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Choice of Incisions for Dupuytren’s Contracture


- Choice of Incisions:
    - attempt to raise flaps so that normal skin lies at the base of the flap whereas diseased skin (nodules or cords) should lie at the flap tip;
    - if a flap is not to be raised, incisions should be placed directly over skin nodules or cords, inorder to minimizes ischemia to normal skin;

- Transverse Palmar Incision:

- Web Space Contracture:
     - if contracture of thumb-index web space exists, adequate exposure for excision of offending fascia may be obtained by standard
            or a four-flap z-plasty, or the T-shaped incision;

- Brunner Incision:
    - modified Brunner zigzag incision is effective w/o the need carrying tips of flaps to mid-axial line;
    - w/ multiple ray involvement, avoid having digital incisions cross at the web space;
           - Urbaniak (personal communication) recommends that the little finger incision cross the phalangeal crease on the
                   ulnar border (as is seen in the diagram);
    - closure can be effected by a V-Y advancement of flaps to gain additional skin length;
           - major skin creases should not be crossed at a right angle;
    - advantage: the V-Y flap allows for a variable amount of flap elevation, so that the flap does not need to be completely elevated for wound closure;
    - pitfalls:
           - note that placing the base of the phalangeal flap on the same side as the digital cord, risks flap necrosis;
    - ref:
           - Treatment of Dupuytren's contracture by extensive fasciectomy through multiple Y-V plasty incision

- Z plasty:
    - see: general Z plasty discussion;
    - incision is used in pts who have involvement of multiple rays w/o fear of N/V compromise to intervening palmar skin; 
    - after excision of disease fascia & correction of contractures, 3 small z-plasties are planned, so that w/ transposition of flaps
           horizontal limbs fall near PIP, MP, & distal palmar creases;
           - generally the limbs of the Z plasty should not be made until the fascia is removed, so that because this allows to
                  surgeon to make the Z limbs based on flap viability;
    - even when contracture appears to be limited to PIP Joint alone, excision of palmar pre-tendinous cord
           to involved ray should be performed in conjunction w/ digital dissection;
    - disadvantage: once Z plasty flaps have been raised, they can only be closed in the transposed position;
           - hence, the proposed flaps may "overshoot" or "undershoot" the required amount of correction;
    - ref:
           - Fasciotomy and Z-plasty in the management of Dupuytren's contracture.

Wound complications in the surgical management of Dupuytren's contracture: a comparison of operative incisions.

Surgical alternatives in Dupuytren's contracture.

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