Introduction to wound healing and scars.
Millions of people annually develop scars in response to injuries after surgery, trauma, or burns. Our skin has a number of functions, from body temperature regulation to being the main barrier protecting us from our immediate environment. When we sustain an injury, the quicker the wound closes and heals, the quicker the barrier is restored and we are protected from infection. But skin also helps us communicate with our social worlds, we sense being touched by another human through the nerve endings in our skin, and we can also become aware of how the world sees us.
Even well healed scar tissue loses some of its original integrity, depending on the level of damage sustained. To simplify the idea, think about having a body suit that tears: when you approximate the surfaces together to sew it, the area loses some of its elasticity. Our bodies are not like body suits, but rather complex tensegrity structures, if one part is a little restricted, they are really good at “borrowing” from elsewhere - compensating. To understand a little more about the tensegrity model in relation to the human body, please visit Anatomy Trains.
Wound healing is a delicate and complex process, that is still not fully understood (Landen et al., 2016). One healing model describes the overlapping of four phases from the time of the injury: haemostatis, which could be described as the emergency response - from 0 to several hours after an injury, inflammation from 1 to 3 days after, proliferation from 4 to 21 days, and remodelling from 21 days to 1 year, but in some cases it is up to 2 to 2.5 years – much longer than the majority of us realise!
We can also look at wound healing in maturity stages - immature scar is in its very active healing stage and is usually red, raised and rigid - this process can sometimes take up to 6 months; maturing scar is still in its healing stages but changes are happening at a slower rate, it is slowly becoming paler, flatter and more mobile - this can take about 18 to 24 months (remodelling stage above); lastly, mature scar is no longer changing.
The above stages are not separate from one another, they are dependent on each other and overlap. It is believed that the transition from inflammation to regeneration is one of the most critical stages. Although inflammation is part of a normal healing process, excessive inflammation is associated with healing disorders (Landen et al., 2016 and Wilgus, 2020) that will be discussed later.
Research suggests that physical scar management has a significant positive effect on pain, pigmentation, pliability, pruritus (itchiness), surface area, and scar thickness. Treatments include massage, silicone gels and sheets, shockwave therapy (ESWT), high intensity light therapy, laser treatment and more, while combinations of different therapies are often used (Deflorin et al., 2020). Also, massage therapy, lymphatic treatment, stretches and exercise can help reduce the risk of secondary lymphoedema after surgery for breast cancer (Torres Lacomba et al., 2010).
De Valois et al. (2021) recently published research in patients who underwent surgery (and/or radiotherapy) for breast, colorectal, gynaecological, head and neck cancers or melanoma. The mean scar age was from 6 months to 17 years. After treating the patients' scars, the authors found significant improvements in appearance, consciousness, satisfaction with appearance, and satisfaction with symptoms, which included itching, frequency of discomfort, sensations of numbness and overall troublesomeness.
But how many of us are given any advice on scar care post surgery or injury? Generally speaking, there is very little scar care knowledge or advice given by medical practitioners, unless your practitioner has a specific interest in scar tissue - or if you have a scar as a result of a burn, or the scar is located on your hand, as those departments have an excellent knowledge and provide great care. For everyone else, I hope you will find this article helpful, and will help share the knowledge and educate others.
Every type of scar requires a different approach. There aren’t two people whose injury or circumstances are the same and therefore one treatment approach/protocol doesn’t fit all. Tailored advice is needed. For this reason, this article is not prescriptive, it is to give you a basic understanding of scars, and I hope it will encourage you to seek help/advice for your scar, whether it is 1 month or 20 years old, as even a 20-year-old scar can benefit from treatment.
Scar healing complications.
Infection and consequent prolonged inflammation are the biggest complications in scar healing. The wound is more likely to develop infection if there is puckering or overhanging tissue, creating an ideal environment for bacteria or fungus. You need to keep it clean and dry until the wound heals. You might have heard about MRSA (methicillin-resistant Staphylococcus aureus), which is a bacteria that lives on our skin. MRSA infection mainly affects people who are staying in hospital. It is treatable and to find out more about prevention and treatment, please visit the NHS MRSA website (2020).
It is important to keep an eye on your scar, especially in the first 2 to 4 weeks, as infection can lead to sepsis, which is a very serious condition and can be fatal. This is not to scare you, but to stress how important prevention is.
Look out for anything out of the ordinary - warm or red skin around the wound, yellow or green discharge, rash, itching, unpleasant odour, scar opening - and seek medical help when these appear. More serious symptoms can include red streaks on the surrounding skin, fever, chills, aches or pains, nausea or diarrhoea. If you experience any of these, please seek immediate medical attention, this is a matter of emergency.
