ORIGINAL ARTICLES

The Role of Massage in Scar Management:A Literature Review

THUZAR M. SHIN, MD, PHD, AND JEREMY S. BORDEAUX, MD, MPH*

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, numberof patients, scar location, time to onset of massage therapy, treatment protocol, treatment duration, out-comes measured, and response to treatment was tabulated.

RESULTS Ten publications including 144 patients who received scar massage were examined in thisreview. Time to treatment onset ranged from after suture removal to longer than 2 years. Treatment proto-cols ranged from 10 minutes twice daily to 30 minutes twice weekly. Treatment duration varied from onetreatment to 6 months. Overall, 65 patients (45.7%) experienced clinical improvement based on PatientObserver 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 orPatient Observer Scar Assessment Scale score.

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

The authors have indicated no significant interest with commercial supporters.

Despite appropriate planning and technique,

healing after dermatologic surgery may not

be perfect, resulting in redness, pruritus, pain, or

scar. Patients may suffer from anxiety or depres-

sion due to unaesthetic scar appearance and may

be less willing to undergo further recommended

surgical procedures.

Nonsurgical techniques to help prevent and treat

abnormal scars include laser therapy, intralesional

agents, cryotherapy, radiation, pressure therapy,

occlusive dressings, topical agents, and scar mas-

sage.1–10 Some surgeons recommend scar massage

during wound healing to improve aesthetic out-

come.11,12 There is a lack of consistency regarding

when to initiate treatment, technique, frequency,

and duration of therapy.13–18 The aim of this

review article was to summarize the published lit-

erature regarding the use of scar massage and to

propose ways to integrate this therapy into the

practice of dermatologic surgery to improve scar

cosmesis.

Methods

We searched PubMed (http://www.ncbi.nlm.nih.

gov/pubmed) using the following key words:

“massage” in combination with “scar,” “linear,”

*Both authors are affiliated with the Department of Dermatology, University Hospitals Case Medical Center andSchool of Medicine, Case Western Reserve University, Cleveland, Ohio

© 2011 by the American Society for Dermatologic Surgery, Inc. � Published by Wiley Periodicals, Inc. �ISSN: 1076-0512 � Dermatol Surg 2012;38:414–423 � DOI: 10.1111/j.1524-4725.2011.02201.x

414

“hypertrophic,” “keloid,” “diasta*,” or “atro-

phic.” Relevant citations within the studies

retrieved were reviewed. We included studies in

English in which scar massage was used for pre-

vention or treatment of scars. Review articles

without original data and studies not involving

scar massage of the skin were excluded. Publica-

tions meeting the inclusion criteria were reviewed,

and data on study type, scar type, number of sub-

jects, scar location, interval before onset to mas-

sage therapy, treatment protocol and duration,

outcomes measured, and response to treatment

were extracted.

Results

Our results are summarized in Table 1. Ten publi-

cations met our inclusion criteria—eight prospec-

tive studies including 167 adults and 38 children

and two case studies including one adult, three

children, and 11 patients of unknown age. One

hundred forty-four patients (107 adults, 26 chil-

dren, and 11 of unknown age) received scar mas-

sage therapy. Locations of scars included upper

extremities (n = 36, 25%), face (n = 15, 10%),

eyelids or periorbital skin (n = 14, 10%), multiple

locations (n = 8, 6%), chest (n = 1, 1%), and not

reported (n = 70, 49%). Thirty of the scars treated

with massage were postsurgical and were located

on the face, eyelids, or periorbital skin. All other

massaged scars were traumatic or as a result of

burns. Time to initiation of treatment ranged from

immediately after suture removal (n = 15) to

longer than 2 years after injury (n = 8); this vari-

able was not reported in four of the studies

(n = 75). The remaining patients (n = 46) had a

time to treatment of 4.3 months on average (range:

3.2–6.4 months). Massage protocols differed from

10 minutes twice a day to 30 minutes twice a

week. Duration of therapy was as short as one

treatment and as long as 6 months.

