Combined Renuvion and Endolift Therapy Suggests Enhanced Skin Tightening Compared to Monotherapy in Upper Arm Rejuvenation: A Case Report

Abstract

Introduction

Skin laxity, a common esthetic concern, drives demand for non-surgical solutions. Energy-based devices like Renuvion^® (helium plasma/radiofrequency) and Endolift^® (1,470 nm diode laser) offer minimally invasive tightening, yet their combined efficacy remains underexplored. This study evaluates synergistic effects of Renuvion^® and Endolift^® through an intra-patient comparison.

Case Presentation

A 44-year-old female with moderate upper arm laxity underwent Renuvion^® alone on the right arm and combined Renuvion^® + Endolift^® on the left. Endolift^® (6 W, 50 ms ON/OFF pulses, 600 μm fiber) delivered 4,000 J–5,000 J per arm via subdermal scraping. Renuvion^® followed 1 week later, using standard subdermal settings. Outcomes were assessed via laxity scoring, circumferential measurements, blinded practitioner evaluations, and patient feedback at 8 weeks. The combination arm demonstrated a higher reduction in circumference (34.3% vs. 28.8%) and superior practitioner ratings (3/3 vs. 2/3), indicating enhanced skin tightening. Blinded practitioners rated the left arm’s improvement as “marked” (score 3/3) vs. “moderate” (score 2/3) for the right. Patient satisfaction aligned with objective metrics, citing the left arm as “tighter” and “more contoured.” No adverse events occurred.

Conclusion

Combining Renuvion^® and Endolift^® enhanced skin tightening compared to Renuvion^® monotherapy, which may suggest synergistic subdermal remodeling. This dual-modality approach may optimize outcomes in fibrous anatomical regions, though larger controlled studies are warranted.

Introduction

Skin laxity remains a prevalent esthetic concern, particularly among middle-aged individuals seeking non-surgical rejuvenation options. The advent of energy-based devices has revolutionized the approach to skin tightening, offering minimally invasive alternatives with reduced downtime and enhanced safety profiles [1]. Although several energy-based technologies have demonstrated efficacy in non-surgical skin tightening, there remains a lack of evidence on how different modalities may complement one another when used in combination. In particular, no peer-reviewed studies have yet evaluated the sequential application of Endolift^® (1,470 nm diode laser) and Renuvion^® (helium plasma/radiofrequency [RF]) for skin laxity. Reinforcing this gap is crucial as the two technologies rely on distinct but potentially synergistic mechanisms of action [2]. The present case, therefore, aimed to provide preliminary insights into this unexplored therapeutic approach. Renuvion^®, a helium plasma and RF energy device, has emerged as a promising modality in this domain [3]. Its unique mechanism combines RF energy with helium gas to create a plasma that delivers controlled thermal energy to subdermal tissues [4]. This process induces immediate collagen contraction and stimulates neocollagenesis, leading to improved skin firmness and elasticity. Notably, the rapid heating and near-instantaneous cooling facilitated by helium gas minimize thermal diffusion, reducing the risk of damage to surrounding tissues [5]. Clinical studies have substantiated the efficacy and safety of Renuvion^® in various anatomical regions. A randomized controlled study of 176 arm-contouring patients demonstrated comparable efficacy between RF-assisted liposuction, Renuvion helium subdermal coagulation, and VASER-assisted liposuction alone. Both energy-assisted groups (RF-assisted liposuction/Renuvion) achieved significant skin tightening and fat reduction, with 80.6% patient satisfaction and 97/119 cases rated good-to-excellent by an independent surgeon, offering safer, scar-free alternatives to brachioplasty for moderate arm laxity [6]. A retrospective review of 47 patients (mean age 45, BMI 25.8) treated with helium-based plasma RF (Renuvion) for soft tissue coagulation revealed no serious device-related adverse events. Abdominal, gluteal, and thigh regions required the highest energy delivery (averaging 13.7 kJ, 13.5 kJ, and 10.6 kJ, respectively), underscoring Renuvion’s safety profile and adaptability for targeted body contouring [7]. Despite these encouraging findings, literature comparing the synergistic effects of Renuvion^® with other energy-based modalities, such as Endolift^®, remains scarce. Endolift^® employs a 1,470 nm diode laser delivered via micro-optical fibers to target subdermal tissues, promoting collagen remodeling and skin tightening. The potential complementary mechanisms of Renuvion^® and Endolift^® warrant exploration to optimize treatment outcomes. The rationale for combining these modalities lies in their complementary mechanisms of action. Endolift^® induces controlled subdermal thermal injury and mechanical disruption of fibrous septa, thereby stimulating collagen remodeling and tissue tightening from within. Renuvion^®, in contrast, provides helium plasma mediated RF energy that produces rapid collagen contraction with minimal collateral damage. Used sequentially, Endolift^® may prime the subdermal matrix for enhanced responsiveness to subsequent Renuvion^® application, suggesting a potential synergistic effect on skin tightening. This case report presents a unique intra-patient comparison, wherein a 44-year-old woman underwent combined Renuvion^® and Endolift^® treatment on one arm and Renuvion^® alone on the contralateral arm. To our knowledge, no peer-reviewed studies have yet evaluated the sequential use of Endolift^® and Renuvion^® in a clinical setting. To support this claim, a literature review was conducted using PubMed, Scopus, and Google Scholar databases. Search terms included “Renuvion,” “helium plasma,” “Endolift,” “1,470 nm laser,” and “combination therapy,” with filters applied for English-language publications between 2015 and 2025. While several studies have explored each modality independently, we found no published reports on their combined application. The objective was to evaluate the differential outcomes and assess the potential synergistic benefits of combining these two modalities for enhanced skin tightening.

