultrasound imaging, and then the device could fine-tune the output every 0.001 seconds the moment the doctor delivers the energy. If it avoids areas with nerves and applies stronger energy where there is more fat, pain would approach zero while the effect would theoretically reach its maximum.

The lifting of the future seems likely to center on “regeneration” rather than “construction.”

If lifting in the past was closer to “physical construction” by cutting away sagging tissue (surgery) or burning it with heat to make it contract (HIFU/RF), then the future will likely enter the realm of “biohacking,” which pushes the body’s regenerative abilities to the extreme. Since Bellevue Clinic is leading the latest lifting trends through ONDA and Titanium, I think it will also be exciting to introduce such future technologies to patients faster than anyone else when they are actually commercialized.

Bellevue Clinic will continue to focus on clearly understanding the physical limitations and possibilities of each device, and on designing the most efficient combination of energy according to each patient’s tissue density and fat distribution to bring about natural and healthy change. Thank you today as well!

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