Outcomes measured included the Patient and

Observer Scar Assessment Scale (POSAS), Vancou-

ver Scar Scale (VSS), scar thickness, scar perfusion,

color, pain, pruritus, range of motion of joints

with overlying scar tissue, mood, anxiety, depres-

sion, patient-reported skin status, and subjective

clinical appearance (photograph). The POSAS con-

sists of a patient scale and an observer scale and is

a reliable instrument used to evaluate linear surgi-

cal scars using subjective criteria.19 The patient

scale includes questions regarding pain, pruritus,

color, stiffness, thickness, texture, and overall opin-

ion. The observer scale incorporates vascularity,

pigmentation, thickness, relief, pliability, and sur-

face area into the total score. The VSS is a widely

used assessment tool with good interrater reliability

that quantifies scar pliability, height, vascularity,

and pigmentation.20,21

Of the 144 patients who underwent scar massage

therapy, 65 (45.7%) experienced improvement in

one or more of the following: POSAS, VSS, mood,

range of motion, pruritus, pain, depression, and

anxiety. The remaining 79 patients (54.9%) had

no improvement. Of the 30 surgical scars treated

with massage, 27 (90.0%) had improvement in

POSAS or appearance.

Discussion

Evidence to support the use of scar massage is

inconclusive, although efficacy appears to be

greater in postsurgical scars. There was much vari-

ability and inconsistency with regard to when treat-

ment should be initiated, treatment protocol and

duration, outcomes evaluated, and how the out-

comes were measured. Because these results are dif-

ficult to interpret, evidence-based recommendations

cannot be made. Potential positive effects of scar

massage include involving patients in their treat-

ment, hastening the release and absorption of bur-

ied sutures, aiding the resolution of swelling and

induration, and economic value—especially com-

pared with silicone gels. Possible negative aspects of

this therapy include wasting the patient’s time if

massage is not an efficacious treatment, irritation

from friction, and developing irritant or contact

dermatitis from the lubricant used for massage.

SHIN AND BORDEAUX

38 :3 :MARCH 2012 415

TABLE1.Summary

ofScarMassageLiterature

Reference

sSca

rType

StudyType

nLoca

tion

Skin

Grafts

Average

Tim

eto

Treatm

ent

Treatm

ent

Protoco

l

Treatm

ent

Duration

Outcomes

Resu

lts

Bianch

i

etal.40

Group1:14

surgical,9

traumatic

Group2:16

surgical,4

traumatic

Prosp

ective,

controlled

Group1:15

adults

Face

NR

Aftersu

ture

removal

Group1:

Self-

drying

silico

ne

gel

without

massage

2months

Patient

Obse

rver

Sca

r

Assessment

Sca

leat0

and2

months

Both

groups

showed

improvement

inpatient

andobse

rver

scores;

massagewas

aseffective

assilico

ne

gel

Group2:

15adults

Group2:

Massage

10minutes

twicedaily

Bodian41

Surgical

Case

report

14adults

and

children;all

rece

ived

massage

Eyelid,

periorbital

skin

No

NR

Massage

consisting

of20–3

0

rotary

movements

with

backward

pressure,

three

timesa

day

3weeks

to

“months”

Appearance

11of14

patients

had

improvement

ofvarious

postsu

rgical

complica

tions

Roh

etal.(2010)42

Postburn

Prosp

ective,

controlled

Group1:13

adults

Handor

forearm

NR

Group1:

3.4

months

Group2:

3.4

months

Group1:

Massage

30minutes

threetimes

aweek

(same

protoco

l

asRoh

etal.2007)

3months

Thickn

ess

(ultraso

und),

perfusion

(Doppler),

depression,

subjective

skin

status,

and

burn-specific

health

measu

redat

0and

3months

No improvement

ineither

group,but

there

was

atrend

toward

scarmassage

preventing

thicke

ningof

thescar

overtime

Group2:13

adults

Group2:

