Why Are Plastic Surgeons Discouraging Nonsurgical Skin Tightening? Comparing Facelift vs XERF
I always find it interesting to hear plastic surgeons' perspectives on nonsurgical skin tightening treatments. Their expertise in facial anatomy and surgical techniques is incredibly valuable; however, nonsurgical energy-based treatments are a distinct area of aesthetic medicine that requires its own clinical experience and technical understanding.
Providers who regularly perform these treatments have the opportunity to observe patient outcomes firsthand and understand how treatment technique, energy delivery, device settings, and patient selection can significantly influence results. Each skin tightening technology is different, and outcomes are often highly dependent on the knowledge and skill of the person performing the treatment.
In many ways, this is similar to surgery. The same surgical procedure can produce different outcomes depending on the surgeon's experience, technique, and clinical judgment. Nonsurgical skin tightening should be viewed with the same level of nuance—both the technology and the expertise of the provider matter.
As a medical doctor performing nonsurgical cosmetic treatments since 2019 combined with 20 years of Emergency Medicine experience, I have been performing Genius RF microneedling, Exilis Ultra 360, and most recently XERF (needle-free dual radiofrequency) with outstanding results. During a consultation, I show patients realistic before/after photos to help determine if the patient is a good candidate for the treatment. Patients who typically come to medspa’s are generally seeking non-surgical options for rejuvenation, but occasionally I will tell a patient that plastic surgery is their best option to achieve the results they are looking for.
Why do some plastic surgeons advise against nonsurgical skin tightening treatments?
In my opinion, part of the discussion may reflect the different perspectives and incentives within aesthetic medicine. Plastic surgeons primarily specialize in—and build their practices around—surgical procedures, while nonsurgical providers often focus on earlier intervention, maintenance, and preventative approaches to facial aging.
Patients who begin treatments such as XERF or RF microneedling earlier in the aging process may be seeking to improve skin laxity and maintain tissue quality over time. For many patients, this approach may delay their desire for surgical intervention or reduce the likelihood that they pursue surgery altogether.
It is reasonable to acknowledge that financial incentives exist throughout aesthetic medicine, including both surgical and nonsurgical practices. Rather than assuming that one perspective is inherently more objective than the other, I believe patients benefit most when recommendations are based on anatomy, realistic expectations, and the treatment that is most appropriate for their individual goals.
How does XERF work and what are the benefits compared to facelifts?
XERF is a non-invasive Radiofrequency device that provides two different frequencies to allow for deeper penetration than other skin tightening devices. XERF affects the retaining ligaments and SMAS layer(superficial musculoaponeurotic system) to improve the structural integrity of the tissue underneath the skin. The treatment is comfortable as a result of built-in cryogen that keeps the skin cooler while the heat is transferred deeper.
What is the best age to start XERF?
We start to loose about 1% of collagen every year from the age of 25 years old. Starting XERF in your 30’s is a good way to replace the collagen that we naturally lose through the aging process. This early start helps to prevent thinner, more textured appearance of skin as well as the associated sagging that occurs with gravity over time. Starting XERF at later ages will help to reverse some of these changes, and regular maintenance is recommended (one treatment per year).
lifting effects of xerf vs facelift:
Strengthening the SMAS layer and retaining ligaments with XERF creates a lifting effect non-surgically, whereas a deep plane facelift relies on a surgical approach to release the natural retaining ligaments in order to reposition the deep facial structures. The lifting effect with XERF can be less dramatic than with plastic surgery in patients with more skin laxity. While surgery may work best in older patients with more sagging and loose skin, XERF can be performed at earlier ages to prevent laxity and loose skin. XERF can also be used in conjunction with plastic surgery to preserve the lifting effects of a deep plane facelift.
improving wrinkles and skin texture with xerf vs facelift:
By boosting collagen, XERF can improve the appearance of wrinkles for a brighter, smoother complexion. Facelifts improve the appearance of wrinkles by stretching the skin and cutting away excess loose skin, but that does not change the quality of the existing skin. XERF can be used in conjunction with plastic surgery to preserve the lifting effects of a deep plane facelift while also improving the quality of the skin. Alternatively, XERF can delay or prevent the need for a facelift especially if started at the age of 30’s or 40’s.
improving pore size with xerf vs facelift:
XERF has the advantage of reducing pore size while facelifts do not change pore size or the quality of the skin.
improving scars with xerf vs plastic surgery:
XERF can lessen the appearance of scars by promoting collagen production. Surgical incisions, on the other hand, create scars that take a long time (several months, even years) to heal to the point where they are not as visible. Surgical incision sites can also have complications such as hypertrophic or keloid scars.
