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Post surgical scar tissue

Updated: Feb 7, 2023

With the exception of very minor lesions, every wound, after accident, surgery and disease results in some degree of scarring.

Surgery is a form of trauma. Any type of trauma ends up causing inflammation and swelling of the tissues. Over time, that inflammation ends up being "converted" into scar. That scar can demonstrate itself in many different ways. While most patients are concerned mainly with the aesthetic appearance of surgical scars, excess scar tissue, layers deep, can significantly reduce function and movement months after surgery.

Scarring is a natural part of the tissue's healing process. In normal circumstances, new tissue is being deposited in direction with the line of tension imposed on the structure. In bony tissue following a fracture osteoblasts will start to deposit new bone which will eventually be forming bony trabeculae in line with tensional and compressional forces acting on the bone.

In connective tissue, it is created by fibroblast proliferation, a process that begins with a reaction to the clot during inflammation. An injury does not become a scar until the wound has completely healed; this can take time. To begin to "patch" the damage, a clot is created; this clot is the beginning process that results in a provisional matrix. In the process, the first layer is a provisional matrix and is not a scar. Over time, the wounded tissue over-expresses collagen inside the provisional matrix to create a collagen matrix. This collagen over-expression continues and crosslinks the fibre arrangement inside the collagen matrix, making the collagen dense. We should think of maintaining the irregularity in the organisation of connective tissue during this process by multidirectional forces applied to it.

Since the tissue is being organised in response to the tension acted on it, it can be very beneficial to apply gentle manual therapy in the form of fascial normalisation to encourage multi-directionality in the newly forming provisional collagen matrix in line with the biomechanics of the given tissue. For example, superficial scars in the abdomen will be "pulled" in multiple direction by the different layers of the abdominal muscles' aponeurosis which will be different at different parts of the abdomen. If the scar reaches deeper, after an abdominal surgery past the fascia transversalis and into the peritoneum, it should be treated accordingly as it would be very important to reduce the chance of adhesion between the peritoneal layers.

Healthy young people tend to form more surgical scar tissue than older patients because they have a bigger scar response to surgery. At the skin level, a thickened, whitened, elevated scar, called a hypertrophic scar, can develop. Keloids occur when collagen buildup creates a larger, puffy-looking scar that grows beyond the boundaries of the surgical wound. With deeper scar tissue, patients complain about a sense of tightness rather than sharp pain. That tightness can translate to soreness, restriction in mobility and pain. If there’s no improvement after several months, surgical removal might be the next step, which comes with a risk of more scar tissue. This increases the risk of repeated injuries, chronic inflammation and repair are susceptible to fibrosis where an accidental excessive accumulation of collagen and other extracellular matrix components which can lead to the formation of a permanent fibrotic scar.

The goal of manual and exercise therapy is also to prevent the dense unidirectional organisation of collagen matrix and fibrosis, to prevent the adhesion of adjacent layers and encourage movement of tissue layers relative to one another.

Moving the affected body parts the right way after surgery not only improves function, it helps prevent excess scar tissue from forming. When this movement isn't possible due to healing time, fascial normalisation with manual therapy can start to initiate the process and prepare the tissue in the right direction so when the joint is ready to be moved the surrounding connective tissue will readily authorise that movement. The earlier you get going, the better the outcome.

In addition to improved movement, this will also help restoring the health of the area by enhancing lymph and bloody flow and improve the aesthetics of the scar.

What is fascial normalisation?

Fascial normalisation will focus on the intrinsic quality of the fasciae and will address it in relation to its continuity in their respective chains. Fascial chains can include direct links where there is a traceable continuity of the same tissue throughout the kinetic chain as well as indirect links where contiguity, being immediately adjacent, of fascial tissue has a significant influence on the function of the chain. Water is constantly being linked and unlinked to glycosaminoglycans and proteoglycans in the extra cellular matrix. This continual process of GEL and SOL of linking and unlinking of free and bound water is fundamental for not only for the health of the fasciae but also the health of the body as a whole.

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