Effectiveness of various methods of manual scar therapy

**Background:** Scars result from skin damage and can progress into pathological forms (hypertrophic, keloid) affecting quality of life through pain, pruritus, contractures, and cosmetic concerns. Manual scar therapy includes various techniques, but evidence for optimal combined protocols is limited. This study aimed to evaluate the effectiveness of combined manual scar therapy on postoperative scars.

**Methods:** Eleven women (mean age 32.9 ± 5.2 years) with postoperative scars (elbow n=1, abdominal n=3, cesarean section n=7; mean scar age 5 ± 2.9 months) were enrolled. One participant was excluded due to initiating other treatment. Inclusion criteria: at least one linear surgical scar <12 months old, no current scar therapy, no topical treatment. Exclusion criteria: topical treatment use, other scar therapy, unhealed wounds or scar <6 weeks. The 8-week protocol included two 30-minute sessions per week: manual scar manipulation and massage (every session), cupping (every second session, 4 times total), dry needling using the 'surrounding the dragon' technique (twice total at sessions 9 and 13), and taping with 'zig-zag' or 'star' technique (every second session, 8 times total). Cupping and dry needling were introduced from week 5. Outcomes assessed pre- and post-therapy included: clinical photography (dermatoscope Heine DELTA 30, ×10 magnification), skin parameters via Multi Probe Adapter MPA 10 (hydration via Corneometer CM 825, TEWL via Tewameter TM Hex, melanin and hemoglobin via Mexameter MX 18, viscoelasticity via Cutometer 580), high-frequency ultrasound (DUB SkinScanner, 33 MHz transducer) for scar height and structure, and the Patient and Observer Scar Assessment Scale (POSAS). Statistical analysis used Statistica 13.3 and MS Excel 2016; normality tested with Shapiro-Wilk, parametric data with Student's t-test, nonparametric with Mann-Whitney U test; p<0.05 considered significant.

**Key Results:** Visual comparison showed scars became paler, flatter, and more regular after therapy. High-frequency ultrasound revealed a statistically significant improvement in scar structure (collagen fiber arrangement): Avg = 3.1 ± 1.3 vs. Avg = 5.7 ± 1.3; p < 0.005. No significant change in scar height was observed. Skin parameter improvements included: hydration (Avg = 37.8 ± 7.7 vs. 48.6 ± 1.2), TEWL (g/m²/h) (Avg = 13 ± 4 vs. 9.7 ± 2.4), stretchability (mm) (Avg = 0.003 ± 0.0003 vs. 0.05 ± 0.01), and erythema level (Avg = 352.1 ± 103.1 vs. 249.9 ± 89.8). Melanin level change was not statistically significant (Avg = 104.9 ± 44 vs. 83.7 ± 27.7). POSAS patient self-assessment showed statistically significant improvements in all domains: pain, pruritus, color, stiffness, regularity, vascularization, and elasticity. Patients were most satisfied with scar color and elasticity improvements.

**Clinical Implications:** This combined manual therapy protocol (massage, cupping, dry needling, taping) over 8 weeks demonstrated significant positive effects on multiple scar characteristics including pain, pruritus, pliability, pigmentation, surface area, and stiffness. Objective measurements confirmed improved hydration, reduced TEWL, increased elasticity, and better collagen fiber organization. The study supports combined manual therapy as an effective approach for postoperative scar management. However, limitations include small sample size (n=11), lack of control group, and no comparison to normal skin. The optimal dosage, timing relative to wound healing phases, and comparative effectiveness of individual techniques remain unclear. Further studies with larger samples, control groups, and standardized protocols are needed to establish evidence-based guidelines for manual scar therapy.