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2. In the inammatory and proliferation phase,
the cortical mapping of the primary wound
area receives hardly any signals in patients
with deep dermal defects. The cortical
arrangement of the primary wound area is
therefore dependent on indirect information
from the secondary wound area. This results
in a more difcult differentiated perception
with an additional slowed motor and/or verbal protective response. These two disadvantages present therapists with a major
challenge.
Thus, pain statements from patients with deep
dermal defects are not sufcient to ensure an adequate dosage of the therapeutic intervention.
Based on tissue and pain physiology as well as
the phases of wound healing, an appropriate
functional stimulus can be set using the tactile
diagnosis of the rst and second connective tissue resistance. This has been empirically well
proven [1, 5, 6, 10, 11].
It is the task of the therapist to discuss this
pain processing problem in detail with the
patient to develop a strategy together. Fear of
pain can cause patients to avoid movement.
However, it is important that they are again able
to distinguish “pulling” (Aδ-ber) from “hurting” (C-ber).
Caution!
• Subjective pain statements by the patient
should never be the only criterion for the
adequate dosage of therapeutic interventions for deep dermal defects or
hypertrophic scars.
• In addition to the high pain medication
in the acute phase and different (emotionally colored) pain perception, the
direct or indirect pain conduction is
altered.
• Therefore, objective indicators are
required, for example the rst and second increases in connective tissue
resistance.
Connective Tissue Resistance
(R1 andR2)
Basically, it is important to distinguish between
the quantity and quality of movement. The quantity of movement is the physically objectively
measurable extent of movement. In contrast, the
quality of movement includes the ow, dynamics
as well as rhythm, and harmony of movement.
These are qualities that are subjectively palpable
during movement. To be able to assess the quantity and quality of a movement correctly, the therapist rst needs theoretical knowledge: What
quantity and quality can be expected of a joint or
tissue in an uninjured state? In addition, however,
extensive practical experience and tactile skills
are also required.
As a rule, a healthy joint or tissue always
behaves in the same way: within its range of
motion, it has a smaller or larger “neutral zone.”
At the end of the range of motion there is a
“physiological space,” followed by a “paraphysiological space” (Fig.2).
The “neutral zone” is usually located in the
middle of the range of motion and is characterized by a very small increase in resistance (R1 at
the end of “neutral zone”). The “physiological
space” begins with the second signicant resistance of the connective tissue (R2). The therapist passively mobilizes the tissue to a greater or
lesser extent in this area—depending on the
intensity of the manual gradation (dosage) and
the currently prevailing wound-healing phase.
The “paraphysiological space” can only be
reached by an impulse mobilization (manipulation). Post-traumatically or postoperatively the
anatomical barrier has moved forward. The reason for this is collagen type III, which predominates in the proliferation phase. It is responsible
for the integrity of the injured structure and
causes the rapid formation of water-soluble
crosslinks. Temporary collagen type III does not
withstand mechanical shear and acceleration
forces very well. Overdosage is therefore
quickly possible, especially in the proliferation
phase. Microtraumatic injuries trigger new
inammatory phases, which can lead to
Range of movement
Neutral point
al
Anatomical
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Activemovementlimit
resistance
neutral zone
R1
Fig. 2 Behavior of resistance depending on the extent of
movement in joints and connective tissue. R1 represents the
rst and R2 represents the second signicant increase in
connective tissue resistance. Depending on the intensity of
the manual gradation (dosage), therapists treat passively
more or less into the physiological space. The paraphysiological space is only achieved by impulse mobilization. If
the anatomical barrier is exceeded, cell damage occurs
Barrier (potential
cell damage)
Paraphysiologic
space
R2
(manipulation)
Physiological
space
(mobilisation)
(lesion) which results in an inammatory reaction. This anatomical barrier is important in posttraumatic and postoperative conditions due to adhesions and water-soluble crosslinks
that are moved to the front. Especially in the proliferation
phase, this can quickly lead to overdosing. Microtraumatic
injuries trigger new inammatory phases, which result in
increased tissue and movement restriction [12] (Courtesy of
Own illustration)
increased tissue restriction, and thus restricting
movement.
Clinical Tip
• In comparison to healthy skin, the rst
marked increase in connective tissue
resistance usually occurs much faster
around a spontaneously healed scar or in
an area with surgical coverage.
• The distance between the rst and second marked increase in connective tissue
resistance is also usually considerably
shorter than in healthy skin.
