Working in Cardiac Rehabilitation a common issue for patients who have had open heart surgery is that their scar is very tender. Many patients scars are so sensitive they don’t like feel of the weight of their shirt to be rubbing against the scar. I would like to present you with some information as to how to manage the scar and give you some tips to ease any discomfort you feel. Physically you may not remember the pain from your surgery but your body does. It can over respond to certain stimuli and give signals of pain which may seem for no reason. The body has to learn what is good sensations again and what is bad. It’s normal to feel discomfort in the form of numbness, deep itchiness, tightness, or a burning sensation during healing.
The skin forms a scab over a wound within three to four days following an injury. By day ten the scab usually shrinks and sloughs off. The body then begins to form collagen fibers to strengthen the surgical incision site. Scar tissue remodeling occurs as you start to stretch and pull on it. The stretching of the scar tissue helps to align the collagen fibers to allow them to return to normal. This realignment of the collagen fibers makes the tissue better able to tolerate the forces that are placed on it during the day. It takes damaged tissue approximately between three months to over a year before it returns to full strength. Scar tissue management involves early and consistently exercise, massage of scar tissue to decrease the possibility of developing any long-term concerns.
While the degree of scar formation varies from person to person, there are some distinguishing characteristics:
- Becomes hard and non-pliable
- Bands of fibers form on or below the surface
- Skin tightens or shortens. This is called a contracture and may limit range of motion, leading to postural changes.
- Becomes dry and reopens to form a wound if not managed properly.
- Scar tissue has no melanin in it and will burn, be aware in summer to apply sunscreen or keep covered with a shirt.
The scar tissue acts almost like glue, adhering the skin to the layers of fascia, and muscle. Normally these different layers are able to glide smoothly, however the scar tissue inhibits this and may set the stage for the following problems include:
· Nerve impingement
· Limited range of motion and flexibility
· Postural misalignment
A scar’s healing progression consists of two phases, immature and mature.
· Immature - Immediately after a wound heals, the scar is immature. During this period it may be painful, itchy or sensitive as nerve endings within the tissue heal. While it is typically red in appearance, most scars fade to normal flesh color with maturation. Exercise, massage and heat application will have the greatest positive effect on an immature scar.
· Mature - Depending on the size and depth of the wound, scar tissue will cease production 3 to 18 months following wound healing. When scar tissue is no longer produced, the scar is considered mature. It takes a more disciplined and vigorrous approach to scar tissue management when the scar is mature.
As soon as the wound is knitted, you no longer have steri strips or staples and no open areas or scabs you can begin massage techniques. Initially begin while in the shower, soap the area as this works as a lubricant and prevents infection if the wound has small openings that may not be visible The heat from the water helps the pliability and flexibility of the scar. During the initial immature stages of wound recovery, it is imperative that a gentle approach be taken. The following techniques can improve scar tissue:
- Manual Lymph Drainage helps lymphatic circulation and drainage around the injured area. Gentle, circular, draining motions within the scar itself or a gentle stretch to the skin above and below the scar, first in a straight line and then in a circular motion. Placing the fingers above the scar, then making gentle circular pumping motions on the scar also helps drain congested lymph fluid.Drainage techniques should not hurt or make the scar redden.
- Myofascial Release helps ease constriction of the affected tissue. To stretch the skin next to the scar, place two or three fingers at the beginning of the scar and stretch the skin above the scar in a parallel direction. Then move the fingers a quarter of an inch further along the scar and repeat the stretch of the adjacent tissue, working your way along the scar. An alternative method is to follow the same pattern of finger movements using a circular motion instead of straight stretches. Work your way along the scar in a clockwise and counterclockwise fashion.
- Deep Transverse Friction can prevent adhesion formation and rupture unwanted adhesions. With your hand on opposite sides of the scar gently push the scar to the left, then to the right. Repeat along the entire distance of the scar .This deep tissue technique can make the scar much more pliable.
- Stretching aids in increasing range of motion. Scar tissue will lengthen after being stretched, especially if the stretch is sustained for several seconds and is combined with massage. However, be cautious not to over stretch the scar. Some stretching is good, but if you overstretch it it can make the scar wider. Remember gentle!
- Do not continue if your actions cause significant pain or increase tissue redness.
- Never perform massage on any open lesions.
Scars may become senitive to touch and feel ‘tingly’ if the surrounding nerves have been effected. Desensitisation is the process of teaching the scar to accept many different textures without feeling uncomfortable. Start with using the softest smoothest cloth you can find, silk or satin. Begin with gently rubbing over the scar for two minutes. Initially this will drive you crazy, and two minutes can feel like an hour. Then progress to adding two more minutes with more abrasive cloths such as a cotton t-shirt, or terry cloth wash cloth. This helps to teach the skin the difference between the sensation of touch. It sounds a bit crazy but can make a big difference. Do this consistently for one to three months.
Signs and symptoms of Infection
Contact your physician right away if you have any of the following symptoms. Infection is serious and can tunnel under the skin requiring further surgery to treat it. Don’t try home treatment get in right away!
- Hot Incision: An infected incision may feel hot to the touch. This happens as the body sends infection fighting blood cells to the site of infection.
- Swelling/Hardening of the Incision: An infected incision may begin to harden as the tissue underneath are inflamed. The incision itself may begin to appear swollen or puffy as well.
- Redness: An incision that gets red, or has red streaks radiating from it to the surrounding skin may be infected. Some redness is normal at the incision site, but it should decrease over time, rather than becoming more red as the incision heals.
- Drainage From the Incision: Foul-smelling drainage or pus may begin to appear on an infected incision. It can range in color from blood-tinged to green, white or yellow. The drainage from an infected wound may also be thick, and in rare cases, chunky.
- Pain: Your pain should slowly and steadily diminish as you heal. If your pain level at the surgery site increases for no apparent reason, you may be developing an infection in the wound. It is normal for increased pain if you “overdo it” with activity or you decrease your pain medication, but a significant and unexplained increase in pain should be discussed with your surgeon.
Sometimes the body will reject a suture or spit a stitch, in this case it often appears like a pimple on the scar. There may be a small amount of the stitching material coming out. If this occurs call your surgeon’s office. It can usually be handled very easily in the office however in some cases may require antibiotics.