Written by Dr Gerard Ee | Medically reviewed by Dr Gerard Ee | Expert opinion by Dr Gerard Ee
Dr Gerard Ee is an aesthetic doctor and the founder and medical director of The Clifford Clinic, which he established 14 years ago. He has treated acne scars for 16 years and more than 2,000 acne-scar patients, and is one of Singapore’s longest-standing users of the Infini RF microneedling system (16 years). He holds a Diploma in Dermatology (Cardiff) and is a Member of the Royal College of Surgeons (MRCS). More on Dr Gerard Ee.
A common pattern is that several Sylfirm X sessions in, the skin is brighter and more even while the depressed scars remain unchanged. That outcome rarely reflects anything the patient did wrong. Almost always it represents a mismatch between the device, the spacing of sessions and the underlying cause. The four most common reasons are set out below, building on the opinion of Sylfirm X and the device comparison. When a patient tells me a full course of Sylfirm X produced nothing on their depressed scars, the explanation is usually that mismatch rather than anything peculiar to their skin.
Reason 1, underpowered for deep scars
Depressed scars require substantial energy delivered deep into the dermis, which is what decides which devices can address them. The FDA-cleared maximum for Sylfirm X is 16 W (K213612), whereas Secret RF is cleared to 25 W (K170325) and the insulated Infini to around 50 W (K121481). Sylfirm X is tuned for precise, lower-energy work and is not built for the deep remodelling a boxcar or rolling scar requires. No number of sessions fully overcomes a power ceiling. Having used the insulated Infini platform for sixteen years, I have found the difference between roughly 50 W and 16 W shows most clearly on deep boxcar and rolling scars. For a patient whose concern is pigment rather than depth, that same ceiling is an advantage.
Reason 2, too many sessions, too close together
A frequent and counter-intuitive pattern is that treating more frequently produces a worse result. Collagen requires an interval in which to form, and monthly treatment does not provide it, while attempting several modalities in one sitting under-doses every one of them. Delivering proper energy and spacing sessions four to six weeks apart outperforms crowding gentle treatments together, because that interval allows each session’s collagen to mature. The commonest scheduling error I see in a previous course is a run of closely spaced, low-energy sessions.
Reason 3, the acne was never addressed
Scar treatment carried out while acne remains active addresses damage that is still being generated, because every fresh breakout adds another scar. The acne is stabilised first, often with non-insulated Secret RF that calms the oil gland and sometimes with AGNES RF. Sylfirm X is a pigment-and-vessel device, and it is not the instrument for that acne-control step. A course begun before the acne has settled may improve tone while the scar count rises.
Reason 4, it is treating the wrong thing well
Sylfirm X delivers genuine gains on melasma, redness, pigmentation and pores. Clearer tone reflects the device performing the task it was designed around, and tone is a separate property from texture. A true depressed scar is a matter of depth, confirmed by stretching the skin or directing a light across it, as in the scars versus pigmentation guide. In my experience the most common reason a patient concludes that Sylfirm X has failed is that the colour improved while the shadows under angled light did not.
What to do next
Where Sylfirm X has not moved the scars, that rarely means the scars cannot be treated. It usually means the plan requires more power, better spacing and attention to the root cause. The rebuilt plan is a higher-energy backbone (Secret RF or Infini), combined with subcision, resurfacing and biostimulators, with the acne controlled first. The full plan is set out in the complete treatment guide, and the candid six things your doctor isn’t telling you is also worth reading. Of the patients who consult me after a stalled course, most received a reasonable treatment at an inadequate dose, and a minority have scars that respond only partially even to a properly powered plan.
What a proper RF plan looks like, by the evidence
Where Sylfirm X has underdelivered, the useful comparison is with what an evidence-based radiofrequency plan involves. Trials of fractional RF microneedling typically use a series of sessions spaced about four weeks apart, with scar improvement accumulating over the months that follow (split-face RCT, systematic review), rather than in quick succession. Because the energy delivered is a determinant of success (energy-as-factor study), a properly powered device used at adequate settings achieves what a 16 W device at the same cadence cannot.
The corrective is therefore rarely more of the same treatment. It is a better-matched device, used at proper energy and spaced sensibly, with the acne controlled first and combination treatments added for the scar types actually present. Under those conditions, both the published evidence and clinical practice indicate that previously stalled results usually begin to move. The improvement is measured in degrees rather than in erasure, and its extent varies with the scar types and the skin.
The collagen remodelling timeline
Part of the dissatisfaction with any scar treatment arises from misjudging the timeline. New collagen is laid down after each radiofrequency session and then matures over the weeks and months that follow. The gradual nature of that change makes it easy to miss from one day to the next, and an assessment made a few weeks after treatment often produces a falsely negative impression. Most of the visible improvement from a properly dosed course appears over three to six months, so patience is not encouragement but a component of how the treatment acts. When a patient reports at four weeks that nothing has happened, I have found the observation accurate about that moment and premature as a verdict on the course.