• The second marked increase in connective tissue resistance feels hard, stiff,
and wooden. The aim is to use therapeutic measures to gradually extend the distance between the rst and second
marked increase in connective tissue
resistance and thus restore the function
of the connective tissue.
Mechanical Stimulation
Mechanotransduction
It is known from the literature that the absence
of mechanical stimulus is associated with a
loss of functional alignment of the bers. It has
also been shown that too much mechanical
stress quickly leads to an overdosing (cell
damage, renewed inammatory reaction) [1, 4,
5, 13, 14].
The transmission of mechanical stimuli in the
body, for example, by manual techniques, seems
to take place in two signaling pathways.
Empirically, a “release” in the tissue can often be
perceived after only a few minutes. The mechanical stimulus must, therefore, have an effect
directly on the tissue, for example, the release of
possible pathological crosslinks (water-soluble
type) or reactive tonus changes in the connective
tissue. The second signaling pathway has been
scientically researched under the term “mechanotransduction.” This is the reaction inside the
cell to a mechanically applied external stimulus.
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If the stimulus is adequate, the cell reacts with a
gene transcription and thus inuences the cytoskeleton and the ECM and thus the quality of the
affected cell [7, 13, 15–19]. The aim of the therapeutically applied manual techniques is therefore
not (as previously assumed) to lengthen collagen
bers by stretching but to directly inuence cell
biological processes by means of adequate
stimulation.
What dosage is adequate during the woundhealing phases in relation to functional stimulation at the cellular level? Various aspects are
described below:
Bouffard etal. (2008) observed a decrease in
TGF-beta 1 concentration and collagen synthesis
after tissue injury by 20–30% static tissue stretching for 10min daily [15].
TGF-beta 1 is a local cytokine that is associated with wound healing and tissue brosis. The
results of this study suggest that tissue stretching
during wound healing leads to a reduction in
TGF-beta 1 levels and thus to altered collagen
synthesis. This could be an important natural
mechanism in limiting excessive scarring [3].
Balestrini and Biliar (2009) were able to
demonstrate a positive effect on the extensibility of the extracellular matrix with daily 5% tissue stretching for 24h. The authors found that a
stretching stimulus that was too strong and
lasted too long led to increased collagen synthesis and thus to increased tissue restriction.
This could only be achieved therapeutically
with the help of a splint and well-dosed stimulation [13].
In a review, Andalib etal. (2016) summarized
selected studies on mechanotransduction. They
also addressed the question of mechanical forces
acting on cells. These are given in the former
force unit “Dyne” (replaced by the SI unit
“Newton” [N] since 1978). The converted data
shows that all cells were mechanically stimulated
with a force between 0.00002N and 0.00058N.In
all included studies, a mechanotransduction
effect was found [16]. These ndings indicate
that cells are highly mechanosensitive. Only minimal forces are required for a cell to respond to a
mechanical stimulus.
The mechanotransduction process is shown
schematically in Fig.3. The mechanosensors are
stimulated by an external mechanical stimulus
(here using the example of a broblast). These in
turn activate “adapter proteins,” which are located
on the cell nucleus membrane (nuclear membrane). These “adapter proteins” transmit the
mechanical stimulus to the cytoskeleton. In this
way, they stimulate the skeletal structure. The
cell reacts with a gene transcription and passes on
correspondingly altered (adapted) processes and
products to the extracellular matrix. Thus, a cell
response to an external mechanical stimulus
takes place [8, 15].
The cytoskeleton of every cell is normally
under physiological tension. This tension is in
balance with the texture of the ECM and the
functional mechanical stimuli in daily life.
In the case of pathological scarring, however,
this physiological tension of the cytoskeleton is
already increased. This leads to higher sensitivity
to mechanical stimuli. Due to the increased collagen deposits and myobroblast activity, the
ECM has a higher tension and stiffness than
physiological skin (tissue). This imbalance is
responsible for the fact that mechanical stimuli
occurring in daily life can already be perceived as
overload at the cellular level and lead to an overreaction in the cell. This can end in a pathological
brosis process.
Important to Know
• In manual scar therapy, the dosage
approach should be selected in such a
way that a physiological balance can be
restored regarding intra- and extracellular mechanical tension.
Unfortunately, the facts explained so far do
not allow a clear conclusion regarding the correct
dosage. However, by putting the individual pieces
of the puzzle together, it is possible to approach
the area of adequate and functional dosage.
