the role of massage in scar management a literature review

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The role of massage in scar management: a literature review

Affiliation.

• 1 Department of Dermatology, University Hospitals Case Medical Center and School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
• PMID: 22093081
• DOI: 10.1111/j.1524-4725.2011.02201.x

Background: Many surgeons recommend postoperative scar massage to improve aesthetic outcome, although scar massage regimens vary greatly.

Objective: To review the regimens and efficacy of scar massage.

Methods: PubMed was searched using the following key words: "massage" in combination with "scar," or "linear," "hypertrophic," "keloid," "diasta*," "atrophic." Information on study type, scar type, number of patients, scar location, time to onset of massage therapy, treatment protocol, treatment duration, outcomes measured, and response to treatment was tabulated.

Results: Ten publications including 144 patients who received scar massage were examined in this review. Time to treatment onset ranged from after suture removal to longer than 2 years. Treatment protocols ranged from 10 minutes twice daily to 30 minutes twice weekly. Treatment duration varied from one treatment to 6 months. Overall, 65 patients (45.7%) experienced clinical improvement based on Patient Observer Scar Assessment Scale score, Vancouver Scar Scale score, range of motion, pruritus, pain, mood, depression, or anxiety. Of 30 surgical scars treated with massage, 27 (90%) had improved appearance or Patient Observer Scar Assessment Scale score.

Conclusions: The evidence for the use of scar massage is weak, regimens used are varied, and outcomes measured are neither standardized nor reliably objective, although its efficacy appears to be greater in postsurgical scars than traumatic or postburn scars. Although scar massage is anecdotally effective, there is scarce scientific data in the literature to support it.

© 2011 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.

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The Role of Massage in Scar Management: A Literature Review

Shin, Thuzar M. MD, PhD 1 ; Bordeaux, Jeremy S. MD, MPH 1

1 Department of Dermatology, University Hospitals Case Medical Center and School of Medicine, Case Western Reserve University, Cleveland, Ohio,

Address correspondence and reprint requests to: Jeremy S. Bordeaux, MD, MPH, 11100 Euclid Avenue, Lakeside 3500, Cleveland, OH 44106, or e-mail: [email protected]

The authors have indicated no significant interest with commercial supporters.

Background 

Many surgeons recommend postoperative scar massage to improve aesthetic outcome, although scar massage regimens vary greatly.

Objective 

To review the regimens and efficacy of scar massage.

Methods 

PubMed was searched using the following key words: “massage” in combination with “scar,” or “linear,” “hypertrophic,” “keloid,” “diasta*,” “atrophic.” Information on study type, scar type, number of patients, scar location, time to onset of massage therapy, treatment protocol, treatment duration, outcomes measured, and response to treatment was tabulated.

Results 

Ten publications including 144 patients who received scar massage were examined in this review. Time to treatment onset ranged from after suture removal to longer than 2 years. Treatment protocols ranged from 10 minutes twice daily to 30 minutes twice weekly. Treatment duration varied from one treatment to 6 months. Overall, 65 patients (45.7%) experienced clinical improvement based on Patient Observer Scar Assessment Scale score, Vancouver Scar Scale score, range of motion, pruritus, pain, mood, depression, or anxiety. Of 30 surgical scars treated with massage, 27 (90%) had improved appearance or Patient Observer Scar Assessment Scale score.

Conclusions 

The evidence for the use of scar massage is weak, regimens used are varied, and outcomes measured are neither standardized nor reliably objective, although its efficacy appears to be greater in postsurgical scars than traumatic or postburn scars. Although scar massage is anecdotally effective, there is scarce scientific data in the literature to support it.

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Dermatologic Surgery > 38 > 3 > 414 - 423

Many surgeons recommend postoperative scar massage to improve aesthetic outcome, although scar massage regimens vary greatly.

To review the regimens and efficacy of scar massage.

PubMed was searched using the following key words: “massage” in combination with “scar,” or “linear,” “hypertrophic,” “keloid,” “diasta*,” “atrophic.” Information on study type, scar type, number of patients, scar location, time to onset of massage therapy, treatment protocol, treatment duration, outcomes measured, and response to treatment was tabulated.

Ten publications including 144 patients who received scar massage were examined in this review. Time to treatment onset ranged from after suture removal to longer than 2 years. Treatment protocols ranged from 10 minutes twice daily to 30 minutes twice weekly. Treatment duration varied from one treatment to 6 months. Overall, 65 patients (45.7%) experienced clinical improvement based on Patient Observer Scar Assessment Scale score, Vancouver Scar Scale score, range of motion, pruritus, pain, mood, depression, or anxiety. Of 30 surgical scars treated with massage, 27 (90%) had improved appearance or Patient Observer Scar Assessment Scale score.

Conclusions

The evidence for the use of scar massage is weak, regimens used are varied, and outcomes measured are neither standardized nor reliably objective, although its efficacy appears to be greater in postsurgical scars than traumatic or postburn scars. Although scar massage is anecdotally effective, there is scarce scientific data in the literature to support it.