Downtime associated with XERF vs Facelift:
XERF has the advantage of being painless without any associated downtime. In fact, most patients see an immediate improvement after the treatment. These immediate changes are related to the mild heat-associated soft tissue swelling and are temporary, while the slower process of collagen stimulation happen over the course of the next several weeks to months. Facelifts on the other hand, require time off to recover from the effects of anesthesia and bruising/swelling associated with surgery which could take several weeks to months for healing.
complication potential of xerf vs plastic surgery:
Since there are no breaks in the skin, XERF has a negligible risk for infection, bleeding, bruising, hyperpigmentation, or scars that are associated with surgery. Facelifts also have more serious potential complications not seen with XERF including risks of anesthesia and nerve damage - possibly leading to changes in sensation or muscle paralysis.
cost of xerf vs plastic surgery:
Depending on the region/provider, XERF might cost $1800 -$2500 for one full face/neck session. Whereas a facelift ranges in the 30K- over 100K for a deep plane facelift, which will not necessarily include the forehead or neck.
lasting effects of xerf vs facelift
Because the natural aging process continues through time, no procedures’ effects lasts forever. Every year, we continue to lose collagen, fat volume, muscle and bone density leading to a more hollow appearance in certain areas, especially to the upper face. Thinning of skin leads to wrinkles, and sagging ligaments displace the fat pads below the nasolabial folds and jawline to produce jowls. XERF is typically recommended annually - perhaps less often for a person in their 30’s and possibly every 6-12 months past the age of 60.
After the initial soft tissue swelling of surgery declines in about 6 months, so does the dramatic lifting effects of a facelift. Some patients may need another facelift after 5-10 years.
Because XERF is so new (first available in the US in October 2025), the long-term results have not been fully established. However, based on my experience with other Radiofrequency devices such as Genius RF microneedling, I would expect that the benefits of collagen stimulation and structural skin tightening with XERF to extend beyond 1-2 years.
Who perfroms the treatments at Rejuve Medspa: About Dr. Kaplan
Dr. Kaplan has been performing radiofrequency skin treatments along with advanced injectable treatments since 2019 after finishing a 20-year career in Emergency Medicine. She introduced XERF at her boutique medical spa in Newcastle, WA during November, 2025 - one of the first in the Pacific Northwest. Dr. Kaplan was voted Top Aesthetic Doctor in the Seattle Times Best in PNW 2026. Her expertise with radiofrequency treatments and comprehensive medical background puts her patients at ease knowing they are in good hands.
Structural Skin Tightening with XERF: A New Era in Non-Invasive Lifting
XERF is the world’s first multifrequency monopolar RF structural skin tightening treatment, that uses AI-guided precision to lift, firm, and rejuvenate the skin from within. Its intelligent cooling and multi-depth technology deliver powerful, comfortable, and natural-appearing results—without needles, pain, or downtime.
What is XERF and How does IT Work?
Utilizing dual monopolar radiofrequencies of 6.78 MHz and 2 MHz, XERF generates controlled thermal energy to target the superficial, mid, and deep dermal layers. This precise thermal energy activates the skin’s natural repair response, stimulating the production of fresh collagen and elastin. Over time, the treated area appears lifted and the skin becomes visibly firmer, smoother, and more refined, with softened lines and improved elasticity. The XERF system combines Wave Fit™ pulse and Advanced Integrated Cryogen Delivery cooling technology to control energy delivery while maintaining surface temperature.
Summary of Xerf benefits:
Deep structural skin tightening and increased collagen levels
Improved skin texture
Dual Radiofrequency: The XERF system delivers the world’s first multifrequency monopolar RF treatment, combining 6.78 MHz and 2 MHz frequencies to target energy precisely where it’s needed
Multiple depths: Histological analyses from multiple clinical studies confirm that the XERF system effectively delivers RF energy to the SMAS (Superficial Musculoaponeurotic System), a key tissue layer beneath the skin that supports lifting, tightening, and reducing the appearance of jowls. In vivo porcine studies demonstrate that XERF stimulates thickening and tightening of collagen bundles across multiple tissue depths, while producing a measurable upward lift of the fascia.
Artificial Intelligence: XERF uses AI technology to provide a personalized, consistent, and safe approach to skin tightening and contouring by precisely controlling radiofrequency energy delivery.
Intelligent treatment parameters: Using advanced AI, XERF precisely analyzes the skin’s depth to customize the ideal treatment depth and energy settings for every patient.
Real-time monitoring and feedback: A built-in temperature monitoring system provides instant feedback to maintain effective heating while preventing overheating or discomfort.
Smart cooling: The AI-regulated ICD system cools the skin surface in real time, protecting the epidermis and improving comfort during treatment.
Predictive performance: XERF uses a "Wave Fit™ pulse" technology that automatically adjusts the energy output based on the treatment conditions, optimizing performance.