Standard

therapy

without

massage

SCAR MASSAGE: A LITERATURE REVIEW

DERMATOLOGIC SURGERY416

TABLE1.Continued

Reference

sSca

rType

StudyType

nLoca

tion

Skin

Grafts

Average

Tim

eto

Treatm

ent

Treatm

ent

Protoco

l

Treatm

ent

Duration

Outcomes

Resu

lts

Morien

etal.43

Postburn

Prosp

ective

8ch

ildren,

allrece

ived

massage

Arm

s,legs,

trunk,

face

Yes,

all

massage

was

perform

ed

onskin

grafts

�2years

Massage

20–2

5

minutesdaily

consisting

of5minutes

effleurage,

5minutes

petrissa

ge,

2–5

minutes

friction,

5minutes

lengthening

androlling

3–5

days

Mood,range

ofmotionof

knees,

neck,

andsh

oulders

withoverlying

scartissue

measu

redat

0and5days

Improvedrange

ofmotion

inmassaged

tissue

Roh

etal.(2007)4

4

Postburn

Prosp

ective,

controlled

Group1:18

adults

Handor

forearm

NR

Group1:

127.6

days

Group1:

Massage

10minutes

daily

(tech

niquenot

specified)

andskin

rehabilitation

massage

therapy

30minutes

weekly(light

strokingof

palm

,

acu

pressure

onunscarred

areason

forearm

and

hand,followed

byvarious

topicals)

3months

Pruritus,

VSS,

depression

measu

redat

0and3

monthsand

subjective

skin

status

measu

redat

3months

Pruritus,

VSS

score,

and

depression

improved

more

in

massaged

patients

Group2:17

adults

Group2:

95.3

days

Group2:

Standard

therapy

without

massage

SHIN AND BORDEAUX

38 :3 :MARCH 2012 417

TABLE1.Continued

Reference

sSca

rType

StudyType

nLoca

tion

Skin

Grafts

Average

Tim

eto

Treatm

ent

Treatm

ent

Protoco

l

Treatm

ent

Duration

Outcomes

Resu

lts

Li-Tsa

ng

etal.45

Postburn

and

traumatic

Prosp

ective,

randomized,

controlled

Group1:

24adults

NR

NR

NR

Group1:

Massage

15minutes

twiceaday

plus

silico

negel

sheeting

6months

Color

(spectro-

colorimeter),

scar

thickn

ess

(ultraso

und),

VSS,pain,

pruritus

measu

red

at0,1,2,

4,and6

months

Massage

plus

silico

ne

wasbetter

atreducing

thickn

ess

andheight

and

increasing

scar

pliability

than

massage

alone

Group2:

21adults

Group2:

Massage

15minutes

twiceaday

Field

etal.46

Postburn

Prosp

ective,

randomized,

controlled

Group1:10

adults

Group2:10

adults

NR

Massaged

areas

were

not

grafted

Group1:

115days

Group2:

118days

Group1:

Massage

30minutes

twiceaweek

(circu

lar,

transv

erse,

and

vertical

stroke

s,

pinch

ing,

lifting,

rolling,

gliding

stroke

s)

5weeks

Pruritus,

pain,

anxiety,

mood

measu

red

before;

andafter

treatm

ent

at0and

5weeks

Patients

in

themassage

group

showed

immediate

andlong-

term

improvement

inall

outcomes

measu

red

Group2:

Standard

therapy

without

massage

SCAR MASSAGE: A LITERATURE REVIEW

DERMATOLOGIC SURGERY418

TABLE1.Continued

Reference

sSca

rType

StudyType

nLoca

tion

Skin

Grafts

Average

Tim

eto

Treatm

ent

Treatm

ent

Protoco

l

Treatm

ent

Duration

Outcomes

Resu

lts

Patino

etal.47

Postburn

Prosp

ective,

randomized,

controlled

Group1:15

children

Group2:15

children

NR

NR

NR

Group1:

Compression

garm

ents

only

3months

ModifiedVSS

measu

redat

0and

3months

Massage

improved

VSSscores

in13%

(2patients),

worsened

VSS

scoresin

47%

(7patients),

andhadno

effect

in40%

(6patients)in

thetreatm

ent

group.