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Thuzar M. Shin

• University Hospitals Case Medical Center and School of Medicine, Case Western Reserve University

Jeremy S. Bordeaux

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• Corpus ID: 80043896

Role of Massage on the Management of Hypertrophic Scar: Review

• Published 16 March 2017
• International journal of multidisciplinary and current research

2 Citations

Effects of mechanical stimulation on mastectomy scars within 2 months of surgery: a single-center, single-blinded, randomized controlled trial., effect of skin rehabilitation massage therapy on burned patient' outcomes, 28 references, the role of massage in scar management: a literature review, massage in hypertrophic scars., scar contractures, hypertrophic scars, and keloids, [international clinical recommendations on scar management]., the effect of burn rehabilitation massage therapy on hypertrophic scar after burn: a randomized controlled trial., incidence of hypertrophic scarring in burn-injured children., effects of skin rehabilitation massage therapy on pruritus, skin status, and depression in burn survivors., quality of life of patients with keloid and hypertrophic scarring, what is the prevalence of hypertrophic scarring following burns, hypertrophic burn scars: analysis of variables., related papers.

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The role of scar massage in cleft lip surgery

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Introduction : Despite advances in surgical technique for cleft lip, minimal evidence exists for methods of scar management, particularly scar massage. Some parents express concern that lip massage creates pain and distress to their children. This study aims to determine whether scar massage has enough cosmetic advantage to justify its use.

Method : We reviewed 33 unilateral complete cleft lip repairs performed at our institution. Information on repair technique, suture material and scar management were recorded. Parent questionnaires and clinical photography were used with a panel of eight trained blinded observers asked to assess photos taken 24 months postoperatively. Scars were graded using a scale of one (very poor) to five (excellent). Twenty patients were included. Ethics approval was obtained from The Royal Children’s Hospital Melbourne Research Ethics and Governance office with HREC reference number QA/60562/RCHM-2019.

Results : Frequency of scar massage was not associated with a better scar score (p = 0.36). Both the technique of repair and type of suture material used had greater effect on scar grading than massage therapy.

Discussion : Problematic scarring following cleft lip surgery is a challenging outcome. This is the first study aiming to explore the effect of scar massage following cleft lip surgery.

Conclusion : We found no conclusive evidence to support the use of scar massage in the postoperative care of cleft lip patients. Limitations include the retrospective nature of the study, low patient numbers and heterogeneity of surgical techniques. Nevertheless, there was no correlation seen between the frequency of massage and scar quality. Lip scar massage can cause significant pain to patients and distress to their family, warranting further studies to justify its use.

Cleft lip is the most common congenital malformation of the head and neck, affecting one in 700 births. 1 Unilateral cleft lip deformity occurs with the failure of fusion of the medial nasal and maxillary prominences during early gestation. The result is an aberrant insertion of the orbicularis oris muscle as well as myriad of changes to the lip and nose construct. 2 There is often an association with a cleft palate with the combined treatment requiring multi-disciplinary care that continues into adulthood. The aims of treatment are to attain normal oral occlusion and speech as well as reconstruction of the affected facial units. 3

Modern cleft lip surgical technique reflects the evolution of repairs used over many decades. The rotation-advancement principle was first described by Millard. 4 Many modifications have since been described, including techniques described by Fisher that emphasise scar placement, in the ideal line of repair as defined by aesthetic subunits, and the importance of pre-planned markings over ‘cut as you go’. 5

Regardless of the technique used, upper lip scars are at risk of hypertrophy and widening. The incidence of hypertrophic scaring in cleft lip surgery is 11 per cent in the Caucasian population and up to 36 per cent in the Asian population. 6

In an attempt to modulate scar formation, postoperative management typically includes massage with moisturising cream, scar taping and the use of topical silicone. Previous studies have found that topical silicone does not form stable adhesion on small and irregular upper lip areas. 7 The implementation of any physical scar treatment in cleft lip repair scars is challenging due to the age of the patients, and the pain and distress associated with lip massage.

As clinicians, we recommend scar massage as it has little clinical downside, gives the parents ownership of the scar and has no financial cost. We all hear anecdotal experience of hypertrophic scars that seem to improve with this intervention, hence a reluctance to discard this recommendation. However, many of us have also experienced a vastly improved scar where parents have admitted to little or no massage. There is no conclusive experimental evidence supporting scar massage in the cleft lip population. Thus, the aim of this study was to measure the effects of postoperative scar massage on the appearance of unilateral cleft lip scars.

Between May 2009 and August 2011, 33 unilateral complete cleft lip repairs were performed at Royal Children’s Hospital Melbourne by four different surgeons. All patients were fitted with arm splints following the operation. Patient demographics, type of suture material used and technique of repair were recorded. Patients were professionally photographed preoperatively and then postoperatively at approximately three, six, 12, and 24 months by a single photographer.

A panel of eight blinded observers comprising four plastic surgeons and four surgical allied health workers were selected to participate. Observers were shown a slideshow containing de-identified photographs of patients 24 months postoperatively, distributed in random order ( Figure 1 ). They were instructed to rate each photo on a scale of one to five based on the quality of the scar alone, with one equal to ‘very poor’, two to ‘poor’, three to ‘good’, four to ‘very good’ and five to ‘excellent’ (see Appendix 1 ). To standardise the method of ranking, clear written instructions were provided to each member of the panel making clear that the study was solely looking at the appearance of the scar and that the result of the cleft lip repair itself (symmetry, alignment, etc) should not be taken into consideration.