It can be assumed that there is a signicant
difference between the application of a high and
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1
Mechanical stimulus
2
3
Fig. 3 Schematically depicted mechanotransduction process of the reaction of a broblast cell to an external
mechanical stimulus [7, 13, 15–19] (Courtesy of
T.Koller). (1) A mechanical stimulus is applied by a physiological movement or manual input by hand. (2)
Mechanosensors on the cell membrane register the uid
displacement and transmit this signal into the cell. (3) The
5
Gene
Transcription
4
mechanosensors activate “adapter proteins” which transmit the mechanical stimulus to the cytoskeleton. (4) The
cell reacts with a gene transcription and passes on correspondingly altered (adapted) products to the extracellular
matrix. (5) Newly functionally aligned collagen networks
after an injury or through “new use” due to a new activity
a low dosage. This consideration refers to the
active phase of a scar and it is not yet mature
state. Therefore, amplitude, duration, and frequency are important parameters that should be
considered in connection with the wound-healing
phases [15].
Amplitude
Amplitude is dened as the largest excursion of
an oscillation or a pendulum from the center
position or as the oscillation range. If the mechanical stimulus (the amplitude) is too strong, the
reaction of the cell nucleus becomes much less
controllable. This can quickly lead to an overreaction of the cell. Due to the persistent inammatory state, the cell is more sensitive. This leads to
the hypothesis that stimuli that are harmless to
the physiological skin may already represent an
overdose in scars [20].
Since mechanotransductive cell responses are
initiated by minimal forces (up to 0.00058 N),
functional alignment is already achieved with
very gentle manual therapeutic interventions. In
the back region, the empirically known marked
increases in connective tissue resistance R1 and
R2 are 1–2N for R1 and 2–4N for R2 [10, 11].
Thus, it can be assumed that manual interventions in the area of R1 probably already provide a
sufciently adequate stimulus for the scar tissue
to induce a mechanotransductive response of the
cell and thus a functional alignment of the extracellular matrix.
In the proliferation phase, R1 appears to be an
important indication for a wound-healingadapted dosage. In the remodulation phase, a
dosage up to R2 is acceptable.
Several years of clinical experience with
severely burned patients show that in the prolif-
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eration phase manual scar techniques should only
be used until the rst increase in connective tissue resistance is reached. This is because the tissue is signicantly less resilient than comparable
connective tissue in the same wound-healing
phase [5]. Due to the delayed wound healing,
burn scars often have a considerably prolonged
proliferation phase. As a result, the transition
from R1 to R2 is empirically experienced as
smooth (Fig.4).
In the case of linear (surgical) scars, the clinical situation is more stable. There is no mechanical overdosage if the dosage is increased up to the
second connective tissue resistance in the proliferation phase and if it is increased into the second
connective tissue resistance in the remodulation
phase (Fig.5).
Koller (2018, 2019) conducted a pilot study
on interrater reliability to determine R1 and R2.
Stretching tissue / scar
The results were promising. Therapists appear to
be able to detect the rst signicant increase in
connective tissue resistance with moderate
(ICC2=0.67) and the second signicant increase
in connective tissue resistance with good interrater reliability (ICC2 = 0.80). Regarding direct
and indirect pain conduction, it can be assumed
that C-ber activity progressively sets in with the
second marked increase in connective tissue
resistance (R2) and that until R2 mainly the Aδ
bers are active as a “warning signal” of cell
damage [10, 11].
Frequency
The frequency describes how fast repetitions
within a periodic process follow each other per
second. The unit of frequency is Hertz (Hz).
