Ultherapy delivers heat deep into the skin, causing the tissues to contract and stimulating nerves, which leads to sharp and achy discomfort. Areas with thinner skin and fat, or areas close to bone such as the jawline, tend to be more painful. Higher energy levels and more shots also increase the level of pain. Rather than sedation, safer options include oral pain medication, numbing cream, cooling, and customized treatment planning. CoolSoniq is another alternative that is significantly less painful than Ultherapy.
The Fundamental Reason Ultherapy Hurts
Ultherapy uses high-intensity focused ultrasound (HIFU) energy to create thermal coagulation points (TCPs) in deep layers of the skin—specifically the subcutaneous fat layer and the SMAS (muscle fascia). These heat spots cause the tissue to contract.
Just like meat on a grill contracts when heated, aged and stretched tissue deep within the skin also tightens when heat is applied.
To create tissue remodeling, the temperature must reach over 60°C. Ultherapy generates these high temperatures instantly. At that moment, pain receptors (nociceptors) activate and produce intense discomfort.
There are two types of nociceptors delivering pain signals:
· A-delta fibers – fast, sharp pain
· C fibers – dull, lingering pain
What Does Ultherapy Pain Actually Feel Like?
The thermal coagulation point formed the moment each shot is delivered stimulates the A-delta fibers, creating:
→ A deep, sharp, needle-like pain.
After the treatment, tissue remodeling and mild inflammation activate the C-fiber pathway, leading to:
→ A heavy, aching sensation that may linger lightly for 3–4 weeks.
How Painful Is Ultherapy?
Medically, pain is rated using the NRS (Numerical Rating Scale), ranging from 0 to 10.
Most patients rate Ultherapy around 6–8, often described as the second most painful dermatologic procedure after Rejuran.
Why Pain Varies So Much Between People
1) Differences in Skin & Fat Thickness
The average skin thickness of the cheek and jawline—the main Ultherapy areas—is about 1.5 mm.
Thin skin: ~1.0 mm
Thick skin: ~2.0 mm
Fat layer: 5–15+ mm (large individual variance)
· Thin skin + thin fat → energy reaches deeper nerves → more pain
· Thick skin + thick fat → most heat forms within fat → less pain
This is why choosing the right cartridge for each individual's skin and fat thickness is essential for minimizing pain while maintaining effectiveness.
2) Day-to-day condition
Pain sensitivity increases due to:
· Caffeine
· Lack of sleep
· Feeling tense or anxious
Patients who sleep well, avoid caffeine, and stay relaxed generally experience less pain.
Pain Differences by Area, Energy, and Shot Count
1) Treatment Area
Pain intensifies when energy reaches fascia or bone-adjacent areas.
For example, treating near the jawline—where sagging is corrected—tends to be more painful.
Conversely, areas with more subcutaneous fat like the mid-cheek hurt less.
2) Energy Level
Ultherapy offers four energy settings:
4.5 mm cartridge: 0.75 / 0.9 / 1.0 / 1.2J
3.0 mm cartridge: 0.25 / 0.3 / 0.35 / 0.45J
In the past, higher energy levels were assumed to be more effective.
However, studies now show almost no difference between level 2 and level 4.
→ Today, level 2 is recommended.
3) Shot Count
Treatment time:
300 shots → ~15 minutes
600 shots → ~30 minutes
More shots = more pain.
Also, longer sessions may reduce the effectiveness of numbing.
If you have low pain tolerance, 300 shots + another lifting device (e.g., Onda) is the best balance of effect and comfort.
Do You Really Need Sedation for Ultherapy?
Sedation (conscious sedation) is possible but not recommended.
1) Safety Concerns
Sedatives like propofol, midazolam, and ketamine may suppress breathing.
They require continuous oxygen saturation monitoring.
However, many dermatology clinics perform sedation without proper monitoring equipment, and some have limited experience administering sedation—leading to real complications.
For this reason, I do not perform sedation for Ultherapy and instead recommend safer pain-management alternatives.
2) Movement During Treatment
With conscious sedation—similar to endoscopy—patients remain partially aware.
If a patient moves their head or face due to discomfort, it can compromise the precision of the treatment.
Ultherapy requires extremely accurate placement, so movement is problematic.
How to Reduce Ultherapy Pain
1) Oral Pain Medication
NSAIDs (Ibuprofen): reduce nociceptor sensitivity
Acetaminophen (Tylenol): reduces brain perception of pain
These complement each other.
Taking both 30 minutes before treatment significantly reduces discomfort.
2) Numbing Cream
Applying lidocaine cream for a longer duration improves absorption into the dermis.
Apply on dry skin after cleansing, wrap with plastic film, and leave for at least 30 minutes.
Numbing cream helps reduce superficial stinging pain but has limits for deep, sharp pain.
3) Customized Treatment Design
If a clinic applies the exact same Ultherapy protocol to every patient, results decline and pain increases.
For example, applying a 4.5 mm cartridge uniformly along the jawline of someone with thin skin and little fat will only increase pain and decrease effectiveness.
Poorly customized treatment can also increase the risk of cheek hollowing.
Ultherapy requires a patient-specific treatment plan.
4) Epidermal Cooling
Cooling slows nociceptor conduction and activates A-beta fibers, which suppress pain pathways (A-delta and C).
Pre-treatment cooling significantly reduces discomfort.
Some newer devices come with built-in cooling—one such example is CoolSoniq, often called “pain-free Ultherapy.”
Cooling + HIFU = CoolSoniq
CoolSoniq uses the same HIFU principle and maintains strong output, but built-in cooling dramatically reduces pain.
If Ultherapy pain is around 7–9, CoolSoniq is around 2–3.
Its pen-type cartridge also makes it effective on detailed areas like nasolabial folds, which are harder to treat with Ultherapy.
Ultherapy Pain – FAQ
Q. If I don’t feel much pain, does that mean the treatment isn’t working?
A. No. Many patients say Ultherapy hurts less than expected.
Patients with thicker skin and fat usually form thermal coagulation points in the fat layer, resulting in less pain but the same effect.
Q. What about nitrous oxide (laughing gas)?
A. It’s a good option for those worried about pain but hesitant about sedation.
It doesn’t eliminate pain completely—you simply feel mildly relaxed, similar to being tipsy.
Q. Is Ulthera Prime (Ultherapy 2) less painful?
A. No. The new model only improves ultrasound imaging resolution.
Hardware, treatment mechanism, pain level, duration, effectiveness, and side-effect risk remain essentially the same.
Many patients feel anxious because they’ve heard Ultherapy is painful, and anxiety can heighten perceived pain.
However, most end up saying, “It wasn’t as bad as I thought.”
To prevent complications and ensure safe, effective lifting, it’s worth reconsidering full sedation.
Since multiple pain-reduction options are available, I recommend visiting the clinic for individualized consultation first.
This has been Dr. Dohoon Kim from ODE Clinic!
Author: Dr. Dohoon Kim, Chief Director of ODE Clinic
Specialty: Anti-aging (Lifting, Volumizing, etc.)