Intheco

ntrol

group,7%

(1patient)

improved,

33%

(5

patients)

worsened,

and60%

(9patients)

hadno

changein

VSS

scores

Group2:

Compression

garm

ents

plusfriction

massage

10minutes

daily

SHIN AND BORDEAUX

38 :3 :MARCH 2012 419

TABLE1.Continued

Reference

sSca

rType

StudyType

nLoca

tion

Skin

Grafts

Average

Tim

eto

Treatm

ent

Treatm

ent

Protoco

l

Treatm

ent

Duration

Outcomes

Resu

lts

Silverberg

etal.48

Postburn

Prosp

ective,

randomized,

controlled

Group1:5

adults

Wrist

Yes,

all

massage

was

perform

ed

onskin

grafts

Group1:

5.8

months

Group2:

6.4

months

Group1:

Pressure

garm

ents

and

active-

assisted

ROM

exercises

One

treatm

ent

Wrist

extension,

wrist

flexion,

radial

deviation,

ulnar

deviation,

pliability,

vascularity

80%

(4patients)

intheco

ntrol

grouphad

betterwrist

extension

ROM

andulnar

deviation;40%

(2patients)in

themassage

grouphad

improvedwrist

extension

ROM

andradial

deviation;

there

wasno

changein

wrist

flexion,

pliability,or

vascularity

in

eithergroup

Group2:

5adults

Group2:

Pressure

garm

ents

andactive-

assisted

ROM

exercises

plus

10–1

5

minutes

ofso

fttissue

mobilization

(sustained

pressure,

direct

oscillation,

friction

massage)

Hallam

etal.49

Postburn

Case

report

1ch

ild

Chest,

lower

extremities

Yes

NR

Massage

20minutes

daily

(tech

nique

not

specified)

Not

reported

Appearance

Improvement

NR=notreported;VSS

=Vanco

uverSca

rSca

le;ROM

=rangeofmotion.

SCAR MASSAGE: A LITERATURE REVIEW

DERMATOLOGIC SURGERY420

Based on the publications analyzed, it is reasonable

to recommend beginning scar massage after nonab-

sorbable sutures are removed from wounds closed

using primary intention. This is generally 10 to

14 days after primary closure but will vary depend-

ing on the anatomic site and the presence of skin

flaps or grafts. Early massage should be avoided in

light of evidence that mechanical pressure during

early phases of wound healing promoted hypertro-

phic scar formation in a mouse model.22 Contrain-

dications include compromised integrity of the

epidermis, acute infection, and bleeding. Clean

hands are obligatory before massage therapy. The

emollient used should be nonirritating and free of

any known sensitizers. Enough pressure should be

applied to blanch the scar, but one should avoid

excessively sliding the fingers across the skin to

prevent injury to the epidermis. Friction massage

for 10 minutes twice a day can be titrated up or

down as tolerated. The duration of massage ther-

apy reported in the literature ranges from one

treatment to 6 months, and further investigation is

needed to determine the optimal treatment interval.

Realistically, patients will probably discontinue the

therapy when they deem it is ineffective or when

the scar is optimally improved. Scar massage

should be promptly terminated if the patient devel-

ops a break in the epidermis, infection, bleeding,

wound dehiscence, graft failure, intolerable dis-

comfort, or hypersensitivity to the emollient.