Balestrini and Biliar (2006) found that a cycli-
cal stretch stimulus with 0.2 Hz and moderate
Fig. 4 Summarizing presentation of wound-healingphase-adapted and tissue-specic dosages in the manual
therapy of burn scars (Courtesy of Own presentation). (1)
In the proliferation phase, around the rst signicant
increase in connective tissue resistance (amplitude). (2) In
the remodulation phase, progressing up to the second
2-58 Dynes
corresponds to
0.00002-
0.00058N
Dosage during
the proliferation
phase
Tissue specific
(collagen type III)
n
3
Dosage during the
remodeling phase (tissue-
specific) and later
(collagen type I)
1
1.CTR*
(R1)
*Connective tissue
resistance increase (CTR)
Stretching tissue / scar
2
Paraphysio-
logical
2.CTR*
(R2)
remarkable increase in connective tissue resistance
(amplitude). (3) R1 and R2 are exemplary. Connective tissue displaceability in the back is within a range of 1–4N
[11] (much higher than the broblast needs for mechanotransductive cell response)
potential
cell damage
space
mechanotransduction
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Stretching tissue/ scar
Dosage during the
proliferation phase
Tissue specific (collagen
*Connective tissue
resistance increase (CTR)
2-58 Dynes
corresponds to
0.00002-
0.00058N
1.CTR*
(R1)
3
Stretching tissue / scar
Fig. 5 Summarizing presentation of wound-healing
phase adapted and tissue-specic dosages in manual therapy of injured tissue (post-traumatic/postoperative)
(Courtesy of Own presentation). (1) In the proliferation
phase, progressing up to the second remarkable increase
in connective tissue resistance (amplitude). (2) In the
Dosage during the
remodeling phase (tissue-
specific) and later
2
1
type III)
Paraphysio-
logical
2.CTR*
(R2)
remodulation phase, into the second remarkable increase
in connective tissue resistance (amplitude). (3) R1 and R2
are exemplary. Connective tissue displaceability on the
back is within a range of 1–4N [11] (much higher than the
broblast needs for a mechanotransductive cell response)
potential
cell damage
space
amplitude stimulates the broblasts to produce a
more resistant matrix. The tissue density
increases, and the bers are reorganized.
Histologically, a signicant decrease in thickness
was observed. After this stimulus, the tissue was
thinner, denser, and better organized [14].
increase in collagenase production with cyclic
stretching on broblasts compared to static
stretching [21].
a slight stretching, tailored to the respective
wound-healing phase with intermittent oscillation (0.2Hz) at the end of the respective amplitude. These assumptions correlate with empirical
and clinical experience but have not yet been
proven in human research.
Carano et al. (1996) demonstrated a 200%
Clinically recommendable would therefore be
Duration
How long should a stimulus be applied? This is
another fundamental question regarding dosage. Although splints and other stretching
techniques are widely used, there are no
research results on humans available in the literature. Only effects from animal studies can
serve as a basis for clinical considerations and
empirical experience.
Bouffard etal. were able to demonstrate good
results (reduced TFG-beta 1) with daily 10min
stretching and moderate amplitude (20% stretching) [15]. However, practical experience shows
that splint applications over several hours also
produce positive effects.
Carano et al. (1996) conducted research on
cell cultures of articial ligaments. They found
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that a ve-minute application time was most
effective in terms of wound healing for a previously placed lesion [21].
Empirically, good results are achieved with
application times of 1min per location, three to
ve times per therapy unit. Usually, one to two
therapy units per day are realistic in the clinical
setting.
Clinical Tip
• Recommended dosage for large-area
and deep dermal scars:
– In the proliferation phase: around the
rst marked increase in connective
tissue resistance (amplitude)
– In the remodulation phase: progres-
sively up to the second marked
increase in connective tissue resistance (amplitude)
• Dosage recommendations for linear
scars:
– In the proliferation phase: up to the
second marked increase in connective tissue resistance (amplitude)
– In the remodulation phase: progres-
sively into the second marked
increase in connective tissue resistance (amplitude)
• Application duration: In general 1min
per location, three to ve times per therapy unit in addition to an oscillating frequency of 0.2 Hz at the end of the
respective amplitude
effective and purposeful in terms of regaining
function:
– Manual scar therapy
– Compression
– Silicone
– Splints
– Tape (Kinesio®)
– Vacuum massage
– Scar care (with ointments)
Important to Know
In order to counteract pathological scarring, the following factors must always be
considered:
• Avoid increase of blood ow
• Mechanical forces in adjusted dosage
• General tension reduction of the tissue
• Prevent overstrain from daily activities
Caution!
Sliding on the skin leads to increased shear
forces and hyperemia. Excessive external
mechanical forces can result in pathological wound healing [8]. The tension can be
positively inuenced by manual techniques, compression and silicone, splints,
tape, and vacuum massage. Behavior that is
in line with wound healing is also essential
for daily life.