Case Presentation

A 44-year-old female presented to our esthetic practice with concerns about moderate skin laxity affecting the upper arms. She had no significant medical history, was a non-smoker, and reported no history of substantial weight fluctuations, recent pregnancies, or major surgical interventions.

This patient was selected because she had moderate bilateral arm laxity, no comorbidities, and symmetrical baseline anatomy, making her suitable for intra-patient comparison. Her primary esthetic goal was to improve skin firmness and contour definition, particularly in the upper arm region. Following a comprehensive clinical assessment and discussion of available options, an intra-patient comparative design was proposed to explore the effects of Endolift^® and Renuvion^® both as standalone and combination therapies, while acknowledging potential sources of bias such as arm dominance, anatomical asymmetry, and the 1-week interval between treatments.

Treatment Protocol

Circumference measurements were taken at standardized anatomical landmarks (midpoint between the acromion and olecranon) using a non-stretch tape, with the arm relaxed at the patient’s side. This standardized position ensured reproducibility across follow-ups. Measurements were recorded in triplicate by a single trained operator to minimize inter-operator variability, and the mean value was used for analysis. Endolift^® was performed first on the left (non-dominant) arm using the LASEMAR 1500^™ device (Eufoton s.r.l., Italy) with the following parameters: power 6 W, pulse 50 ms ON/50 ms OFF, and a 600 μm fiber. Total energy delivered to the left arm ranged between 4,000 J and 5,000 J. The fiber was inserted parallel to the skin in the subdermal plane, using rapid back-and-forth motions to mechanically stimulate the dermal underside, followed by side-to-side passes to release fibrous adhesions. One week later, Renuvion^® treatment was administered to both arms using standard subdermal techniques (power 80, helium flow 1.5 L/min, total energy 18 kJ, suction 150 mm Hg). The sequencing – Endolift^® followed by Renuvion^® on the left arm – was noted as a potential factor influencing collagen remodeling and tissue healing. The rationale for performing Endolift^® first was to induce subdermal collagen remodeling and tissue priming, thereby enhancing the subsequent effect of Renuvion^®. This sequencing was also chosen to minimize overlapping thermal injury. A 1-week interval was selected between Endolift^® and Renuvion^® to allow initial post-laser inflammation to subside and to reduce the risk of overlapping thermal injury. This timing reflects common clinical practice for sequential energy-based treatments and aims to optimize collagen remodeling while maintaining patient safety. In addition, the sequence of performing Endolift^® prior to Renuvion^® was chosen because Endolift^® induces controlled subdermal thermal injury and mechanical disruption of fibrous septa, which may “prime” the tissue for enhanced collagen contraction with subsequent Renuvion^®. While no preclinical studies directly compare the sequence, this rationale is supported by theoretical synergy and current clinical practice. The left arm received Renuvion^® following the prior Endolift^® session, while the right arm received Renuvion^® alone (Fig. 1). Both procedures were well tolerated, with no intraoperative or immediate postoperative complications. Mild erythema and transient tenderness resolved within 48–72 h without additional analgesia beyond routine care. Written informed consent was obtained for both the procedures and the publication of de-identified clinical photographs.

Fig. 1.