The natural history of acute wound healing pro-

gresses through distinct but interconnected stages:

inflammation, proliferation, and remodeling.23,24

The remodeling phase can last from months to

years, during which time the scar matures and

improves in appearance and pliability. This process

occurs in the absence of any intervention. Although

the effect of massage on this phase of wound heal-

ing is unknown, it may shorten the time needed to

form a mature scar.

Notwithstanding the lack of evidence, massage

should theoretically be effective. One hypothesis to

support its use is that mechanical disruption of fibro-

tic tissue increases the pliability of the scar. Mechan-

ical forces induce changes in the expression of

extracellular matrix proteins and proteases, and

massage may alter the structural and signaling

milieu.25,26 In a study of cultured human skin fibro-

blasts, Kanazawa and colleagues demonstrated a

decrease in messenger ribonucleic acid (mRNA) and

protein levels of connective tissue growth factor and

collagen type 1 alpha 2 (Col1a2) after 24 hours of

uniaxial cyclical stretching.27 Because connective tis-

sue growth factor has been implicated in maintaining

transforming growth factor-beta-induced fibrosis,28

its downregulation may prevent abnormal scarring.

In another in vitromodel, human hypertrophic scar

samples responded to mechanical loading by induc-

ing apoptosis and decreasing levels of tumor necrosis

factor-alpha,29 although another study showed that

biaxial mechanical strain upregulates matrix metal-

loproteinase-1 and collagen type 1 and 3 mRNA

expression and downregulates the proapoptotic pro-

tein Bax.30 These results suggest that massage may

be effective through its ability to affect matrix

remodeling and fibroblast apoptosis, although the

exact mechanism remains to be determined.

In addition to physical modification of the scar,

massage may have other benefits. Massage therapy

is an effective adjunct therapy in managing lower

back pain, depression, addiction, and other condi-

tions, including atopic dermatitis.31–33 Connective

tissue massage produced a statistically significant

elevation of beta-endorphins over baseline in

healthy volunteers,34 supporting a role for this ther-

apy in pain relief and a sense of well-being. Other

studies have demonstrated lower urinary cortisol

and higher serotonin and dopamine levels after mas-

sage therapy,35,36 supporting its role in improving

mood and decreasing anxiety. In addition to the

release of endogenous opioid peptides and neuro-

transmitters, massage may alleviate pain through its

effect on the gate theory of pain, described by Mel-

zack and Wall in 1965.37

Future studies addressing suitable protocols, efficacy,

and mechanism of action of scar massage should

SHIN AND BORDEAUX

38 :3 :MARCH 2012 421

attempt to use standardized, objective measures to

produce high-quality, reliable, and reproducible

results. Currently, the metrics used to evaluate the

severity and characteristics of a scar include color,

thickness, pliability, texture, total area, pain, and

pruritus, most of which are subjective measurements.

The use of ultrasonography and chromometers are

alternatives to obtain objective data. There is a lack

of consensus with respect to the ideal scar assessment

scale,38 although the POSAS is used to evaluate lin-

ear scars, with satisfactory internal consistency and

agreement between patient and observer scales,

patient intraobserver reliability, and interrater reli-

ability of the observer scales.39

Limitations of this review include the small number

of studies meeting inclusion criteria, restricted abil-

ity to calculate response rates based on the data

reported, and the lack of standardized and objec-

tive outcome measures. In addition, the majority of

scars treated with scar massage resulted from burn

injuries, limiting our ability to generalize these

results to postsurgical wounds.

Conclusion

Despite the paucity of data on the technique and

efficacy of scar massage, it is frequently recom-

mended to patients in an effort to improve scar

cosmesis. Our results demonstrate the need for

well-designed clinical trials that use objective crite-

ria to establish evidence-based recommendations

for or against the use of scar massage in healing

surgical wounds.

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Address correspondence and reprint requests to:Jeremy S. Bordeaux, MD, MPH, 11100 Euclid Avenue,Lakeside 3500, Cleveland, OH 44106, or e-mail:jeremy.bordeaux@uhhospitals.org

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