By Katie McGee, PT, DPT (they/them) & Brianna Durand, PT, DPT (she/her)

Top flattening scars require special care over time for the best healing possible. If you are considering top flattening surgery, or recently had top flattening surgery, read on to learn how you can optimize your scar recovery.

Use the proper bandaging:

Bandages achieve two goals to promote healing of a surgical incision. The first goal bandages achieve is reducing swelling. When swelling is reduced, the edges of an incision can come closer together. Accordingly, the collagen involved in closing the incision is able to form better aligned cross bridges. Better aligned cross bridges mean that a scar is more flat and strong. Light activity, such as walking and torso rotation without arm movement can also help reduce swelling in the chest and thereby promote better incision healing. 

The second goal bandages achieve is protecting the new incisions. Bandages do this by keeping out dirt and other material. They also prevent tension from pulling the incision wider and affecting the collagen cross bridges. It is most important to limit tension across the incision during the first two weeks of healing. Interestingly, after two weeks, scars need a light amount of tension to direct the alignment of the collagen cross bridges. This is one reason scar massage is generally started a few weeks after surgery instead of immediately after surgery.

You may have bandages that stay on from surgery all the way through the first month after surgery, or your medical team may decide to change your bandages sooner. You might be instructed to use a silicone bandage, such as Meptiac. Silicone bandages can make scars feel more pliable and further minimize their appearance. Some people find that silicone use leads to flatter and less visible scars. A provider may recommend a silicone ointment instead of a bandage.

Note: Silicone bandages and ointments can be expensive! Sometimes people will attempt to use a less costly silicone product not designed for scars, such as silicone lubricant. Substitutions for medical silicone products may not create the right level of moisture and protection from oxygen. Talk to your healthcare team if you need a different product to fit your budget before trying out an alternative.

Manage chest swelling:

A special vest from your medical team can help reduce swelling as you heal, again reducing tension across the incisions. Typically, a vest is worn for around two weeks after surgery although sometimes longer. Your medical team may opt for compression bandages, such as an Ace wrap, or nothing at all. Note: This compression vest is not the same as a binder that might have been used prior to surgery.

Your medical may also suggest a low sodium diet to decrease the risk of swelling on your chest. It might help to practice low sodium eating and/or cooking prior to surgery so that you are prepared when you come home.

Follow movement & lifting guidelines:

The goal of mindfully limiting arm movement is to reduce tension across the scars. You might be instructed to avoid lifting your elbows above your shoulders for four weeks, but possibly longer. In addition, some surgeons may recommend that you avoid sleeping on your belly for the first few weeks to further avoid healing complications.

Protect scars from the sun:

Sun exposure can cause scars to become either very light or very dark. Your medical team might encourage you to wear silicone tape over your scars when topless outside for about the first three months after surgery. (Alternatively, some providers recommend silicone gel with sunblock applied over the top, or a combined silicone-sunblock product.) For at least the first six months and possibly even the first year, sunblock is highly important for scar protection. Try to use a sunblock with a SPF of 35 or higher. Some providers recommend a combination of silicone gel and sunblock.

Try scar massage:

Scar massage helps scars move better over the chest wall so that they do not feel stuck or cause a sensation of pulling. Some surgeons will recommend this while others may not. It is important to follow the guidance of your medical team when deciding whether to begin scar massage. Not all scars need scar massage. If scar massage is recommended, it is typically begun after scars have fully closed. Sometimes scar massage may be helpful even years after surgery. A physical therapist or massage therapist trained in scar management can help you with scar massage if you need further guidance.

Steps for scar massage: 

1. Find the right pressure for scar massage.

   • Look at your dominant hand. 

   • See the pads at the fingertips on the index and middle fingers. 

   • Place these pads over the skin on the back of your non-dominant hand. 

   • Use the pads of the dominant hand to slide around the skin on the back of your non-dominant hand. Do this without the nail beds of your dominant hand changing color. Your nail bed changing color is an indication of too much pressure.

   • Just the amount of pressure your need to slide the skin around is about how much pressure you will need on your scars. 

2. Gently move the scar(s)

   • Place the pads of the index and middle fingers on one end of your scar. 

   • Using the pressure described in Step 1, try lightly sliding the scar. It’s okay if the scar only moves a tiny amount

   • AVOID PAIN. Pain can be a sign that too much pressure is being applied, however, it is normal to feel a light tugging or burning sensation. 

   • Spend about 5 to 10 seconds massaging over each 1 inch of scar. You can typically expect to spend 5 to 15 total minutes per day on scar massage.  

3. Be regular with your scar massage. 

   • Continue scar massage daily or most days of the week until your scars slide easily. 

   • Scars are often more mobile by a month of treatment.  

Note: It is also possible to perform scar massage with tools that might more commonly be associated with facials, such as rollers and gua sha tools (gua sha uses tools to scrape the skin and promote circulation.) Be aware that the pressure for using these tools on scars yourself is very light - less than a pound of pressure. Traditional use of gua sha tools risks damaging chest tissue, unless performed by a traditional practitioner of these methods.

Manage substance use:

Tobacco products, alcohol, and recreational drugs can impair scar healing. If you need help reaching the right amount of substance use for you, there are a number of resources: 

• Smoking cessation: https://smokefree.gov/

• SAMHSA National Substance Abuse Helpline: 1-800-662-HELP (4357)

Speak up if something doesn’t seem right: Is your scar suddenly looking raised? Has the scar started growing beyond the original incision line? Is your scar limiting your movement? These are all reasons to reach out to your medical team. There are multiple medical interventions available for scar improvement that are not described in this blog (i.e. MicroPen, BroadBand Light Therapy, and Kenalog steroid injections). Know that you have options, and it is always your right to advocate for yourself when receiving medical care.