Dual-position Renuvion^® technique. a Renuvion^® procedure performed in the supine position for initial subdermal coagulation. b Subsequent treatment phase in the seated position within the same session to assess and enhance skin tightening under gravitational influence, ensuring natural contouring outcomes.

Outcome Assessment

At the 8-week follow-up, outcomes were assessed using two complementary measures: a validated clinician-derived 5-point skin laxity scale and standardized arm circumference measurements. For the circumferential evaluation, upper arm girth was recorded at a fixed mid-humeral landmark. Each value was measured in triplicate and averaged to reduce operator variability. The right arm, which had received Renuvion^® alone, decreased from 45.8 cm before treatment to 32.6 cm at follow-up, representing a mean reduction of 28.8% with a standard deviation of 0.5 cm. The left arm, treated with Endolift^® followed by Renuvion^®, showed a reduction from 46.1 cm to 30.3 cm, corresponding to a 34.3% decrease with a standard deviation of 0.4 cm (Fig. 2). In parallel, skin laxity was graded independently by two board-certified dermatologists who were blinded to the treatment allocation. A five-point scale adapted from Hexsel et al. [8] was used, where 0 represented no laxity and 4 indicated severe laxity. This validated scale, originally described by Hexsel et al. [8], is commonly applied in clinical studies of skin laxity.

Fig. 2.

Clinical photographs showing upper arm contour and skin laxity before and after treatment. a Left arm before treatment. b Left arm after Renuvion^® + Endolift^® combination therapy. c Right arm before treatment. d Right arm after Renuvion^® monotherapy.

The right arm improved from a baseline score in the moderate-to-severe range to a post-treatment score corresponding to moderate laxity, while the left arm progressed from the same baseline category to a post-treatment score consistent with only mild residual laxity. In addition, the patient’s subjective satisfaction was estimated at 10/10 on a visual analog scale for the combination-treated arm versus 8/10 for the Renuvion^®-only arm. Although the numerical differences between arms were modest, the combination-treated side demonstrated firmer tissue on palpation, more defined contouring, and higher qualitative ratings from both clinicians and the patient. The right arm also improved, but mild residual laxity remained along the posterior and medial upper arm. Comparative results are summarized in Table 1 for circumferential changes and in Table 2 for laxity scores.

Table 1.

Mean upper arm circumference before and 8 weeks after treatment, with absolute and percentage change

Arm	Before, cm	After, cm	Change, cm	Change, %	SD from triplicates, cm
Right (Renuvion® only)	45.8	32.6	13.2	28.8	0.5
Left (Endolift® + Renuvion®)	46.1	30.3	15.8	34.3	0.4

SD from triplicates indicates measurement variability from three repeated readings.

Table 2.

Laxity score assessment before and after treatment

Arm	Baseline laxity score (0–4)	Post-treatment laxity score (0–4)	Blinded practitioner rating (0–3)	Patient satisfaction
Right (Renuvion® only)	1	3	2	Moderate
Left (Endolift® + Renuvion®)	1	4	3	High

Laxity scores were graded on a 0–4 ordinal scale (0 = none, 4 = severe) by two blinded dermatologists using standardized photographs. Practitioner ratings were based on a separate 4-point scale (0 = no change, 3 = marked improvement). Patient satisfaction was recorded qualitatively at the 8-week follow-up.

Statistical Analysis

Due to the single-patient design, only descriptive statistics were applied, reporting mean, absolute, and percentage changes for laxity scores and arm circumference. Variance was estimated from the standard deviation of triplicate measurements, and results were presented in tables for visual comparison. No inferential testing was performed.

