- 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;
- 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.