Customizable: Depth and energy settings can be adjusted to target the skin precisely, allowing the treatment to be tailored to each individual’s unique needs.
No downtime: There is no associated redness or appearance of external skin injury so patients can immediately return to normal daily activities after the procedure.
No numbing: Integrated cooling technology ensures patient comfort, allowing the treatment to be performed without anesthesia or topical numbing.
Fast and convenient: Each session takes only about 60 minutes, depending on the area(s) treated.
Versatile: Can be used to tighten skin on face or body.
Quick results: Although true remodeling after new collagen/elastin formation takes a 3-6 months, the effects of the skin tightening are apparent immediately after the treatment. The initial tightening with wane over time and slowly build back up over the next 3-6 months.
All skin types: XERF uses radiofrequency energy, safely reaching deeper layers to stimulate collagen and elastin without affecting the surface pigment (melanocytes). While XERF is generally safe for darker skin tones, patients with melasma may experience worsening of their pigment, as their skin is sensitive to heat.
What to Expect After Your XERF Treatment:
Following your XERF session, you may notice mild redness or a gentle tightening sensation—both normal signs that the treatment is stimulating your skin. These effects are temporary and typically fade within a few hours. Unlike more invasive procedures, XERF requires no downtime, allowing you to leave with refreshed, radiant skin and resume your day right away. To support optimal results, we recommend avoiding direct sun exposure and keeping your skin hydrated with a gentle moisturizer in the days after treatment.
What Results Can I Expect From XERF?
One of the most exciting features of XERF is the immediate visual improvement, which offers an encouraging preview of your skin’s transformation. This initial effect may soften after a few days. The full effects of skin tightening and texture improvement appears around three months post-treatment, when collagen stimulation produces more noticeable, long-lasting improvements.
This combination of instant and progressive results makes the XERF journey both exciting and rewarding, with the delayed peak delivering more substantial and enduring changes in skin firmness and texture.
Before and After Photos:
How does XERF compare to other skin tightening devices?
After nearly seven years of dedicated research and development in South Korea, XERF made its clinical debut there. Just over a year later, it received FDA clearance for use in the United States — bringing this advanced dual-frequency RF technology to a broader audience. Below is a brief summary of the nonsurgical skin tightening devices currently on the market based on their mechanism of action. The key difference with XERF compared to all the other devices is it’s depth of penetration and the amount of heat that it can comfortably transfer. No other device on the market besides XERF is able to utilize Artificial Intelligence to measure the skin's depth and accordingly set the optimal treatment depth and energy level for the individual patient.
Ultrasound: Ultherapy, Sofwave, HIFU (High Intensity Focused Ultrasound)
RF (Radiofrequency): Thermage, Ultherapy, XERF
RF Microneedling (micro needling plus radiofrequency): Genius, Potenza, Morpheus 8, Secret RF, Vivace, SylfirmX, etc.)
RF + HIFEM (High Intensity Focused Electromagnetic Energy): EMFACE
depth of treatment for various Skin tightening devices:
SMAS = Superficial Musculoaponeurotic System - a layer of fibrous tissue and muscle beneath the skin surface that provides structural support to the skin.
XERF vs RF Microneedling:
Radiofrequency microneedling combines the microneedling with Radiofrequency heat to treat multiple depths of the skin to induce collagen and elastin formation. RF Microneedling offers customizable depth settings for surface level concerns, but doesn't penetrate as deeply as XERF to provide the same level of structural tightening. RF microneedling requires topical numbing and can be painful. Different RF microneedling devices have advantages and disadvantages, but that is a topic for discussion on it’s own. There is downtime associated with RF microneedling such as redness, swelling, risks of hyperpigmentation; whereas ZERF is more comfortable and has no associated downtime. With the added topical numbing required, RF microneedling sessions can take longer to perform. RF microneedling delivers energy more precisely to the deeper layers of the skin, while XERF works through bulk heating to treat broader tissue areas. Although XERF can help refine pores and improve the appearance of scars, RF microneedling may offer more targeted results for these specific concerns.
XERF vs Thermage:
Thermage is an older RF technology that uses a single 6.78 MHz frequency to stimulate collagen, primarily targeting skin layers by using pulsed RF energy with fixed cooling cycles and manual impedance monitoring. In contrast, the XERF system is the world’s first multifrequency monopolar RF treatment, combining 6.78 MHz and 2 MHz to reach multiple depths of the skin—surface, mid, and deep—for more effective results. Unlike Thermage, which can be painful and lacks customization, XERF features adjustable settings, continuous controlled RF energy with AI impedance feedback and real-time thermal monitoring, and built-in cooling - providing a safer, more comfortable, and tailored treatment.