How to measure whether it is working
Because progress is slow, it requires measurement rather than casual inspection. Standardised photographs taken at each visit in the same lighting and from the same angle make honest comparison possible, and grading scales such as ECCA add a measure of objectivity. A review of those records across three to six months, rather than daily inspection in the mirror, produces a considerably more accurate picture. Measurement also separates a change in tone from a change in depth, since a device may be clearing pigment and improving brightness while leaving the scar contour unchanged. Photographs taken under angled light are the most informative of the set, because a depressed scar declares itself through the shadow it casts.
The under-dosing problem, in depth
The result of radiofrequency treatment depends on the energy delivered into the dermis, and a threshold exists below which a deep scar is not meaningfully remodelled. A device with a low maximum power, or a capable device run at conservative settings, delivers a stimulus that falls short of that threshold. Repetition of a sub-threshold treatment does not accumulate into an adequate dose, since every session under-delivers in the same way. Delivering adequate energy per session is therefore not optional for deep scars, and it is the factor most often missing when a course produces little change. That threshold cannot be read off a specification sheet for an individual patient, so an adequately powered device is a starting condition rather than a guarantee.
Why stacking treatments in one visit under-doses each of them
A related error is attempting too much within a single visit. Combining subcision, radiofrequency, laser and injectables in one sitting divides the tolerable quantity of energy and inflammation between them, so each individual treatment is under-dosed. The skin also has a limited capacity to heal well from several aggressive insults delivered at once. Sequencing the same treatments across separate, properly spaced visits allows each to be delivered at effective intensity, which produces better results than a crowded single session.
The root-cause step, controlling acne first
A course also stalls where the underlying acne was never brought under control. New scars continue to form from ongoing breakouts while older ones are being treated, and inflamed, acne-prone skin tolerates less energy per session. Stabilising the acne first, whether with non-insulated Secret RF that calms the oil gland, AGNES radiofrequency or appropriate medical therapy, is a prerequisite rather than an optional extra. Treating scars on skin that is still breaking out is therefore a frequent reason a course disappoints.
What a corrective plan looks like
Turning a stalled result around begins with a fresh assessment of the scar types present and of the skin tone. The plan is then rebuilt around an adequately powered device, Secret RF or the insulated Infini, with subcision added for tethered rolling scars, fractional CO2 for resurfacing, TCA CROSS for ice pick scars, and biostimulators where volume has been lost. Sessions are spaced four to six weeks apart, the acne is controlled first, and progress is recorded with standardised photographs. Movement in scars that had remained static usually follows the shift from a single under-powered approach to a properly dosed and well-sequenced combination.
Seeking a second opinion
A degree of preparation makes a second-opinion consultation considerably more useful. Bringing a record of the treatments and settings received, the dates and any earlier photographs allows a second doctor to establish what has been tried. It is reasonable to ask about the maximum power and treatment depth of the devices proposed, how far apart the sessions will be spaced, and how each scar type present will be addressed. A clinic that examines the skin in person and explains its reasoning at the level of mechanism, rather than brand, is a reasonable indication of quality. The record I most often wish a patient had brought is the settings used in the previous course, because without them an under-dosed plan and an unsuitable device look identical.
What the research shows
The published literature is consistent with each of these four reasons for an absent result. The energy delivered is repeatedly identified as a key determinant of response in studies of energy-based scar treatment. In one 121-patient analysis, laser energy was an independent factor predicting improvement (energy-as-factor study), and a low-power device therefore underperforms on deep scars whatever the session count. The modalities patients are switched to are themselves well evidenced, since fractional RF microneedling (systematic review) and microneedling (RCT review) both improve atrophic scars when used properly. These trials report averages across whole cohorts, so they establish what a category of treatment achieves rather than what an individual scarred face will achieve.
What the trials suggest to change
The same body of trials indicates which elements of a stalled plan should change. Because subcision combined with energy outperforms either component alone for tethered scars (subcision combination trial, 413-patient analysis), a plan built on a single gentle device was always likely to stall on rolling and boxcar scars. Because a properly powered RF device can match ablative laser (radiofrequency versus CO2 trial), the correction is usually a better-matched, adequately powered device used in combination rather than more sessions of the same one. The evidence therefore addresses the design of the plan rather than its duration.