Scar massage data was obtained retrospectively via telephone questionnaire. Parents were asked whether lip scar massage was performed ‘every day’ (score of one), ‘sometimes (2–3 times per week)’ (two), or ‘never’ (three). Statistical analysis was conducted using Stata software (version 15; StataCorp LLC 4905 Lakeway Drive, College Station, Texas 77845-4512, USA). Group data was compared with one-way ANOVA. P-values less than 0.05 were considered significant.

Ethics approval was obtained from The Royal Children’s Hospital Melbourne Research Ethics and Governance office with HREC reference number QA/60562/RCHM-2019.

Twenty patients responded to phone questionnaires and formed the study group. All patients had their cleft lip repair between the ages of three and nine months with an average of 5.3 months of age. The most common type of cleft lip repair used was based on Fisher’s technique which comprised of 12 patients, followed by Millard’s technique with seven patients and one patient having an operation based on the technique described by Mohler. 8 Eleven patients were treated with absorbable sutures and nine had non-absorbable sutures with removal at a second operation. No postoperative complications such as infection or wound dehiscence were recorded in the cohort.

On questioning, six patients never had any cleft lip massage and formed the ‘no massage group’, seven patients had massage every day (massage group) and seven patients formed the ‘sometimes group’ (performing massage less commonly than every day). Length of time of each massage session and total length of time massaged were not recorded due to the difficulty in recollection and consistency. Qualitative analysis showed that some massage sessions were aborted early due to child distress.

Box plot of scar scores for each group is found in Figure 2 . Average scar score for the no massage group was 3.62 (SD ± 0.58), 3.16 (SD ± 0.43) for the massage group and 3.17 (SD ± 0.82) for the sometimes group. On statistical analysis, frequency of scar massage was not associated with a better scar score ( p  = 0.36). Every day massaging was also not statistically better than no massage ( p  = 0.41).

Regarding other potential variables affecting cleft lip scar, patients undergoing cleft lip repair with Fisher’s technique had better scar scores than patients undergoing Millard’s repair ( p  = 0.027). Scar scores were also better when non-absorbable suture material was used ( p  = 0.0013).

Problematic scarring following facial surgery is a challenging complication often causing significant distress. 9 Scar forms between the three phases of healing: inflammatory, proliferative and remodelling. The final appearance of a scar depends on the level of cellular activity within each phase and is influenced by multiple genetic and environmental factors. 7 , 9 Exactly how massage modifies the construct of a scar is not completely understood. Shin and colleagues have suggested the application of mechanical force in a scar alters the molecular signalling responsible for the formation of connective tissue growth, which in turn downregulates fibrosis. 10 Reno and colleagues suggest that scar massage induces fibroblast apoptosis, thus reducing collagen deposition. 11

Shin and colleagues 2012 systematic review showed that scar massage can have significant efficacy, mainly in the treatment of postoperative scars, but little effect was seen in equivalent traumatic scars. 10 The authors describe vast inconsistencies regarding treatment protocols, duration of therapy sessions and how outcomes were measured, hence evidence-based recommendations were difficult to make. Cho and colleagues 2014 randomised controlled trial in burn patients showed statistically significant improvement in scar pigmentation and skin elasticity with scar massaging albeit when conducted three times a week by a massage therapist. 9 Despite encouraging evidence in other areas, minimal data exists on its use in postoperative cleft lip repair patients. We only found a single case-study regarding the use of massage therapy in a cleft lip scar. 12 Other authors have recommended the use of cleft lip massage but no evidence has been documented. 13 , 14

Scar management advice in our institution is usually based on surgeon’s preference, with common options being avoidance of direct sun exposure, scar taping and scar massage. Other options for scar management following cleft lip surgery have been explored in the literature with variable results. Intense pulsed light laser therapy has shown good short-term outcomes but long-term data is lacking. 7 Botulinum toxin A has been trialled with a positive effect on cleft lip scar width, however, it did not have any statistically significant change in scar pigmentation, vascularity, pliability or height. 15 Long-term data on botulinum toxin A effect on lip scaring is lacking and significant costs and the rare but significant side-effect of oral incontinence is often a barrier for use. One study explored the use of hydrogen peroxide washes, however did not use a control group. 14 One author described the use of an ointment comprising of paraffin, tetracycline, petroleum jelly such as Vaseline® and lignocaine combined with a Logan Bow dressing. 16 Silicon sheeting and silicone gel have also been explored but without a control group. 17

We recognise the presence of confounding factors when assessing the effects massage in cleft lip surgery scars in our study. Surgeons’ experience, surgical technique, suture material, trauma sustained during scar maturation and surgical complications can all play a key role in determining the final look of a scar. 6 , 7 , 10 Our study found a statistically significant improvement in scar scores when the Fisher’s technique of cleft lip repair was used. The results are in keeping with other evidence previously described by Kwong and colleagues and Mittermiller and colleagues. 18 , 19 Further limitations include the retrospective nature of this study and reliance on parents’ recall. In our experience, massaging the lip was a particularly traumatic experience and parents were quite vivid in their recollections.

