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outweigh the forces that inhibit it or reverse it. In other words, scar tissue becomes a problem, not a solution. WHAT IS SCAR TISSUE? Scar tissue is the body's natural response to the disruption of healthy cells. This disruption can take the form of any kind of external or internal injury, infection, chronic inflammation, or radiation. Any of these phenomena can damage cells, leading to a cascade of events that culminates in the formation of collagen fibers that bind up and tie together our broken pieces. Cells that have been damaged—by direct trauma like burns, cuts, or rips; insidious stress like infectious agents that secrete toxic wastes; or chronic irritation like that seen with autoimmune diseases—respond by secreting a variety of chemicals. Some of these chemicals reinforce an inflammatory reaction. Some act as a beacon to nearby fibroblasts, causing the fibroblasts to proliferate, invade affected tissue, and spin out collagen and other extracellular matrix. Some enzymes trigger nearby capillaries to sprout new vessels that support the fibrous tissue that is forming. Local short-term hypoxia may also alter cell function, causing the secretion of more proinflammatory enzymes and interfering with apoptosis— the normal cell death that would inhibit and reverse these processes. Ultimately, if the activity of chemicals that promote scar-tissue formation is more powerful than the activity of those that inhibit it, the result may be nonfunctional gobs of sticky collagen, which can take the form of keloid or hypertrophic scars on the surface of the skin, or internal adhesions—places where surfaces that should slide freely over each other become essentially glued together. NOT ALL COLLAGEN IS CREATED EQUALLY The terms collagen and scar tissue are sometimes used interchangeably, and this is technically inaccurate. Collagen is a term that describes a group of protein molecules produced by fibroblasts. It is a vital component of our body, accounting for some 25–35 percent of our whole-body protein count. Different types of collagen fibers are found in different areas, but the basic pattern is that each fiber is composed of a triple-helix of molecules. At this point, 28 subtypes of collagen have been identified, but the vast majority of our tissues are invested with some combination of five types. Type I collagen is found anchoring the skin, in tendons and ligaments, and as the scaffolding for working cells of organs and the mineral deposits of bones. Type II collagen is found in a three-dimensional matrix holding the liquid and chemicals that make up articular and elastic cartilage. Type III collagen is found with type I. Type IV collagen is found in cell basement membranes. Type V collagen is found on some cell surfaces, in hair follicles, and in the placenta. Scar tissue is usually formed of types I and III collagen. Fibroblasts expel the fibers as a random mass, but if the injury is in a muscle, ligament, or tendon, then weight-bearing force during the postacute phase of inflammation helps those fibers to align along with functioning tissues for the best quality healing. This is why it is important to mobilize a musculoskeletal injury (within pain tolerance) as soon as possible. WHEN SCAR TISSUE BECOMES A PROBLEM When the forces that promote its formation outweigh the forces that inhibit or reverse its formation, scar tissue becomes a problem. The result is that type I and III collagen fibers are deposited around and within tissues. They may never fully align with functioning lines of force, and they may be in an extracellular matrix that promotes stickiness rather than slickness. As scar tissue matures, it begins to pull in on itself, dragging other tissues along with it. In organs, this can interfere with function (think of a liver imbued with scar tissue: this is cirrhosis); in tubes, it can cause obstructions; and in serous membranes, it can make surfaces stick together (this is a description of pleurisy, which limits lung function and can raise the risk of life-threatening pneumonia). Even the pericardium can develop adhesions, dragging directly on the heart muscle or sticking to the chest wall. Excessive collagen production on the surface of the skin can lead to prominent, permanent, sometimes disfiguring scars. When piles of collagen are elevated from the skin, but stay essentially within the boundaries of the wound, this is called hypertrophic scarring. When the scar tissue appears to expand beyond the edges of the wound and even invest nearby tissues, this is called keloid scarring. Anywhere that scar tissue becomes problematic— Celebrate ABMP's 25th anniversary and you may win a refund on your membership. ABMP.com. 43