Anatomy of Scar Tissue

 Visible scars start at the surface, but what we see on the skin may just be the tip of the iceberg. Scars can run deep, affecting multiple tissues at once, influencing their texture, function, and relationship with each other. Scar tissue feels different under our hands. Often more fibrotic and palpably distinct from the surrounding tissue, it is not always easy to make sense of what we are touching. 

Taking a closer look at the anatomy of scar tissue can help refine our understanding of what makes scars, and how our massage work influences them. 

REGENERATION vs. SCARRING

All animals, including humans, have the built-in capacity to heal their bodies when wounded. But we don’t do it in exactly the same way. There are two major biological mechanisms of wound healing: regeneration and scarring. 

Regeneration occurs when the body is able to recreate the original damaged tissue. Some creatures, including salamanders, have this ability and can actually regenerate entire limbs when severed. Humans, however, have very little regeneration capacity (unless you happen to be a mutant character from a popular comic book). Instead, we heal primarily through scarring. 

While regeneration recreates the original tissue, scarring patches the injury with new fibrotic tissue. Scarring successfully closes the wound, but at a cost: changed tissue architecture. Let’s take a closer look at how scar tissue is made.

A SCAR IS BORN 

Paper cuts, surgical incisions, and even internal injuries like heart attacks all initiate the body’s response to heal. The creation of scar tissue both patches the wound and replaces damaged tissue. Scar tissue may look and feel different, but it’s made from the same types of protein fibers that naturally exist all throughout our body. Some of the fibers in a scar are optimized for tensile strength (collagen fibers) and others for elasticity (elastic fibers). It’s the combination of fiber types and their specific organization that determines a tissue’s mechanical properties which contribute to the overall tissue integrity. 

The repair process happens through an overlapping series of highly-regulated physiological events: 

Phase 1. Stop the Bleeding & Call in the Troops

Phase one begins immediately upon injury. The body’s healing mechanisms mobilize to first stop any bleeding (hemostasis) through clotting and vasoconstriction, and to restore the integrity of our skin’s barrier to the outside world. The injured region is flooded with a series of immune cells and protein “instigators” with accompanying inflammation and swelling that trigger the next phase to begin. 

Phase 2. Clean Up & Rough Draft

Patching the wound with new tissue happens next during the proliferation phase. Starting around day three, fibroblast cells migrate into the region and do what they do best: make fibers! Creating a disorganized meshwork of webby Collagen Type III fibers, they make an initial scar “rough draft” that will go through robust editing and revision.

Phase 3. Edit & Rewrite

As early as day eight and lasting for up to three years, the body begins remodeling the scar. During this period, the initial Collagen Type III fibers of the provisional scar are replaced with tougher Collagen Type I fibers in a more organized fashion, forming a mature scar. 

GOOD AS NEW?

The formation of scar tissue allows the body to heal, but creates a new normal. Scar tissue is never identical to the original pre-injury tissue; the local tissue architecture has changed down to the level of protein fibers. While hopefully the tissue retains functionality, sometimes it doesn't. Changes in stiffness and tissue relationships can create pain, impact movement, and have ramifications distant from the original injury. This is often the point at which clients seek treatment.

Which brings us to the million dollar massage question: Can you get rid of scar tissue? The answer is far more complex than a simple yes or no, and depends in part on when you are first meeting the scar and where it is in its healing process. Simply put, scar tissue never goes away (and at the level of tissue integrity, that's a good thing!), but how well it integrates can vary greatly. 

Though bodyworkers can’t prevent or get rid of scar tissue, our skillful touch can aim to influence its development, remodeling process, and its long-term integration into the surrounding tissue. And that is a big deal.

TEACHABLE TISSUE 

The kind of input a wounded area gets during the remodeling phase can have a significant effect on how the scar tissue is organized as it matures. Whether from natural movement demands of daily life or from structured hands-on therapy, physical forces apply traction, compression, shearing, pushing, and pulling on the injured tissues. These types of mechanical input help inform how the tissue needs to be re-organized as the new fibers are laid down. What this means is there can be a big difference between a scar that receives no activity or treatment while it's forming versus one that does. As you might expect, massage interventions have the most potential to make an impact during the remodeling phase. 

PALPATE LIKE A PRO

Working with scars starts with a respect for the sometimes life-saving process that creates them. And it serves us well to remember that scars often originate from some kind of trauma.  Treating our clients with sensitivity and skillful touch can be healing on many levels.

Skillful palpation for scar tissue depends on how well you can perceive the difference between normal tissue architecture and the changes that happen when an injury heals. This goes beyond just knowing your anatomy; it requires an understanding of tissue texture, organization, and relationships. As you touch a scar, consider the structural anatomy in the area of injury, including what healthy tissue relationships would feel like from surface to deep.

As you explore scar tissue, look for contrasts in tissue density, stiffness and elasticity between the scar tissue itself and adjacent tissues. Generally speaking, a scar’s texture can feel denser, stiffer, and often less elastic than the original tissue. The organization of fibers in a scar might feel more random and chaotic instead of regular and patterned. Scars can change relationships between tissues from being able to easily glide around each other to being firmly stuck. All of this can be felt with a sensitive, exploratory touch, helping you get to know the nature of each unique scar.

*If you like what you read and want to read more content like this, head over to Associated Bodywork & Massage Professional's website to read their latest issues of Massage & Bodywork magazine.*

Further Reading:

Scott, Stockdale, C., Robinson, A., Robinson, L. S., & Brown, T. (2022). Is massage an effective intervention in the management of post-operative scarring? A scoping review. Journal of Hand Therapy, 35(2), 186–199.

Smith, Nancy Keeney, and Catherine Ryan. Traumatic Scar Tissue Management: Massage Therapy Principles, Practice and Protocols. Edinburgh: Handspring Publishing, 2016.

Stecco, Carla, et al. Functional Atlas of the Human Fascial System. Churchill Livingstone Elsevier, 2015.