Infection prevention and control are really important, as infection can lead to further complications, such as chronic wound healing, impaired circulation, oedema (local swelling) or lymphatic disruption leading to lymphoedema (see NHS website for Lymphoedema (2019)), hematoma (localised collection of coagulated and solidified blood from damaged vessels), seroma (pocket of clear serous fluid that sometimes develops in the body after surgery) or necrosis (premature death of cells in living tissue). All require medical assessment.
Other complications are the formation of scar tissue or fibrosis (thickening of scar tissue), adhesions (abnormal adhering of different surfaces together), skin sensory disruption or damage, skin thinning, discolouration, and reduced mobility. These may be helped with manual therapy and other products discussed below.
Some risk factors associated with impeded wound healing are scar location (some scars are under constant tension due to their location), age (our skin is less elastic in older age, and is thinner, esp. the fatty layer and blood supply are not as efficient), skin colour/origin (darker skin is more predisposed to fibrosis formation than lighter skin), diseases associated with impaired blood supply, connective tissue disorders such as hypermobility Ehlers-Danlos Syndrome or hEDS, diabetes, obesity and smoking.
The wound may also separate or open because of sutures breaking, cutting though tissues, knots slipping or inadequate splinting, obesity, chronic obstructive pulmonary disease leading to excessing coughing (which increases intra-thoracic or intra-abdominal pressure), or simply an excessive and inadequate mechanical load on the wounded area (see Norman et al., 2020).
Pain is expected after an injury or a trauma. It can sometimes be difficult to distinguish if the pain is the expected kind of pain or pain related to infection. If your pain is not shifting or is increasing with any of the above mentioned symptoms, please contact your medical practitioner.
Itching (pruritus) – as nerve endings might have been disrupted during the trauma, itching may be an expected symptom. Any itching should resolve before 4 weeks, once maturation and remodelling starts. Please avoid scratching the scar if possible, as that may lead to further complications. Some products, such as creams and gels, may help.
Contracture scars are often caused by burn injuries. The skin “shrinks” which leads to tension and restriction of movement, especially over joints. This article will not discuss burn scars or scars after radiotherapy as this is a specialist field and requires more complex management by the medical profession. But you may still find the information below helpful.
Skin structure and scar description.
Adult skin covers an area of 1.5 to 2 square meters. The structure is very complex and has 3 main layers – epidermis (the top protective layer – what we see as our skin), dermis (a deeper and thicker layer, it is strong, elastic and tear proof with nerve cells, blood and lymph vessels, and helps us regulate heat) and subcutis (the deepest layer – consisting of fatty cells, it stores energy and acts as padding and protection from cold). Scar tissue formation also depends on which layers where injured. Not all scars need to be treated.
Complete healing, when no scar is visible, can happen in injuries that are very superficial and only affect the epidermis. They may not leave any marks, such as sunburns and superficial abrasions.
Normal fine-line scars still take up to 2 years to mature. These include scars without any of the following features.
Keloid scars are abnormal, raised scars that tend to spread to the surrounding skin and extend beyond the initial site of injury. They can be pink, red, the same colour or darker than surrounding skin. They're often itchy or painful, and can restrict movement if they're tight and near a joint. They are associated with an increase in pro-inflammatory mediators and inflammatory cells (Wilgus, 2020), resulting in excessive collagen formation. They do not normally form until at least 6 months after the injury, and can form even after a minimal trauma such as an insect bite. The earlobe, upper chest and neck are common sites. Surgically removing a keloid scar can lead to more keloid formation.
Hypertrophic scars (HTSs) are raised red scars. Unlike keloids, HTSs are confined to the borders of the original wound. They also are a result of excess collagen production, and can continue to thicken for up to 6 months after the injury, before beginning to soften. HTSs are more likely to develop in areas that are subjected to tensile forces, such as over joints.
Atrophic scars can have sunken recess or pitted appearance and develop when not enough new connective tissue or fat is produced to completely fill out the wound again. They are often the result of severe acne or chickenpox, but can also form in post-surgical scars.
Adhesions are bands of fibrous tissues between and within two surfaces, such as skin, muscle, fascia or organs. Adhesions represent a major postoperative complication, particularly in abdominal, pelvic, uterine, pericardial and tendon surgical procedures. Adhesion formation is typically underestimated by surgeons and their incidence varies – from 55 to 66% (Capella-Monsonís et al., 2019) to an estimated 93% of abdomino-pelvic surgeries (De Wilde et al., 2012). They can remain silent or cause complications, such as pain, stiffness, loss of tissue function or severe complications such as bowel obstruction or fertility issues. Adhesion prevention formation remains a major challenge in surgery. The standard method of treating existing adhesions is surgical adhesiolysis, which can lead to further adhesion formation (Del Wilde et al., 2012).
Contracture scars – see above section on contracture scars.
What can you do?
Don’t forget that your body is working really hard and using a lot of resources and energy to heal. Let alone if you had a complex trauma or just gave birth after an established labour with an emergency C-section. Further to that, the tension strength of the wound, related to cross-linking of collagen, will only be 3% of that of normal skin after roughly 1 week, 30% after 3 weeks, and 80% after about 12 weeks (Buchanan et al. 2016).