Noninvasive Treatment Options
Scar maturation can have a negative effect on
function. Physiological wound contracture leads
to increased tension in the tissue and mobility
decreases. Therapists try to counteract these negative effects as much as possible to achieve an
optimal functional result. The following therapeutic options are based on the mechanotransductor mode of action. They are considered to be
Compression
In everyday clinical practice, textile compression
therapy is standard for the prevention and treatment of hypertrophic scars. However, it has not
yet been conclusively claried on which humoral,
cellular, or mechanical processes the effect of
compression therapy is based [22]. The results of
the systematic review and meta-analysis of Ai
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etal. (2017) show that patients with hypertrophic
scarring receiving compression therapy showed
signicant improvements regarding redness, pigmentation, thickness, and hardness of the scar. In
addition, it is known that the application of pressure relieves itching and pain in active hypertrophic scars [23]. Continuous pressure on an active
scar causes numerous small vessels to close ischemically. Ischemia leads to increased apoptosis
of myobroblasts during scar maturation causing
a reorganization of the extracellular matrix [3].
Compression-induced hypoxia shifts the collagen synthesis toward catabolism [24]. This may
lead to the destruction of existing collagen bers
and thus to a lower density of the scar structure.
At the same time, the new stimulation (mechanical compression) allows a more functional resynthesis of collagen. This results in a
qualitatively better and functionally more resilient scar tissue [22].
Patients with deep second-degree and thirddegree burns as well as with other scars prone to
hypertrophy receive customized compression
garments [25]. It is recommended to wear compression garments consistently day and night
until the end of scar maturation to achieve the
most aesthetic scar maturation possible with minimal functional restrictions. A short interruption
of the compression therapy is needed to change
the compression garment, perform personal
hygiene, and care for the scar [22].
The duration of the compression therapy
depends on several factors:
are used. The terms “comfort” and “strong” refer
to the product descriptions by this company.
Phase 1: Early Phase
Patients receive surgical interventions in the
acute hospital. As a result, the wound volumes
often uctuate greatly and sometimes the wound
areas are still oozing.
Expensive custom-made compression products would not be appropriate in this phase. With
tubular bandages (e.g., Eesiban®) and selfadhesive dressings (e.g., CobanTM®), however, a
transition from classic wound dressing to compression (10–14mmHg) can take place early in
the healing process. At the same time, early compression can be supplemented by ready-to-wear
products. This also improves treatment
adherence.
Phase 2: Customized Compression
(“Comfort”; Viscose/Elastane)
In this phase, wound healing is largely completed. Patients with extensive wounds are usually transferred to a rehabilitation clinic. People
with minor injuries usually receive outpatient
follow-up treatment. Now the compression treatment begins with custom-made, soft, comfortable material of compression class II.
Depending on wound healing, a gradual start
is also possible. In areas with wounds that are
still oozing, materials from the early phase are
still used. The custom-made products are used in
healed regions.
– Severity of scars (depth of burn)
– Localization and extension of scars
– Individually different healing reactions
– Acceptance to therapy, patience of the patient
and relatives
Empirical values show a period of at least
8–24months [22].
The following literature-based “three-phase
model” of compression has established itself in
recent years at the University Hospital Zurich
and the Bellikon Rehabilitation Clinic.
Flat- knitted products of the Swiss company TTK
Phase 3: Customized Compression
(“Strong”; Polyamide/Elastane)
Once wound healing is complete, the scar tissue
becomes more resilient and pressure sensitivity
decreases. The patient is active again and largely
independent in daily life. A further individual
treatment with more robust material should be
aimed for.
They are then more able to tolerate the compression 23h/24h. This is a decisive factor for
the success of compression therapy [26].
Physiologically healed scars do not necessarily
require compression. If patients are involved in
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therapy decisions, this improves their adherence.
If, in addition to the scar problem, lymphatic
insufciency exists, a treatment with compression class III products should be considered.
Custom-made articles should be made of
materials that are comfortable to wear and have
good haptics. Compression materials that are
hard, stiff, or even scratchy are not very well
accepted.
Experience shows that compression garments
should meet the following requirements [22]:
– Exact reproduction of the skin prole without
incisive wrinkling (risk of pressure points)
– Uniform compression with the least possible
functional interference
– Few, at, and exible seams
– Seams should not be directly on the joints
– Good skin tolerance
– Durable, breathable, and easy to clean.
Colored material can promote acceptance.
However, it should be noted that colored materials often have a harder feel due to the higher pigmentation of the material.
The various compression classes (RAL standard) have the following pressure characteristics
[27]:
methods of scar treatment, although so far there
is only weak evidence for this form of therapy to
treat existing scars or for prophylaxis. The effect
is based on increased hydration of the scar tissue,
caused by silicone gel as a water-impermeable
membrane. This mode of action corresponds to
an occlusion. In addition, this probably leads to
reduced blood circulation or angiogenesis and
thus to reduced collagen synthesis [28].