It is indeed possible that the positive effect of scar massage seen in other areas of the body is not replicated in our cleft lip cohort due to technical issues with massaging an infant’s lip. Qualitative feedback from the parents in our study certainly support the concept that children may become distressed during massage, and this may result in cessation or shorter therapy duration. Jin and colleagues systematic review identified therapy related factors responsible for early treatment discontinuation in patients. 20 Long treatment duration as well as the side effect of pain could have a causative effect on the early cessation of cleft lip massage in our cohort. Furthermore, overcoming the parental instinct caused by a crying child can be challenging. Prolonged exposure to a crying child has the neuroendocrine effect of causing stress and placing demands on a parent to act, in this case, by discontinuing cleft lip scar massage. 21

Our study is based on small numbers, however, regardless of surgeon or surgical technique, our evidence shows no correlation between the use of massage and the quality of the scar. Larger studies conducted in a prospective nature will commence at our institution in response to these initial findings.

Future studies will prospectively randomise patients, control for possible confounding factors and use an objective scar assessment scale such as the patient and observer scar assessment scale (POSAS). 22

To our knowledge, this is the first study exploring the important subject of postoperative scar massage in the outcomes of unilateral cleft lip repair surgery. Our study did not find conclusive evidence to support the use of scar massage following primary repair of unilateral cleft lip. Our study revealed that many parents and children reported or experienced distress during lip scar massaging, thus warranting further evidence to support its use. Further studies are encouraged among other institutions to support the use of this potentially distressing postoperative intervention.

Acknowledgements

Statistical analysis was performed with support from Dr Vicky Tobin, Peninsula Health, Victoria, Australia.

Prior publication

This article was accepted for verbal presentation at the Annual Scientific Meeting for the Royal Australasian College of Surgeons.

Consent to publish

Patients/guardians signed informed consent regarding publishing their data and photographs.

The authors have no conflicts of interest to disclose.

Financial declaration

The authors received no financial support for the research, authorship, and/or publication of this article.

Submitted : May 11, 2020 AEST

Accepted : January 12, 2021 AEST

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Effectiveness of various methods of manual scar therapy

Agnieszka lubczyńska.

1 Department of Cosmetology, School of Pharmaceutical Science in Sosnowiec, Medical University of Silesia, Katowice Poland

Agnieszka Garncarczyk

Dominika wcisło‐dziadecka, associated data.

Data sharing not applicable.

The skin is a protective barrier of the body against external factors, and its damage leads to a loss of integrity. Normal wound healing results in a correct, flat, bright, and flexible scar. Initial skin damage and patient specific factors in wound healing contribute that many of these scars may progress into widespread or pathologic hypertrophic and keloid scars. The changes in cosmetic appearance, continuing pain, and loss of movement due to contracture or adhesion and persistent pruritis can significantly affect an individual's quality of life and psychological recovery post injury. Many different treatment methods can reduce the trauma and surgical scars. Manual scar treatment includes various techniques of therapy. The most effectiveness is a combined therapy, which has a multidirectional impact. Clinical observations show an effectiveness of manual scar therapy.

Material and methods

The aim of this work was to evaluate effectiveness of the scar manual therapy combined with complementary methods on the postoperative scars. Treatment protocol included two therapies during 30 min per week for 8 weeks. Therapy included manual scar manipulation, massage, cupping, dry needling, and taping.

Treatment had a significant positive effect to influence pain, pigmentation, pliability, pruritus, surface area, and scar stiffness. Improvement of skin parameters (scar elasticity, thickness, regularity, color) was also noticed.

To investigate the most effective manual therapy strategy, further studies are needed, evaluating comparisons of different individual and combined scar therapy modalities.

1. INTRODUCTION

The skin is a protective barrier of the body against external factors, and its damage leads to a loss of integrity. Scars are formed as an effect of damaging the skin. They affect most people on earth. Scars arise as a result of mechanical damages, burns, surgical procedures, chemical or biological agents, and long‐lasting skin diseases. 1 The optimal result of wound healing is a mature, well healed scar. Normal wound healing results in a correct, flat, bright, and flexible scar. Normal scars do not go beyond the original area of damage and are aesthetically satisfactory. Among the factors increasing the risk of pathological scarring, we can distinguish: age, anatomic location, race, and type of trauma. An important problem in the wound healing process is the formation of pathological scars, such as hypertrophic scars, keloids, and atrophic scars. The keloids and hypertrophic scars incidence is determined at the level of 4.5%–16%. 1 , 2 Pathologic scar formation manifests itself by low tensile strength, pigment alterations, increased tension texture, and sensation irregularities. Abnormal scars arising as a result of disorders in the process of fibrosis raised above the surface of the skin, beyond the original area of damage. Often abnormal scars are accompanied by pain, itching, and contractures. 1 , 2

Initial skin damage and patient specific factors in wound healing cause that many of these scars may progress into widespread or pathologic hypertrophic and keloid scars. Any dysfunction in the wound healing process may result in excessive scar tissue formation. Despite the continual advancement or surgical care, patients who have undergone surgical interventions are often left with scars, persistent functional impairments, and symptomology. 3