Rest and minimal loading – as we saw above, we all underestimate how long healing takes. If you do too much too soon, or the wound becomes dirty or infected, the healing can be prolonged leading to complications.
Different trauma/scars require different management. You may be prescribed physical or occupational therapy in your hospital after a complex or burn injury. Do follow the instructions and do not overstretch yourself. In contrast, contracture scars require mobilisation on a daily bases for the rest of your life.
Hydration – drink plenty of fluids each day, especially if you are breastfeeding. The recommended water intake for a woman is 2 litres per day, for breastfeeding women it is an extra 600-700ml per day. But let’s not forget that this amount also depends on your body weight, your level of activity, which climate you live in and what time of the year it is. You will certainly need to drink more in summer than in winter. Dehydrated skin is less elastic, more fragile and more susceptible to breakdown. It will also reduce efficiency of blood circulation, which will impair the supply of oxygen and nutrients to the wound.
Balanced diet – ideally we would get all our nutrients from our diet. Some current agricultural methods can lead to decreased nutritional values in our food. So if you can, choose organic. You do need a good supply of protein and energy from carbohydrates and fats for wound healing. Please monitor your sugar levels if you are diabetic. Try to avoid going on a diet whilst healing as if your metabolism starts breaking down protein for energy, it can negatively affect both the proliferative and remodelling stages. It is recommended that you avoid pro-inflammatory foods, processed sugars and alcohol during that period.
If you are a mother of a baby or a small child, you are very likely to be on the go all the time, snacking and drinking coffee to cope. Please have a look at my article on Postnatal Depression Part II for different coping strategies ensuring you eat and drink well.
Vitamins and minerals – Vitamin C helps with collagen synthesis (DePhillipo et al., 2018). Vitamin A also has a positive effect on wound healing, but we must be aware that Vitamin A toxicity can be critical and even result in death; it shouldn’t be taken during pregnancy (Zinder et al., 2019). Vitamin E may be controlling excessive free radicals and assist in wound healing, but there is limited evidence for the benefits of vitamin E in decreasing scar formation. Vitamin B complex is essential for carbohydrate metabolism and therefore energy production (Southern Health NHS National Trust, 2014). Some human and animal studies suggest that zinc deficiency negatively affects wound-healing rate and therefore supplementation may be advisable (Kogan et al., 2017). Iron is also important in wound healing as it carries oxygen to the wound.
Ideally, you would be getting your vitamins and minerals from your balanced diet. For example, iron absorption from non-meat sources, such as green leafy vegetables, can be enhanced with food containing vitamin C consumed together. But if you are supplementing, you may want to know that zinc and iron compete for absorption, so it is advised to take them at different times of the day with meals.
Vitamins A and C (not at the same time), and zinc can be used topically, directly on the scar, and some of the products below do contain those vitamins.
Avoid sun exposure – scars exposed to the sun may darken, and direct sunlight promotes the formation of hypertrophic scars. Ensure you always cover with sun-protective clothing (not all clothing protects you from UV light), a compression garment, sun cream or, as you will see below, creams and silicone gels that contain UV protection.
Compression therapy is suitable for scars that are increased in size and height, that are in a location where they get irritated by clothing or rubbing, large scars, burn scars, graft and flaps, scars that itch or are painful. Compression therapy/garments can be started as soon as the wound closes. They must fit well and be checked regularly to make sure they are working. Garments that are too large or too small are ineffective and can cause damage.
Companies specialising in compression garments in the UK are Jobskin, who also customise their products for children. And Juzo, who have a specific children’s range Juzo Julius.
Compression underwear after a C-section or hysterectomy helps reduce swelling, supports weakened tissues and also stimulates the healing process. In principle, post C-section underwear is to have a high waist and be seamless so it doesn’t rub on the scar, be made from elastic material and may have a silicone panel that sits over your scar to reduce irritation. Although the latter is not necessary if you are applying a silicone sheet directly (see below). And most importantly use an appropriate size – don’t forget that you may need a bigger size due to some swelling immediately after the surgery and may need a smaller size when the swelling reduces later. John Lewis also offer some underwear, but you may find other suitable garments on the market.
Natural products - you might have heard about natural products such as Aloe Vera, onion bulb extract, colloidal silver, vitamin E oil, green tea, and lavender, frankincense or rosehip essential oils. However, as an Osteopath, I am not qualified to advice on those products or to prescribe. I always recommend to explore and see what works for you.
Therefore I will be providing details of medical grade products, those introduced to me by my scar tissue training company and those recommended to patients in hospitals. You are advised to speak with your medical practitioner, do your own research and decide if you want to purchase any of them or look into alternatives. Note that many of the products below can be sourced on prescription via your GP or specialist.
Dressing, creams, silicone gels, patches and sheets.