Discussion

The findings from this intra-patient comparison suggest that combining Renuvion^® with Endolift^® therapy may offer enhanced skin tightening compared to Renuvion^® monotherapy in the treatment of moderate upper arm laxity. Both objective and subjective assessments favored the dual-modality approach, with greater percentage reduction in arm circumference (34.3% vs. 28.8%), improved tissue firmness, higher practitioner ratings, and increased patient satisfaction. This supports the hypothesis that the two energy-based modalities may exert complementary effects when used sequentially. Renuvion^® has demonstrated efficacy in non-excisional skin tightening through precise subdermal heating and helium-assisted cooling, which minimizes collateral tissue damage and induces both immediate collagen contraction and long-term neocollagenesis. However, its performance may be limited in highly fibrous areas or in patients requiring deeper dermal stimulation. Endolift^®, while effective for tissue remodeling, requires significant operator skill and may produce variable outcomes depending on fiber angulation and tissue resistance. This balanced appraisal underscores that neither modality alone is universally effective. The synergistic results observed may stem from the mechanical scraping and controlled thermal injury induced by Endolift^®, which could prime the tissue for enhanced responsiveness to subsequent Renuvion^® application. However, the 1-week interval between treatments may have independently influenced wound healing and collagen remodeling, potentially amplifying the combined effect. Speculatively, a shorter interval might have increased the risk of cumulative inflammation or overlapping thermal effects, whereas a longer interval could have reduced the synergistic potential by allowing partial collagen remodeling to occur before the second modality. Future controlled studies are needed to determine the optimal sequencing interval. This temporal factor must be considered in interpreting the findings. Importantly, a balanced perspective must also acknowledge the limitations of each technology in isolation. Although the combined use of these modalities appears promising, further studies are needed to validate optimal parameters and treatment sequencing. Despite these encouraging findings, this case is limited by its short-term follow-up period of only 8 weeks. While early improvements in skin laxity and contour were observed, such a timeframe is insufficient to evaluate the durability of results or the full extent of collagen remodeling, which typically evolves over several months. Longer follow-up is essential to determine whether the observed improvements are sustained, diminish, or continue to progress over time. Moreover, objective imaging modalities such as high-frequency ultrasound or histological sampling were not employed, which could have provided more robust evidence of subdermal remodeling. Several studies have independently demonstrated the efficacy of Renuvion^® and Endolift^® in non-surgical skin tightening across various anatomical areas. Tambasco et al. [9] reported significant improvements in facial and neck skin laxity (p < 0.05) and 85% patient satisfaction at 6 months following Renuvion^® treatment, with effects lasting up to 5 years in some cases. Similarly, Barone et al. [10] observed enhanced contouring and statistically significant laxity reduction in post-massive weight loss patients undergoing abdominoplasty when Renuvion^® was used adjunctively with liposuction. Driscoll et al. [5] further reinforced Renuvion’s reliability in body contouring through a multi-site retrospective analysis, highlighting its consistent outcomes and minimal recovery time, while also noting the importance of operator expertise to avoid complications like subcutaneous emphysema. In parallel, Endolift^® has also demonstrated clinical value. Nilforoushzadeh et al. [11] reported significant improvements in skin elasticity and jowl fat reduction (p < 0.01) with 85% patient satisfaction at 6-month follow-up. Haykal et al. [12] examined a combination of Endolift^® with poly-l-lactic acid (Endoskin protocol) and found that it produced better results in both tightening and volumization compared to Endolift^® alone (p < 0.05), with no major adverse events. Meanwhile, Suh et al. [13] reviewed Endolift’s use in treating facial and neck laxity and acknowledged its potential but emphasized the need for standardized treatment protocols to ensure reproducibility. Together, these studies underscore the individual benefits of both technologies; yet to date, no peer-reviewed reports have evaluated their combined use in a sequential dual-modality protocol. The present case, therefore, provides an early foundation to support this approach and justifies the need for future comparative trials. This highlights the novelty of the current case and its potential to inform future research. As this is a single-patient case report with short follow-up, the findings must be interpreted as preliminary. Larger controlled studies with longer follow-up and objective imaging are required to validate the observed synergy. Nevertheless, this report highlights an important clinical observation that may guide future research.

Statement of Ethics

All procedures performed in this study were in accordance with the ethical standards of the Institutional and/or National Research Committee and with the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from the patient for the treatment procedures described and for the publication of de-identified clinical details and accompanying images. This study protocol was reviewed and the need for approval was waived by the Ethics Committee of Shahid Beheshti University of Medical Sciences. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000549556).

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This study was not supported by any sponsor or funder.

Author Contributions

M.A.N. (Mohammad Ali Nilforoushzadeh) conceptualized and supervised the study. S.N.M. (Seyedeh Nasim Mirbahari) contributed to manuscript drafting, clinical follow-up and image documentation. S.R. (Shohreh Rafiei), T.F. (Tannaz Fakhim) and M.H.S. (Mohammad Hasan Shahverdi) involved in patient treatment and provided technical support during procedures. R.E. (Rozhin Enamzadeh) contributed to manuscript editing. All authors reviewed and approved the final version of the manuscript. patient treatment and data collection.

Funding Statement

This study was not supported by any sponsor or funder.

Data Availability Statement

The datasets generated and analyzed during the current study are not publicly available due to patient privacy and ethical considerations but are available from the corresponding author on reasonable request. Access to the data will require approval by the Institutional Ethics Committee to ensure compliance with confidentiality agreements.