In addition, scar esthetics can also have a negative influence on psychosocial factors. Inevitable problems associated with postoperative scars are adhesions. Adhesions occur after every abdominal operation but the majority of them are clinically silent. Parts of postoperative adhesions (i.e., after cesarean section [CS]) contribute significantly to chronic abdominal pain, recurrent intestinal obstruction, chronic back pain, and infertility. Intraabdominal adhesions occur at a 7% rate after one CS up to 68% with repeated cesareans. Despite recent advances in surgical techniques and scar therapies, there is no dependable strategy to manage postoperative adhesions. In many cases as consequences of deep dermal defects appear hypoesthesia, hyperalgesia around the injured area, and functional limitations. 4 , 5

The normal wound healing process is a strictly controlled state of balance between the process of disintegration of the structure of the damaged tissue and the repair consisting in the synthesis and formation of a new, correct one. Mediators, blood cells, extracellular matrix cells, and parenchymal cells are involved in the process. Increased activation and migration of fibroblasts to the wound bed regulated deposition of the extracellular matrix and its shrinkage are responsible for the proper healing of the skin. 3 , 6 , 7 , 8

During the wound healing, four phases overlapping each other in time and closely related to each other are distinguished. The first phase occurring immediately after the damage is the hemostasis phase; the second phase is the inflammatory phase lasting from 24 to 72 h, which can extend from 5 to 7 days. From 1 to 3 weeks after the damage, there is a phase of proliferation and repair of the damaged tissue lasting about 3–4 weeks. In the fourth stage of the healing process, remodeling takes place, and this phase can be extended from 3 weeks to several years, during which the wound will mature and reach the final strength. 8

Scars can greatly affect the quality of life. Many different treatment methods can reduce the trauma and surgical scars. These include physical methods: manual therapy, appropriate pressure, taping, cryotherapy, dermabrasion, radiation, laser therapy, pharmacological methods, and surgical techniques. The most effective is a combined therapy. Cosmetologists focus on esthetic problems with scars, whereas physiotherapists work with pain and functional limitations caused by tissue damage and scars. The purpose of physical scar management focuses primarily on the prevention of an abnormal healing process of the skin. 9 , 10 , 11

External mechanical impacts in daily activities can lead to in the formation of marked scar strands and adhesions. Overloading leads to renewed inflammatory reaction and thus in further restriction. An effective method used in anti‐adhesions prevention is postoperative scar physiotherapy, including lymphatic drainage, scar mobilization, kinesiotaping, or myofascial relaxation. Manual scar therapy to be effective requires applying physiological stimuli adequately to the phase of wound healing. Scar tissue therapy is a treatment for reducing pain and functional limitations, improving pliability, reducing hyperpigmentation, pruritus, fascial adhesions, to reduce scar thickness and smooth surface area. Scar tissue massage is a form of rehabilitation that uses pulling and stretching to remodel scar tissue. 7 , 8 , 11 Scar massage helps regain mobility and strength in damaged tissue. After a few minutes of mechanical stimuli directly in the scar, a release in the tissue can be observed. The second way of influence of mechanical stimuli from outside to the body is a mechanotransduction. It describes the ability of a cell to actively sense, integrates, and converts mechanical stimuli into biochemical signals. Every stimulus has result in intracellular changes, such as ion concentrations, activation of signaling pathways, and transcriptional regulation. The aim of the therapeutically applied manual techniques is therefore not only to mechanically lengthen collagen fibers but also to directly influence the cell biological processes by means of adequate stimulation. The protocol of effective manual scar therapy should include correct dosage of stimulation. The adequate dosage should be determined according to the wound healing phase and needs adjustment of amplitude, duration, and frequency of stimulation. Overloading the scar tissue can lead to cellular damage and triggers a new inflammatory reaction. However, underloading leads to reduced elasticity, resilience, and disorganized form of cross‐links. 7 , 8 , 11 Koller 11 suggested dosage recommendations depend on the wound healing phase. In the proliferation phase (until day 21), stimulation should be lower, in the area of the first remarkable increase in connective tissue resistance. In the last remodulation phase of wound healing, stimulation can be higher, until the second remarkable increase in connective tissue resistance, but not exceeding the anatomical barrier. The recommended duration of application is 1 min per localization, three to five times per a therapy unit and supplemented by an oscillating frequency of 0.2 Hz at the end of the respective amplitude. 11

To increase the effectiveness of the scar therapy, it is advisable to use combined treatment. Manual work often proceeds alternately or together with cupping, dry needling, kinesiotaping, instrument therapy, electrodermal therapy, exercises, compression, pharmacotherapy, and other. Adjusting of the therapy requires considering various factors and an individual approach to the patient. 12

Cupping is a supporting method used in scar treatment. Subatmospheric pressure suction affected by cup, promote peripheral blood circulation, and improve tissue elasticity. Cupping therapy can be used with caution only in the remodeling phase of the wound healing and in old scars treatment. The reported effect of cupping therapy includes modification of the skin's biomechanical properties and improving local anaerobic metabolism. However, too high pressure can induce microtraumatic injures and triggers new inflammatory phases. Especially in the early phase, it can quickly lead to an overdose. 12 , 13 , 14