XERF vs Exilis:
Both Exilis and Thermage use monopolar radiofrequency (RF), which delivers energy through a single electrode to create a closed-loop circuit that penetrates deeply into the dermis, but does not reach the deeper structures (SMAS level). Unlike Thermage which relies solely on Radiofrequency, Exilis is able to cool the skin for a more comfortable experience and also incorporates ultrasound to control the depth of penetration. Exilis requires multiple sessions to obtain the results of a single session of XERF. Exilis treatments are also lengthy - a full face/neck treatment could take up to 2.5 hours to perform, while XERF treatments takes 60-90 minutes. Both Exilis and XERF do not require topical numbing, and have no associated recovery time.
XERF vs Ultherapy:
Ultherapy uses micro-focused ultrasound energy to heat the tissue to a precise temperature at three specific depths. Ultherapy is difficult to perform and requires an experiences/skilled practitioner to achieve optimal result. The treatment is painful and can unintentionally cause fat loss or nerve damage. Ultrasound also heats everything in it’s path because it does not target a specific chromophore.
1.5 mm - mid dermis (skin layer)
3 mm - deep dermis (fat layer)
4.5 mm - SMAS (Superficial Musculoaponeurotic System)- A network of collagen and elastic fibers, fat, and muscle that lies underneath the skin for lifting effect.
XERF can also penetrate all three depths, but with radiofrequency - not ultrasound. Radiofrequency has the benefit of targeting water as a specific chromophore. So rather than targeting everything in its path like Ultherapy, XERF can specifically target the retaining ligaments which contains high water content while sparing fat and nerves which have low water content. While Ultherapy relies on smaller coagulation zones, XERF relies on bulk heating and can therefore have a broader effect. In addition XERF can emit more energy (higher peak temperature 55-72 degrees Celsius) without being painful because of its surface cooling technology.
XERF vs SofWave:
Sofwave delivers synchronized ultrasound energy into the mid-dermis (1.5 mm) to induce collagen and elastin formation. Although more comfortable than Ultherapy, topical numbing is still recommended for Sofwave. The results from Sofwave develop gradually over time, while XERF produces visible tightening sooner thanks to its bulk heating technology, which targets the skin’s deeper structural layers. With it’s dual monopolar radiofrequencies, XERF can treat multiple depths (surface, mid, deep, whereas Sofwave only treats at the 1.5 mm depth producing superficial skin tightening, rather than the deeper structural tightening seen with XERF.
Comparison of Energy-Based Skin Tightening & Lifting Devices
| Device | Energy Type | Target Depth / Tissue | Primary Mechanism | Fat Impact Risk | Lifting vs Tightening | Pain / Anesthesia | Downtime | Key Strengths | Key Limitations |
|---|---|---|---|---|---|---|---|---|---|
| XERF | Monopolar RF (2 MHz & 6.78 MHz) with AI-guided depth control + dynamic cooling | Shallow, mid, deep (includes retaining ligaments & SMAS) | Bulk collagen contraction + long-term neocollagenesis with controlled volumetric heating | Low when properly set | Lifting, tightening, & structural support | Mild–moderate (no numbing) | None | Precise depth control, uniform heating, strong tightening/lifting without needles, low discomfort | Newer technology; availability limited |
| RF Microneedling | RF delivered via insulated or non-insulated needles | Dermis ± superficial subcutaneous fat (needle-dependent) | Fractional thermal injury → collagen remodeling | Moderate | Primarily tightening; limited lift | Moderate–high; topical numbing required | 3–10 days | Texture improvement, acne scars, customizable depth | Invasive, risk of fat loss, hyperpigmentation, operator-dependent |
| Sofwave | Synchronous ultrasound (SUPERB™) | Mid-dermis (~1.5 mm) | Focused thermal injury stimulating collagen | Low | Tightening only | Mild–moderate | None | Safe, quick | Limited depth; does not reach SMAS |
| Ultherapy | Micro-focused ultrasound | 1.5 mm (dermis), 3.0 mm (deep dermis), 4.5 mm (SMAS) | Coagulation points → tissue contraction | Low–moderate | Lifting & tightening | Moderate–high; analgesia often needed | None | True SMAS targeting, FDA-cleared for lifting | Painful, spotty energy delivery, variable results |
| Thermage | Monopolar RF with surface cooling | Dermis → superficial fat | Bulk heating → collagen contraction | Moderate | Tightening only | Moderate | None | Well-studied, single-session treatment | Less precise, discomfort, inconsistent heating |
| Exilis | Monopolar RF + ultrasound | Dermis → superficial fat | Thermal heating + tissue stimulation | Moderate | Mild tightening | Mild | None | Body contouring, non-invasive | Limited lifting, weaker facial tightening |