The 'Universal Approach' for Dupuytren's disease: A safe and reproducible sequence for planning fasciectomy incisions

Abstract

Dupuytren's disease continues to present many challenges for the surgeon. A variety of surgical approaches and their variations have been described in the literature, further complicated by the degree of skin shortage and/or the need for local flap procedures or a full thickness skin graft. In the face of all these decisions - none of which is supported by Level 1 evidence - it can be very difficult to plan the best incision(s). We describe a safe and reproducible technique to plan fasciectomy incisions in primary or recurrent Dupuytren's disease. Our short communication and accompanying artwork demonstrates the anatomical landmarks and a simple decision-making algorithm based on just 3 key stages: (1) Proximal incision planning and execution of the palmar release(s); (2) Extension distally into the digit(s) based on the tissue quality, with either with zigzag (Brunner's) or a midline longitudinal (McIndoe) incision(s); (3) Flap assisted closure or coverage with a full thickness skin graft where required.

Keywords: Dupuytren's; Fasciectomy; Invision; Skin graft; Z plasty.

Figure 1

The ‘Universal Approach’: a simple algorithm for incision planning in Dupuytrens surgery. (1a) Mark out a zig zag incision in the palm. Adjacent digits can be accommodated by extending the incision transversely (after Skoog) (1b). (2) Decide if the digital skin is of sufficient area and quality to perform oblique (Brunner's) incisions [2a] or if in doubt make a midline longitudinal incision [2b] (after McIndoe). (3) A midline incision can either be closed using one or more Z plasties [3a] or alternatively excised entirely (dermofasciectomy) and covered with a full thickness skin graft [3b].