Unproven concepts needing correlation and further study in lymphoedema

1. Fibrosis in lymphoedema and scarring have much in common There is much concern about removing fluid and macromolecules in lymphoedema management. But it is not always remembered that much more of the excess girth in ‘big legs’ is contributed by collagen (Casley-Smith et al, 1980), and it is surprising how this can be reversed, sometimes even in a short time. In a previous publication (Ryan, 2009) it was pointed out that some 19th century authors (see Hebra and I have suggested before that the answer to lymphoedema lies in the transduction of biochemical signals by mechanical forces (Ryan, 1989), preferably at an optimal temperature of 37°C. The epidermal–dermal relationship is disrupted in lymphoedema by chronic expansion of the upper dermis, with the added destruction of a normally protective elastin system (Ryan, 2010). This has immediate and inevitable consequences, whereas destruction of collecting ducts and lymph nodes by cancer, surgery, or filariasis results in lymphoedema only after some time and in a minority of those injured.