Infection, dehydration and sun damage are some of the concerns during different stages of the healing process, but primarily in the first 2 years. There are many products on the market including creams, gels, oils, patches, sheets, tapes, etc. Some may or may not contain silicone. Silicone helps protect immature scars and reduces the loss of water/maintains hydration. It can work as a prevention or on scars that are becoming keloid or hypertrophic. Some products also have UV protection.
In case of a sign of infection, please contact your medical practitioner immediately.
A product that promotes wound healing and reduces risk of infection is Medihoney® Antibacterial Wound Gel™ by Comvita. It contains sterilised medical grade Manuka honey and is used by homes and in hospitals. It works by releasing hydrogen peroxide as a by-product, by drawing water from the wound through the process of osmosis, causing bacteria to die through dehydration. It lowers the pH of the wound, making it more acidic, which is not a desired environment for micro-organisms. And it also contains flavonoids that act as antioxidants, which reduce tissue damage (Vandamme et al., 2013).
Another useful range is Medihoney HCS Antibacterial Dressings, they come in different sizes, have adhesive and non-adhesive options. Medihoney HCS Surgical can be used on your C-section scar, but if your scar is longer than 16 cm (about 6 inch) you will need 2pcs for a single use. The dressing can stay on for up to 7 days, subject to how well the wound is healing. It is partly see-through so you can monitor progress without taking it off. It is recommended to use Medihoney Barrier Cream on the surrounding skin to prevent maceration formation.
Comvita's Manuka honey is treated by gamma radiation to kill any potential mircro-organisms, therefore it doesn’t cause botulism and is suitable for children under 1 year of age. Medihoney products are suitable for the whole family not only for after surgery, but also for normal cuts and grazes. Medihoney HCS can be cut into desired sizes and used instead of sticky plaster. The Barrier Cream also contains honey and can work well on for example eczema and dermatitis. Do not use if you are allergic to honey or any other ingredients (Grothier & Cooper, 2011). For further research on the use of sterilised honey, feel free to visit Comvita’s website. But please beware that serious or larger wounds must be managed under the supervision of a healthcare professional!
Comvita licensed Integra LifeSciences to sell an advanced range of Medihoney® products into healthcare settings, which means that you might be able to ask about these products in hospital, your GP, or you can purchase it yourself over the counter in your pharmacy, as well as online. Having communicated with Integra's representative, I was assured that Medihoney® Antibacterial Wound Gel™ can be used internally on wounds caused by a tear or episiotomy during vaginal delivery prophylactically. Note - only use medical grade honey for your wounds and never honey purchased in a shop sold for consumption, this can cause serious harm.
Dressing - The NICE guidelines [NG192] Caesarean birth (2021) state that the wound has to be checked for infection daily and that there is no difference in wound risk infection if the dressing is removed 6 or 24 hours after the procedure. But Ridely, 2016, from Lancashire teaching hospitals NHS trust, suggested that dressing in situ for 5 days post surgery decreases the risk of surgical site infection (SSI). And although C-section is a common procedure, SSI is one of the known complications. Mortality due to severe maternal sepsis is a leading cause of maternal death in the UK (in Ridley, 2016). The products they used in their clinic audit were Mepilex safetac (Mepilex Border Post-Op is also recommended to women post C-section by some European hospitals) and OpSite Post-OP Visible.
Dumville et al. (2016), in their systematic review, concluded that there is insufficient evidence to determine whether covering surgical wounds with dressing reduces the risk of SSIs. (Ridley’s study was excluded from this review as it was not an RCT - Randomised clinical trial - but an audit.) Therefore the decision whether to use a dressing or not should be based on the clinician’s assessment and patient’s preference. I suggest that you do ask about it in hospital if they can supply you with dressings, or purchase some should you wish to and your own circumstances indicate it.
Research as early as the 1960s in a pig model showed that wet wound healing sped up the healing process. Some early use of this was documented during the second world war. It is now known that wet or moist wound treatments significantly reduce the healing process and lead to reduced inflammation, necrosis and subsequent scar formation. They also have no adverse effects on wound itself or the surrounding tissues (Junker et al., 2013). Therefore, once the wound is fully healed, silicone therapy is recommended. (Please do not use if you have a known allergy to silicon.)