Kinesiotaping takes advantage of the physical properties of elastic therapeutic tapes and specific methods of its applications. Mechanism of this treatment is based on lifting skin microscopically and improving blood and lymph circulation. It causes fascia relaxation, improves tissue nourishment, and reduces edema. Previous studies have shown that the tape application directly over a wound or scar can reduce skin tension and prevent tissue overgrowth. Tape application, through pulling fresh wound closure, can reduce the mechanical forces affecting the wound. 15 , 16 , 17 , 18

Dry needling is a method applied to decrease pain and improve scar mobility. The classic technique is named “surrounding the dragon” that involves encircling the problem area with needles. The mechanism of action remains unclear. The current literature suggests that dry needling may be an effective method for treating scar tissue by suppressing local inflammation, stimulating reepithelization, and reducing scar hyperproliferation. In older scars, dry needling triggers regenerative mechanisms and induces collagen formation, neoangiogenesis, and skin cell proliferation. 19 , 20

Scar treatment includes various techniques of therapy. Clinical observations show an effectiveness of manual scar therapy. However, the question of which dosage should be applied in which wound healing phase at which intervention time is not easy to answer. Further studies are needed to verify and quantify the efficacy of combined methods, to understand the underlying mechanism, and to establish a protocol of effective intervention.

The aim of the research was to evaluate effectiveness of the scar manual therapy combined with complementary methods on the postoperative scars.

2. MATERIALS AND METHODS

Eleven volunteers (women) of average age 32.9 ± 5.2 with postoperative scar were classified in this study. Patients had scars after elbow operation (1), abdominal operation (3), and CS (7). The average age of the scar was 5 months (±2.9). All respondents notice ailments and discomfort correlated with the scar. One person was excluded from the study due to initiation of the other treatment.

The inclusion criteria for the study were as follows:

• presence of at least one linear, surgical scar;
• age of the scar under 12 months;
• the current lack of any scar therapy;
• nonuse topical treatment.

The exclusion criteria for the study were as follows:

• use of any topical treatment on the scar;
• current other scar therapy;
• unhealed wounds or age scar under 6 weeks.

The research was conducted after receiving a positive opinion of the Bioethics Committee of the SUM, no. KNW/0022/KB1/27/I/16 on 06.06.2016. All volunteers received information about conditions of participation in the study.

Before and after the end of the scar therapy, the patients had a series of measurement. To evaluate objective results of therapy were used: clinical photography, measurement of skin parameters, and high‐frequency ultrasounds (HFUS). Photographies were taken using a dermatoscope Heine DELTA 30 (×10 optical magnifications). Examinations of skin parameters were carried out using Multi Probe Adapter MPA 10 (Courage + Khazaka Electronic GmbH, Germany). Hydration (Corneometer CM 825), transepidermal water loss (TEWL; Tewameter TM Hex), melanin and hemoglobin levels (Mexameter MX 18), and viscoelasticity (Cutometer 580) were measured before and after the therapy on the scar and on the healthy skin. Scar tissue was also imaged using DUB SkinScanner high‐frequency ultrasound equipped with a 33 MHz transducer. The DUB SkinScanner 75 5.21 software was used to evaluate the scar height and their structure and density. Scars were also subjective evaluated by patients and an observer with Patient and Observer Scar Assessment Scale (POSAS) scale (Figure  1 ).

The Patient and Observer Scar Assessment Scale

Statistical data analysis was conducted with the use of Statistica 13.3 (TIBCO Software, Palo Alto, CA, USA) and MS Excel 2016 (Microsoft, Redmond, WA, USA). All results are presented as mean ± standard deviation and were examined for normality of distribution by the Shapiro–Wilk test. Parametric data were analyzed using Student's t ‐test. For nonparametric data, Mann–Whitney U test was applied to indicate statistical significance. A p  < 0.05 was considered statistically significant.

The treatment protocol included two therapies during 30 min per week for 8 weeks. The treatment protocols were the same for all patients but required an individual approach. Therapy included manual scar manipulation (every session), massage (every session), cupping (every second session; four times per whole treatment), dry needling (two times per the entire protocol; at 9th and 13th session), and taping (every second session, eight times per whole treatment). Cupping and dry needling were used from 5th week of the therapy. The classical technique of dry needling was used (“surrounding the dragon”; Figure  2 ). Tapes were applied once a week with “zig‐zag” or “star technique” (Figures  3 and  4 ).

Scar dry needling

“Star” technique of scar taping

“Zig‐zag” technique of scar taping

Visually comparison based on photography confirms noticeable influence of the manual scar therapy. Scars after 8 weeks therapy are paler, flatter, and more regular, which can be observed on Figures  5 , ​ ,6, 6 , ​ ,7, 7 , ​ ,8 8 .