How long to give a corrected plan
Once a better-matched plan is in place, it warrants enough time to work before it is judged. Because collagen remodelling is gradual, a fair assessment requires a full course of several sessions spaced four to six weeks apart, followed by review at around three to six months, when the collagen laid down has matured. An assessment made at one or two sessions will almost always read as falsely negative, since the deepest remodelling remains under way. A corrected plan should nonetheless show measurable change over that window, and where a well-spaced, adequately powered, root-cause-first approach yields no improvement over six months, the diagnosis and the technique are reassessed rather than the course simply continued. I cannot reliably predict at a first consultation how much depth correction a particular scar will show, which is why the review point is fixed in advance.
Warning signs a plan will not deliver
A small number of signs, recognised early, predict that a scar plan is unlikely to deliver. One is not being told the maximum power of the device used, or being treated with a device whose power sits at the low end, since for deep scars that specification matters most. Another is a schedule of weekly or fortnightly treatment, which does not allow collagen to mature between sessions. Promises of complete scar removal are a further warning, since honest treatment offers significant and gradual improvement rather than erasure. A single machine applied to every scar type is another, since a mixed face requires a combination of modalities. The absence of an in-person assessment that maps the scar types present, or of any step to control active acne first, indicates a plan built around a product rather than the patient. Treatment without standardised photographs makes genuine progress impossible to judge. A plan that avoids these errors is far more likely to move scars that a previous course left unchanged, although no combination of those elements guarantees a particular degree of correction.
The bottom line
The common reasons for an absent result are an underpowered device, sessions spaced too closely for collagen to rebuild, and untreated acne. Switching to a higher-power, well-spaced, root-cause-first plan usually moves the same scars. I have not found a session count that compensates for a power ceiling on deep scars, which is why the recommendation after a stalled course is a different device rather than more of the same. The degree of depth correction still varies between patients and is best assessed in person. Continue with why power matters in RF microneedling.
Frequently Asked Questions
Why am I not seeing results from Sylfirm X on my acne scars?
The usual reasons are that the device is underpowered for deep scars, at 16 W against 25 W for Secret RF and around 50 W for Infini, that sessions were too frequent for collagen to rebuild, or that active acne was never controlled. Tone may improve while scar depth remains unchanged, which accounts for skin that looks better and scars that look the same.
Can doing RF microneedling monthly improve results?
Monthly treatment usually produces the opposite of the intended effect. Sessions at that frequency do not allow enough time for collagen to build, and each treatment is often under-dosed. Sessions are best spaced roughly four to six weeks apart, and a longer interval is preferable to a shorter one.
Did Sylfirm X help the skin at all?
Sylfirm X may well have helped, although not in the respect being tracked. It commonly improves pigmentation, redness, pores and overall tone. Those are genuine benefits, and they are different from lifting a depressed scar, which is why tone and depth are best judged separately.
What should be used instead for depressed acne scars?
A higher-power approach is indicated, with Secret RF or the insulated Infini as the backbone, subcision, fractional CO2 and biostimulators added, and the acne controlled first. Outcomes vary with the scar types and the skin, and improvement is gradual rather than immediate.
Key references
- Fractional CO2 for atrophic acne scars: scar type and energy as independent factors (121 patients). PubMed.
- Fractional radiofrequency microneedling as monotherapy in acne scars: systematic review. PubMed.
- Microneedling for atrophic scars: systematic review of randomised controlled trials. PubMed.
Comparative trials cited
- Abdelwahab AA, Omar GAB, Hamdino M. Combined subcision with fractional CO2 laser or cross-linked hyaluronic acid versus subcision alone in atrophic post-acne scars. Lasers Med Sci. 2022;38:20. PubMed.
- Li X, Fan H, Wang Y, et al. Fractional CO2 laser combined with subcision for three subtypes of atrophic acne scars: retrospective analysis of 413 patients. Lasers Med Sci. 2023;38:195. PubMed.
- Qu L, Sha S, He C, et al. Non-insulated microneedle fractional radiofrequency versus ablative fractional CO2 laser for facial atrophic acne scars: pilot randomised split-face study. Acta Derm Venereol. 2025. PubMed.
Device specifications & sources
- S. FDA 510(k) Summary K213612 (SYLFIRM X, ViOL Co., Ltd.): Output power Max 16 W at 50 Ω. 2 MHz. Bi-polar RF.
- S. FDA 510(k) Summary K170325 (Secret RF, Ilooda Co., Ltd.): Max power Max 25 W at 500 Ω. 2 MHz. Needle depth 0.5-3.5 mm.
- S. FDA 510(k) K121481 (INFINI, Lutronic Inc.): insulated RF microneedling system, 49-pin handpiece, maximum RF generator output approximately 50 W.
Written, medically reviewed and expert opinion by Dr Gerard Ee, aesthetic doctor and Founder & Medical Director of The Clifford Clinic. This article reflects my clinical experience treating acne scars in Singapore and is intended for general education, not medical advice. Treatment suitability, results, downtime and cost vary from person to person. Please arrange a consultation for advice specific to your skin.