Jobskin (mentioned above) offer a range of medical grade silicone products. ScarSil® Topical Gel which is typically recommended on smaller scars and its invisibility is ideal for facial scars. It contains vitamin C and may help with reducing scar redness and discolouration. It produces a thin protective film on the wound and can be applied 2-3x per day. If the layer is too thick, it will not dry. Sun cream can be used on top as well as make-up. Oleeva® Fabric Silicone Sheet, and Shapes, such as Oleeva C-section shape are thin and sit better in cavities or misshapen scars. The top layer makes clothing glide well over it, but takes longer to dry. The sheets have to be washed regularly and if looked after well, can last 4-6 weeks. It is recommended that you buy two as you can wear one whilst the other one is still drying. The other recommendation is to use the silicone gel during the day and the sheet at night, as silicone therapy is recommended up to 23 hours per day. ScarFX® Silicone Sheets are a little thicker, may not look as nice as the fabric sheets and can cause a little friction with clothes worn over. Some practitioners advise to use Mefix over it (see Molnlycke products below). The silicone sheets are see-through and you may prefer them to the fabric sheets. They also need to be washed daily and do not take as long as the fabric sheets to dry. If looked after well, they also last 4-6 weeks. It is recommended to buy two pieces, but you might find it helpful to order a large piece and cut it according to your needs, which should also work out cheaper.
Lastly, if your scar is in an area of friction, such as in your armpit or on your hands, you are using a splint or compression garment, or if you have a toddler at home who is likely to accidentally hurt your C-section scar by climbing on you, then you may consider Oleeva Foam Silicone sheets. They create an extra padding and improve pressure distribution. They take the longest to dry - although technically you should only be washing the silicone surface and not the padded surface - and they create the most friction with the clothing layer immediately in contact with it.
For all silicone products, it is advisable to remove any excess hair as that can prevent products sticking well. Also make sure the skin is clean and dry without any creams, oils or lotion on it, as otherwise they will not stick. Again, these are medical grade products and you should be able to ask about them in hospital, your GP or in a pharmacy, depending on how well your practitioner is educated about silicone scar treatment.
BAP Medical make the scar cream range ALHYDRAN, containing aloe vera, vitamins E, C and other natural oils. They have 2 products one with and another without SPF 30. Other products are silicone therapy range BAPScarCare and silicone dressing Scarban. Their UK representative is Espere healthcare Ltd, but you can buy their products through other retailers. I do have some of their samples that I give to patients to try.
The general advice is that a topical cream or gel can be used from about 2 weeks after the trauma – but only when your scar is well closed, there are no signs of infection, no scab formation, and all stitches have been removed or dissolved/ absorbed. The cream can be used 3x per day for 4 weeks. Silicone gels can also be used after approx. 2 weeks and applied 2x per day, and at any time on an existing scar. They propose the use of silicone therapy (tapes and sheets) for at least 12 hours per day for 3-6 months but up to two years – as long as the scar is active. You should see the benefits after 3 months with all silicone products.
Molnlycke Health Care are the manufacturer of dressings (mentioned above), including the Mepilex foam dressing range. Using a silicone adhesive layer, called Safetac, dressings can be removed easily without causing pain. Always discuss your dressing needs with your medical practitioner. Mepilex Border Comfort range is for medium to high exuding wounds and with Mepilex Border Post-op are both flexible dressings suitable for tissues under tensile strain, such as scars over joints or abdomen. They are recommended on wounds for up to 7 days after surgery. Molnlycke's self-adherent dressing range for reduction and prevention of hypertrophic or keloid scarring called Mepiform comes in 3 different sizes and can be cut to size. I am currently awaiting the company's representative to confirm, how many times the product can be re-used and the recommended application. Mefix is sometimes recommended on the outer layer of your silicone sheet (such as the one by Jobskin), if you find that it rubs against your clothing, as Mefix has a smooth surface. It is sold as a 10 meter roll (by either 5 or 10cm). You can buy these products online or in your local pharmacy. Always check that you are buying the correct size, or like in case of Mepiform, you can cut it to the desired size.
Self-massage is a very important part of the healing process. I will not be giving any advice here, as I only give advice once I assess and am happy that you have the appropriate information for your circumstances, for example some women are unable to touch or look at their scar. If you do look up how to do self-massage elsewhere, I would like to give a few words of warning. If your scar is numb, please check the level of pressure that you are applying on a healthy part of your skin before working on the scar, as if you are too aggressive, which you may not feel, you can irritate the tissues, promote more inflammation or even cause damage. Also start gently, for a very short amount of time and see how your scar responds, ideally starting with superficial layers only. Start increasing pressure, length of time and tissue depth gradually if you are happy that there is no reaction.
Manual therapy – only see a qualified practitioner, who understands wound healing processes, and uses the right type of intervention at the right time along the healing process. Again, treating the wound too early, too much or for too long may lead to more damage. Your practitioner also needs to understand if there was mesh used or non-dissolvable stitches as their approach should be adjusted accordingly. If tissues were taken from a different part of your body to restore trauma, sometimes the donor site may cause more issues than the site of the injury – both should be assessed and treated. If you had a fat transfer procedure, manual therapy may displace the fat cells, negatively affecting the desired outcome – your practitioner needs to know you had such procedure.
As it can take 2 to 2.5 years for your scar tissue to mature fully, and as we already learnt different complications may arise at different stages of scar healing, you ideally want your therapist to assess your scar as soon as the wound closes but then again at 3, 6, 12 and 18 months post tissue trauma. If you never had your scar assessed, it is never too late to do it.