Photographs of scar after elbow operation before (A) and after (B) manual scar therapy

Photographs of scar after cesarean section (CS) before (A) and after (B) manual scar therapy

Dermatoscopic view of scar after elbow operation before (A) and after (B) manual scar therapy

Dermatoscopic view of scar after cesarean section (CS) before (A) and after (B) manual scar therapy

HFUS show real‐time images of the skin layers, appendages, and skin lesions in vivo and allow us to evaluate effects of different skin treatments. Pathological conditions (e.g., scars) related to the accumulation of fibers within increase the echogenicity of the skin. In this study, HFUS were used to assess the influence of scar manual therapy on scar height and their structure (Figure  9 ). Differences in scar structure regarding the arrangement of collagen fibers, after the therapy, were observed with statistical significance (Avg = 3.1 ± 1.3 vs. Avg = 5.7 ± 1.3; p  < 0.005). Manual scar work caused its relaxation and reduced the density of collagen fibers cross‐linking within it. The effect on the scar height was not observed (Figure  10 ).

High‐frequency ultrasounds (HFUS) of the skin with scar longitudinal section (A and B) and transverse section (C and D) before (A and C) and after (B and D) manual scar therapy

The results of the measurements the scar height (A) and structure (B) before and after manual therapy; average, average ± SD, and average ± 1.96*SD

Differences in skin parameters, including hydration (Avg = 37.8 ± 7.7 vs. Avg = 48.6 ± 1.2; Figure  11 ), TEWL (g/m 2 /h) (Avg = 13 ± 4 vs. Avg = 9.7 ± 2.4; Figure  12 ), stretchability (mm) (Avg = 0.003 ± 0.0003 vs. Avg = 0.05 ± 0.01; Figure  13 ), and erythema level (Avg = 352.1 ± 103.1 vs. Avg = 249.9 ± 89.8; Figure  14 ), were found. Level changes of melanin in the scar tissue after treatment were not statistically significant (Avg = 104.9 ± 44 vs. Avg = 83.7 ± 27.7; Figure  14 ).

Hydration level of the scar before and after 8 weeks therapy; average, average ± SD, and average ± 1.96*SD

Transepidermal water loss (TEWL) level of scar before and after 8 weeks therapy; average, average ± SD, and average ± 1.96*SD

Stretchability level of scar before and after 8 weeks therapy; average, average ± SD, and average ± 1.96*SD

Melanin and erythema level of scar before and after 8 weeks therapy; average, average ± SD, and average ± 1.96*SD

The POSAS was used in the last part of scar evaluation. Patient self‐assessment was performed using the patient component of the POSAS. Volunteers have to rate using scale from 1 to 10, where 1—means lack of indicated feeling and 10—means high intensity feeling. Patient components, which were assessed, were pain, pruritus, color, stiffness, regularity and additionally vascularization, and elasticity. Differences in all groups were statistically significant (Figures  15 and  16 ). After the therapy, patients were most satisfied with the scar color and elasticity. All respondents observed an improvement in the appearance of the scar and reduction of discomfort associated with this lesion.

Subjective assessment of scar pain, pruritus, color level before and after therapy; average, average ± SD, and average ± 1.96*SD

Subjective assessment of scar stiffness, regularity, elasticity, and vascularization level before and after therapy; average, average ± SD, and average ± 1.96*SD

4. DISCUSSION

Scars are a natural result of the healing process. If during this process any disruptions or elongation time of healing appear, it may result in excessive scar tissue formation. The changes in cosmetic appearance, continuing pain, and loss of movement due to contracture or adhesion and persistent pruritis can significantly affect an individual's quality of life and psychological recovery after the injury. The formation of adhesions can bind the visceral organs to other tissues of the abdominal and pelvic wall, causing low back pain, bowel obstruction, infertility, painful bladder syndrome, severe pain with menstruation/ovulation, and decreased mobility. Hypertrophic scarring has a genetic compound but can sometimes also result from repeated or excessive stresses on the wound site during the proliferative phase of healing. Hypertrophic scars often appear thick, wide, and raised from the skin. 1 , 2

The scar therapy is often a neglected element of postoperative physiotherapy. Patients often do not correlate their pain and mobility restrictions with scar tissue. Early treatment can prevent hypertrophy of the scar reduce discomfort and ailments and learn proper skin care. 10 Many different methods may be used to reduce or prevent pathological scarring. Gianatasio et al. 3 proposed combination scars treatment customized to scar type, depth, texture, and dyschromia. Early intervention is not essential to scar mitigation. Careful and appropriate treatment algorithms may restore significant scar function. 3

The research team under the direction Kantor et al. 21 utilized a rigorous psychometric approach to develop a new scar rating scale, the Scar Cosmesis Assessment and Rating (SCAR) scale. The SCAR scale consists of six items scored by the observer and two simple yes/no questions answered by the patient. In practice the most popular scales to evaluate the scars are the Observer Scar Assessment Scale and the Vancouver Scar Scale (VSS). VSS enables analysis of scars according to four parameters: the vascularity, pigmentation, pliability, and height of scars. In POSAS, there have also been attempts to include subjective symptoms, such as pain, discomfort, and itching, which had not been considered in previous scar assessment scales. 21 , 22

The manual scar tissue therapy uses techniques such as massage, skin rolling, cupping, myofascial release, dry needling, and instrument‐assisted soft tissue mobilization to help the fiber in scar tissue and fascia to become more aligned. These techniques also reduce tension within the scar and improve blood flow to the area which supports the healing process. The aim of the therapy is to introduce motion and nutrition to the affected tissue which will affect the alignment of the collagen fibers. Taping is used as a supporting method between therapeutic sessions. Tapes promote drainage‐treated area, prevent overloading, and exert a slight, constant pressure on the scar tissue. Although taping is a recommended method for scar therapy, there is not any confirmed treatment procedure. 23 , 24 , 25

