This article discusses the history and developments of silicone gel sheeting (SGS) scar therapy. Furthermore, we review a breadth of literature to gain an insight into how and why topical silicone gels remain the favored treatment of medical experts in scar management. We also analyze an ever increasing number of alternative therapies claiming to provide enhanced scar reduction performance. Topical silicone gel treatments seem to remain the first point of clinical recommendation in scar management. SGS has been used in scar therapy for over 30 years, during which its efficacy has been the subject of numerous clinical evaluations. While the exact mechanisms by which SGS improves hypertrophic scars, keloid development and recovery are yet to be fully agreed upon, its ability to do so remains largely undisputed at present. However, there still is ongoing deliberation over the exact mechanism of action of silicone in improving a scar. At present it is likely that through occlusion of the scar site and hydration of the wound bed, the overactivity of scar-related cells is suppressed, and their activity normalized. The clinical support of topical silicone gel products, relative to all alternative scar therapies, is considered the internationally recommended first-line form of scar management, and favored by consensus among healthcare professionals. However, there still remains the need for further clinical evidence and a better understanding of the mechanism behind the benefit of silicone gel for use in the prevention of abnormal scarring.