What can Osteopathy do for you?
The majority of adult patients come to see me because of pain or restricted movement, or stiffness in different areas of their body. It is easy to point to an area that is "not right", as that is the area that hurts or doesn't move well. My job is to find out why it isn't right and what the contributing factors are, why the body hasn't resolved this issue alone and what the maintaining factors are, what other areas of the body are being used to compensate and how can we prevent this from happening again? Scar tissue assessment is part of the overall assessment - remember the tensegrity model described at the beginning of this article? The body is a unit and all parts work together, they are not independent of each other.
If you come to see me for neck pain and also have, for example a scar after a C-section or hysterectomy, I will be assessing your scar - maybe not on the first appointment, but definitely on the subsequent appointments. I need to find out if the scar tissue has an effect on your posture that is then contributing (amongst other aspects) to your neck pain not going away. If you are wearing a shirt right now, hold onto the bottom front of the shirt and pull it down - yes, it creates tension at the back of your neck, doesn't it? This certainly is a simplification, neck presentations are usually multifactorial and unless there is a direct injury, it usually is a build-up of a number of factors, from possibly a historical injury, sleeping awkwardly to prolonged stress.
If you are seeing me for scar tissues release alone, I may see you as early as 6-8 weeks after the event. However, if the scar tissue is a result of a complex surgical procedure, such as breast cancer treatment or abdominal procedure, I will wait for 12 weeks and ask you to forward a form to your surgeon, specialist, consultant or breast care team to inform me of any mesh or any known contraindications to manual therapy.
I will be taking pictures of your scar and will ask you to fill in specific forms to be able to assess progress at later stages. I will also include your range of movement at nearby joints. As an Osteopath I will not be treating your scar in isolation, but will look at the bigger picture - if your affected area is "borrowing" from other areas, can those areas actually "lend" anything and if not, why not? You can expect improved range in your whole body, as your whole body will get assessed and treated during the course of treatment.
Manual therapy is not a standard treatment method for adhesions but physical and manual therapies show positive outcomes on adhesion formation (Capella-Monsonís et al., 2019). There are many research papers published on the use of manual therapy for post-operative adhesion on animal models (e.g., Bove & Chapelle 2012; Bove et al. 2017). With every treatment, I will be engaging different layers of your tissues from superficial to deep, including your organs, taking into consideration the type of injury, the age of the injury and your personal circumstances.
Not every scar needs treatment, but you would be surprised how visually smalls scars, such as from laparoscopy (key hole surgery) can be problematic. Laparoscopy is defined as minimally invasive surgery, but it can cause a lot of trauma to the tissues. And let's not forget scars that are not visible, such as those after episiotomy or perineal tear during vaginal births. They should also be assessed and treated if needed.
For further information on what you can expect during your appointments with me, including internal assessments, please visit my Appointments page.
And for information about scar therapy for breast cancer patients, please visit my page Scar Therapy for Breast Cancer Patients.
Other treatment options - NHS website.
This section is largely copied directly from the NHS website on scar treatment options (NHS, 2020).
Corticosteroids cannot remove scars completely, but they can improve their appearance. Injections can be used to treat some keloid and hypertrophic scars. The scar is injected a number of times to reduce any swelling and flatten it. Depending on the type of scar, the injections may need to be repeated. Injections are usually given on 3 occasions, 4 to 6 weeks apart, to assess your body's response. Treatment may continue for several months if the scar is improving. Steroid-impregnated tape can also be used to try to flatten keloid scars (Ogawa, R., 2020). It can be prescribed by a GP or dermatologist and is applied for 12 hours a day.
Laser therapy or light therapy (pulses of light) can reduce the redness in a scar by targeting the blood vessels in the excess scar tissue. For some pitted scars, laser surgery (laser resurfacing) is used to try to make the scar flatter. This involves using a laser to remove the top layers of skin, which stimulates collagen production in the deeper layers. But there are not many long-term studies to prove the effectiveness and safety of laser therapy. If you have laser therapy, make sure the person doing it is a fully trained medical practitioner with experience in improving scars.
Cryotherapy - liquid nitrogen can be used to freeze keloid scars. If cryotherapy is used in the early stages, it may flatten keloid scars and stop them growing. A side effect of treatment is that it can lighten the colour of the skin in the area being treated.
Dermal fillers are substances that can be injected to "plump up" pitted scars. Treatments can be costly and the results are usually temporary. Repeat treatments are needed to maintain the effect.
Skin needling involves rolling a small device covered in hundreds of tiny needles across the skin, can also help improve the appearance of scars. But repeat treatments are often needed to achieve an effect, and results vary considerably.