Silicone offers a decisive advantage, especially in burn scars: it reduces the mechanical
shearing forces in relation to the “external environment” and thus prevents direct friction on the
scar surface. However, there is still no denitive
evidence of this.
When should silicone be used in scar therapy?
The following methods of application have
proven themselves in practice:
Silicone patches:
– In case of excessive mechanical tension on the
tissue or scar surface
– In case of hypertrophy and excessive keloid
formation
– In case of severe itching (mainly because of
the hydration properties)
Customized silicone pads:
– Compression class I: moderate compression
(18.0–21.0mmHg)
– Compression class II: medium compression
(23.0–32.0mmHg)
– Compression class III: strong compression
(34.0–46.0mmHg)
The unit of measurement [mmHg; millimeters
of mercury] is used to specify the static pressure.
Measuring instruments for compression therapy
are offered by TT Meditrade (Denmark), for
example, Kikuhime®.
Silicone
Since 1981, silicone has been used in the treatment of deep dermal defects and hypertrophic
scars. Today, it is one of the most common
– In case of undercuts (recesses/indentations in
the tissue)
– In case of anatomically complex shapes
– In case of extensive depressions and
unevenness
Silicone in the facial area:
– Always in combination with hard shell masks
or partial masks.
– Silicone gel is used for small areas.
To clean or aerate the skin/scar and the sili-
cone pad, daily application breaks of no more
than 1h must be adhered to. The silicone gel is
applied twice a day to the lesions being treated.
The advantage of this therapy option is its
ease of application. Only rarely do side effects
such as folliculitis, erosion, or itching occur.
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Silicone gel is often used in combination with
other procedures or in postoperative scar prophylaxis. Compared to silicone gel patches, it
has the additional advantage that it can also be
used on highly visible body parts and over joints.
The gel can also be used to apply sun protection
products or cosmetics. The side effect of maceration, which is often observed when the patches
are worn for a longer period, can also be avoided
with silicone gel. Silicone of any kind must not
be used on open wounds. Experience has shown
that failure to observe daily hygiene measures
(during the break in application) can lead to skin
irritation.
223
Fig. 6 Tape for mechanical relief of a scar (Figure:
Rehabilitation Clinic Bellikon)
Splints
A great advantage of specic, custom-made
splints is the duration of application. Splint applications (several times a day in addition to the
therapy) make it possible to set a functionally
adequate stimulus. Optimal tting of a splint is
often a major challenge at the beginning of rehabilitation and is resource intensive. Due to volume uctuations resulting from different
application techniques of the bandages, potential
pressure points are a constant risk, which is why
splints must be checked and adjusted regularly.
Splints are ideal for the hand, wrists, elbow,
ankle, and mouth. The dosage (wearing time,
angle, and extent of movement for dynamic
splints) must be adapted to the respective woundhealing phase (see Figs.4 and 5).
Tape
A standard kinesiotape® can be used to relieve
scars, wounds, or areas that are subject to excessive mechanical tension. This requires the possibility to apply the tape on physiological skin or
already very stable scarred skin. For sensitive
skin, skin protection or removal sprays are
recommended.
The length of the tape should correspond to
the area to be relieved. The therapist cuts the tape
lengthwise, and in the middle, xes the rst
“anchor” on the tissue and xes the two branches
of the tape “surrounding the scar” (Fig.6). There
should be as much scar tissue as possible between
the two legs of the tape. This leads to a visible
and noticeable mechanical stress relief.
The tape may remain on the skin for a maximum of 5days. Further application should only
take place after a day’s rest. In patients with burn
scars, a wearing period of 3 days seems to be
optimal [29].
Vacuum Massage
Vacuum massage is a noninvasive mechanical
massage technique invented to treat burns and
scars. To date, no effects of vacuum massage on
thickness and density of human scar tissue have
been reported. In the skin endothelial cells, broblasts and myobroblasts embedded in the ECM
sense mechanical stimuli (created by vacuum
massage) and may promote intracellular processes leading to matrix remodeling. Preliminary
results show that the disruption of the epidermis
may indicate that vacuum massage could be able
to actually breach the skin barrier. The statistically signicant changes in the dermal layers
could suggest an increased ECM production after
vacuum massage [30]. The use of vacuum massage is recommended toward the end of the
remodulation phase or outside the classic woundhealing phases.
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