The scar massage and manual manipulations are commonly used in the management of linear surgical scarring. They are easy, noninvasive, and low‐cost methods. The scar massage may improve some scar characteristics with evidence supporting its use to reduce pain and increase movement. Deflorin et al., 10 in their systematic review and meta‐analysis concerning on the effect of physical treatment methods on scar tissue, suggested that massage had a positive influence on scar pruritus and pliability. The evidence of improvements in scar thickness was inconclusive. Shin et al., 26 in their earlier literature review, noted that scar massage can be effective, but the lack of a consistent procedure for implementation, complicate an objective evaluation. The similar conclusion is highlighted by Scott et al. in their review. The scar tissue massage may be beneficial in reducing pain, increasing movement, and improving scar characteristics but needs consistent scheme of intervention. Cited protocols used for randomized control trials in the burn scar massage literature include 5 min, three times per week, for 12 weeks with no evidence of long‐term benefit and 30 min, three times per week, for up to 8 weeks with improvements to pain, pruritis, and scar characteristics. Application of scar massage for linear, surgical scar can be different and in clinical practice may be altered to fit the patient. In this study, the treatment protocol includes the scar massage in combination with other manual technique, 30 min, two times per week for 8 weeks. Patients using POSAS evaluate effectiveness therapy in all criteria positively assessed: pain, pruritis, color, stiffness, thickness, regularity, vascularity, and elasticity of scar, after treatment. The scar assessment using high‐frequency ultrasound showed a significant change in tissue structure and also benefits in skin parameters were observed. 10 , 25 , 26 , 27 , 28 , 29

Taping and dry needling are supporting methods. They are more effective combined with other techniques. Dry needling of scars can be an effective method in reduction of pain and other scar‐related symptoms. Existing evidences are limited and require verification. Tapes application in managing scar and keloids has good results as a maintained therapy but also as an independent method. Taping therapy is supposed to weaken subcutaneous adhesions and thus improves the appearance and softness of the scar. In previous studies, Daya and Karwacińska et al. reported statistically significant reduction in itch, pain, thickness, scar elevation, and positive effect on scar color and height. Tape application made scars become brighter, softer, and less elevated. Changes involving scar mobility were also observed, the pulling sensation was reduced, and the range of motion of the involved joint was improved. There are also reports of effectiveness of keloid taping in size and pain intensity reduction. Tapes were mostly applied on 3–5 days with 2–3 days breaks for 12 weeks. The stretch of the tape ranged from 25% to 100%. The final tension depended on an individual evaluation by the therapist. Kinesiotaping is highly effective and recommended especially to hypertrophic, contracture scars, and keloids. 15 , 16 , 17 , 18

Rozenfeld et al. 20 suggested a protocol of effective application of needles. Needles (0.25 mm × 30 mm) should be placed along the entire scar in 0.5–1.0 cm increments. Needles should be inserted at a distance of 0.5–1.0 cm from the scar angled 30°–45° toward the scar. Needle twisting should be depended on the patient's sensitivity. The treatment duration is about 20 min once or twice a week until resolution, or a symptom plateau is achieved. 20

The integrated therapy in this study allowed obtaining an effectiveness protocol of manual therapy in linear, surgical scar. Patients’ satisfaction evaluated by POSAS shows significant positive effect in scar characteristic. After 8 weeks of therapy, improvement in scar elasticity, thickness, regularity, and color was observed. Measurements confirm observations. Objective methods of assessment included HFSU, and examination of skin parameters indicates improvement scar hydration, elasticity, and fiber structure. The decrease in the hemoglobin value was also observed. Differences in height of scar and level of melanin were not noticed.

The limitations of the study include a small number of patients, lack of comparison to completely normal skin, and lack of a control group. In future, the research group should be extended, and the comparison with the control group is necessary and single methods with the same conditions.

5. CONCLUSIONS

The manual scar tissue therapy includes a variety of methods and techniques and requires management protocols with details about the type, frequency, time, and duration of the treatment. However, it should be taken into consideration that each therapy requires adaptation to the patient and has to be treated individually.

The therapy, including scar massage, soft tissue manipulation, cupping, dry needling, and taping, was applied in this study. The treatment has a significant positive effect on pain, pigmentation, pliability, pruritus, surface area, and scar thickness. Improvement of skin parameters was also noticed.

Clinical observations show effectiveness of manual scar therapy. However, the question of which dosage should be applied in which wound healing phase at which intervention time is not easy to answer. Further studies are needed to verify and quantify the efficacy of combined methods, to understand the underlying mechanism, and to establish a protocol of effective intervention.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

ACKNOWLEDGMENT

This study was supported by the Medical University of Silesia (PCN‐2‐092/N/1/I).

Lubczyńska A, Garncarczyk A, Wcisło‐Dziadecka D. Effectiveness of various methods of manual scar therapy . Skin Res Technol . 2023; 29 :e13272. 10.1111/srt.13272 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

DATA AVAILABILITY STATEMENT