Surgery can sometimes be used to improve a scar by making it appear more natural, less noticeable (by using a skin graft) and by releasing a tight scar that's close to a joint to improve movement. It is an invasive treatment and not suitable for everyone. You should carefully consider the pros and cons before deciding to have surgery. As well as the normal risks of surgery, there's also a chance of making the scar worse. If you are considering scar reduction surgery, make sure the plastic surgeon is fully trained and experienced in this type of surgery. Fully discuss the procedure with your surgeon so you are aware of the risks and expected results.
If you have surgery to treat a keloid scar you may need other treatments immediately afterwards to stop the scar growing back larger. These include steroid injections or radiotherapy.
Dr. Gabor Mate noted that "Trauma is not the bad things that happen to you, but what happens inside you as a result of what happens to you".
Trauma, no matter what kind, and scars, no matter what location or how they look, can cause psychological distress. Please do seek professional help if this is what you are experiencing. You can either go privately or via your GP or a self-referral pathway, see my article on Postnatal Depression Part II on local self-referral services.
For further resources, please visit a charity called Changing Faces. For support specific to children, visit Children's Burns Trust.
There are also other services that might be able to help, such as skin camouflage or you can visit the British Association of Skin Camouflage. Also scar tattooing over your scar or even 3D nipple tattoos with areola post mastectomy can make a huge difference to your life. Other options are temporary nipple tattoos or stickers, as well as stick-on prosthetic silicone nipples. Permanent make-up can also be very beneficial. Again, please only work with adequately qualified and experienced practitioners.
Elective plastic surgery might also be an option, but please beware that if you have a predisposition towards adhesions and keloid scars, further surgery might lead to further complications and an experienced surgeon should advice you on this.
Please note that I am not recommending these therapies, purely letting you know what other treatment methods are available for you to research yourself. Most therapies when used together bring better outcomes than if used on their own.
Deep Oscillation therapy is based on creating an electrostatic field in the tissue of the patient, whilst the practitioner applies very gentle massage like movements. The practitioner wears vinyl gloves, the patient holds a little device (or it can be put between your toes) that is connected to the terminal, which is also linked to the practitioner. The contact areas feel pleasant vibrations. To find a practitioner go to Deep Oscillation therapy's page. Deep oscillation is greatly beneficial with lymphoedema and post procedures that require the removal of lymph tissues, such as mastectomy.
WINBACK energy is a high-frequency current operating at 300 KHz ,500 KHz and 1 MHz – a non-invasive current stimulates the body’s natural repair mechanisms, promoting cellular exchange. Find a therapist on Winback’s website.
Negative pressure wound therapy (NPWT) consists of a closed, sealed system that applies negative pressure (suction) to the wound surface. It has been used for a wide range of injuries form abdominal surgeries to open fractures. And is increasingly being used prophylactically on closed incisional wounds to prevent surgical site complications (Norman et al., 2020). In the private sector, you might find a practitioner who uses Lympha Touch device, the licensed distributor in the UK is Physiquipe, try contacting them to find your local practitioner.
Instrument assisted soft tissue mobilization (IASTM) is a popular treatment for myofascial restriction. IASTM uses specially designed instruments to provide a mobilising effect to scar tissue and myofascial adhesions. Several IASTM tools and techniques are available such as the Graston® technique.
Other educational resources.
To learn more about scars, this website on How to treat scars has recently been developed and an information resource.
Please note that the above is only general information and is not intended to diagnose or treat. If you have any concerns, speak with your specialist, consultant, breast support team, GP, midwife or health visitor. If you have any questions about the products, please contact the manufacturers and always follow the product instructions.
Please note that if you are pregnant, I will be unable to treat existing scar tissue on your trunk as scar tissue / tension can travel far through fascia, I may consider treating small scars on your limbs.
If you are still under the care of a specialist, please consult your specialist first if you can start scar treatment at this stage. If you have not discussed it already, I can provide you with a letter for your consultant to ask for permission to commence treatment, ensuring that there are no medical concerns that would suggest that scar therapy is contraindicated.
I have no financial or other interests in any of the products or providers above.
The information was conducted to the best of my knowledge and accurate at the time of writing in June 2021 with minor updates, such as broken website links in March 2023.
Bove, G.M. & Chapelle, S.L. (2012). Visceral mobilization can lyse and prevent peritoneal adhesions in a rat model. Journal of Bodywork and Movement Therapies, 16 (1), 76-82.
Bove, G. M., Chapelle, S. L., Hanlon, K. E., Diamond, M. P., & Mokler, D. J. (2017). Attenuation of postoperative adhesions using a modeled manual therapy. PloS one, 12(6), e0178407.
Buchanan, P.J., Kung, T.A. & Cederna, P.S. (2016). Evidence-based medicine: wound closure. Plast Reconstr Surg. 138(3S):257S–70S.
Capella-Monsonís, H., Kearns, S., Kelly, J., & Zeugolis, D. I. (2019). Battling adhesions: from understanding to prevention. BMC biomedical engineering, 1, 5.
Deflorin, C., Hohenauer, E., Stoop, R., van Daele, U., Clijsen, R., & Taeymans, J. (2020). Physical Management of Scar Tissue: A Systematic Review and Meta-Analysis. Journal of alternative and complementary medicine (New York, N.Y.), 26(10), 854–865.
DePhillipo, N. N., Aman, Z. S., Kennedy, M. I., Begley, J. P., Moatshe, G., & LaPrade, R. F. (2018). Efficacy of Vitamin C Supplementation on Collagen Synthesis and Oxidative Stress After Musculoskeletal Injuries: A Systematic Review. Orthopaedic journal of sports medicine, 6(10), 2325967118804544.
de Valois, B., Young, T., Scarlett, C., & Holly, E. (2021). An evaluation of a ScarWork service for cancer survivors experiencing adverse effects of surgery and/or radiotherapy. European Journal of Integrative Medicine: 44, 1876-3820.
De Wilde, R.L., Brölmann, H., Koninckx, P.R., Lundorff, P., Lower, A.M., Wattiez, A., Mara, M., Wallwiener, M. & The Anti-Adhesions in Gynecology Expert Panel (ANGEL) (2012) Prevention of adhesions in gynaecological surgery: the 2012 European field guideline. Gynecological Surgery, 9(4), 365-368.
Dumville, J. C., Gray, T. A., Walter, C. J., Sharp, C. A., Page, T., Macefield, R., Blencowe, N., Milne, T. K., Reeves, B. C., & Blazeby, J. (2016). Dressings for the prevention of surgical site infection. The Cochrane database of systematic reviews, 12(12), CD003091.
Grothier, L. & Cooper, R. (2011). Medihoney Dressing products for practice made easy. Wounds UK, 6 (2).
Junker, J. P., Kamel, R. A., Caterson, E. J., & Eriksson, E. (2013). Clinical Impact Upon Wound Healing and Inflammation in Moist, Wet, and Dry Environments. Advances in wound care, 2(7), 348–356.
Kogan, S., Sood, A., & Garnick, M. S. (2017). Zinc and Wound Healing: A Review of Zinc Physiology and Clinical Applications. Wounds : a compendium of clinical research and practice, 29(4), 102–106.
Landén, N. X., Li, D., & Ståhle, M. (2016). Transition from inflammation to proliferation: a critical step during wound healing. Cellular and molecular life sciences : CMLS, 73(20), 3861–3885.
National Institute for Health and Care Excellence (NICE) (2021) NICE guideline [NG192] Caesarean birth. Available at https://www.nice.org.uk/guidance/ng192 [Accessed: 30/5/2021].
NHS. (2019). Lymphoedema. Available at: https://www.nhs.uk/conditions/lymphoedema/
NHS. (2020). MRSA. Available at: https://www.nhs.uk/conditions/mrsa/
NHS. (2020). Treatment: Scars. Available at: https://www.nhs.uk/conditions/scars/treatment/
Norman, G., Goh, E. L., Dumville, J. C., Shi, C., Liu, Z., Chiverton, L., Stankiewicz, M., & Reid, A. (2020). Negative pressure wound therapy for surgical wounds healing by primary closure. The Cochrane database of systematic reviews, 6(6), CD009261.
Ogawa R. Effectiveness of Corticosteroid Tapes and Plasters for Keloids and Hypertrophic Scars. 2020 Dec 8. In: Téot L, Mustoe TA, Middelkoop E, et al., editors. Textbook on Scar Management: State of the Art Management and Emerging Technologies [Internet]. Cham (CH): Springer; 2020. Chapter 56. doi: 10.1007/978-3-030-44766-3_56
Ridley, N. (2016) An audit and trial aiming to reduce the rate of surgical site infections for women having a caesarean section. British Journal of Midwifery, 24 (3).
Royal College of Obstetricians and Gynaecologists. (2013). The Use of Adhesion Prevention Agents in Obstetrics and Gynaecology Scientific Impact Paper No. 39. Available at:
Southern Health NHS Foundation Trust. (2014). Guidance on optimising nutrition for chronic wound healing. Available at:
Torres Lacomba, M., Yuste Sanchez, M. J., Zapico Goni, A., Prieto Merino, D., Mayoral del Morallo, Cerezo Tellez E. & Minayo Mogollón, E. (2010). Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial BMJ 2010; 340 :b5396.
Vandamme, L., Heyneman, A., Hoeksema, H., Verbelen, J., & Monstrey, S. (2013). Honey in modern wound care: a systematic review. Burns : journal of the International Society for Burn Injuries, 39(8), 1514–1525.
Wilgus T. A. (2020). Inflammation as an orchestrator of cutaneous scar formation: a review of the literature. Plastic and aesthetic research, 7, 54.
Zinder, R., Cooley, R., Vlad, L. G., & Molnar, J. A. (2019). Vitamin A and Wound Healing. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, 34(6), 839–849.