The role of the skin in Dupuytren's disease.

Previous lectures havepresented Mclndoe's contributions as acombination ofreminiscences andtechnical details and somehavegoneontodevelop those subjects inwhichhehad anespecial interest theburnwound(1,2) andevenmore important, theburnedpatient (3),hypospadias (4),congenital absence ofthevagina (5), handsurgery (6), maxillofacial (7)andoro-pharyngeal surgerywithhisevenmore profound contributions tothestructuring ofplastic surgical enterprise during andafter thewar(8)andinthetraining of youngplastic surgeons-through theestablishment ofthe British Association ofPlastic Surgeons (9,10). Thislecture ispresented asaphilosophical andtechnical tribute toMclndoe inthose twoareas ofhandsurgery which hemadehisown.Thesearethetechnical expertise of fasciectomy never beforeMclndoeso eloquently displayed-and theapplication offree skingrafting tothe mobile regions ofthehand, soclassically enunciated inhis wartinre workontheburnedhand. Theroleoftheskin Onlyinthepasttwenty years havewebecomeincreasingly awareofthecontrolling rolewhichtheskinanditshypodermis playinthepathogenesis ofDupuytren's disease and particularly ofrecurrent Dupuytren's disease (11). Ihavenosimple explanation astowhyrecurrence does notoccurleneath askin graftbutletussummarise whatis knownatpresent ofthevolarskinofthehandandits subcutaneous spaceinrelation tothedevelopment, recurrenceandcontrol ofDupuytren's disease. Anatomical observations ThePalmer Subcutaneous Space Thisisbounded dorsally bythe palmer aponeurosis andits distal digital extensions through whichitisfixed tothemargins ofthephalanges (12,13) and totheoverlying glabrous skinofthepalmanddigits (14). Relative totherestofthehandincross-section this isa remarkably narrowanatomical spaceenclosed between the skinandthepalmaraponeurosis. Thisverythinpalmar subcutaneous spacecontains less fatandmorefibrous tissue withage(15)andiswithin the'zoneofinfluence' ofthe dermis andhypodermis oftheoverlying palmar skin. Creaselines represent lines oftransverse shortening inducedbydorsal stretching ofthedigital integument in flexion. Attheflexure creases thefatcompartments are secondarily displaced distally andproximally, leaving the dermis andhypodermis directly incontact withthedeep fascial plane. Flint hasshownaregional preference forthefat tobereplaced byfibrous inthatverypartclose tothedistal palmcreaseline, wheretheearliest nodules ofDupuytren's disease aremostcommonly found. Thedermis appears tobespecially capable ofinfluencing fibroblast behaviour (16). Tobemoreprecise itisthecells in thehypodermis, soimportant inproviding theactive componentsforhealing ofanyskinwound,whicharemostlikely *Basedoni theMcIlNdoe NIemorial Lecture given attheSummer Nleeting oftheBritish Association ofPlastic Surgeons, Cdambridge,

[1]  J. Hueston,et al.  Dupuytren's contracture , 1990 .

[2]  J. Barron.  McIndoe the gentle giant. , 1985, Annals of the Royal College of Surgeons of England.

[3]  M. Tonkin,et al.  Dupuytren’s Contracture: A Comparative Study of Fasciectomy and Dermofasciectomy in One Hundred Patients , 1984, Journal of hand surgery.

[4]  J. Hueston.  Some Observations on Knuckle Pads. , 1984, Journal of hand surgery.

[5]  Hueston Jt.  Dermofasciectomy for Dupuytren's disease. , 1984 .

[6]  R. Gelberman,et al.  Dupuytren's disease: Comparative growth dynamics and morphology between cultured myofibroblasts (nodule) and fibroblasts (cord) , 1984, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[7]  O. Eikeland,et al.  [Plastic reconstructive surgery of the breast]. , 1983, Tidsskrift for den Norske laegeforening : tidsskrift for praktisk medicin, ny raekke.

[8]  D. McGrouther.  The Microanatomy of Dupuytren's Contracture , 1982, The Hand.

[9]  R. Gelberman,et al.  Ultrastructural Relationship of Skin to Nodule and Cord in Dupuytren's Contracture , 1982, Plastic and reconstructive surgery.

[10]  M. Flint,et al.  The glycosaminoglycans of Dupuytren's disease. , 1982, Connective tissue research.

[11]  D. Bodenham.  McIndoe Memorial Lecture, 1980. In quest of perfection: training in plastic surgery. , 1981, Annals of the Royal College of Surgeons of England.

[12]  Jackson Dm.  McIndoe lecture, 1978. Burns: McIndoe's contribution and subsequent advances. , 1979 .

[13]  R. Rudolph.  Inhibition of Myofibroblasts by Skin Grafts , 1979, Plastic and reconstructive surgery.

[14]  D. Jackson.  McIndoe lecture, 1978. Burns: McIndoe's contribution and subsequent advances. , 1979, Annals of the Royal College of Surgeons of England.

[15]  L. Chang,et al.  Surgery for Dupuytren's contracture: a long-term review. , 1978, The Australian and New Zealand journal of surgery.

[16]  Davies Rm.  McIndoe Lecture, 1976. Relationships. Archibald McIndoe, his times, society, and hospital. , 1977 .

[17]  J. Hueston,et al.  The contracting fibroblast as a clue to Dupuytren's contracture. , 1977, The Hand.

[18]  D. Harrison,et al.  Open palm technique for Dupuytren's contracture. , 1976, The Hand.

[19]  J. Hueston,et al.  The Contracting Fibroblast as a Clue to Dupuytren’s Contracture , 1976 .

[20]  T. Ward.  The maxillofacial unit. , 1975, Annals of the Royal College of Surgeons of England.

[21]  Bruner Jm.  The contributions of Sir Archibald McIndoe to surgery of the hand. , 1973 .

[22]  J. M. Bruner.  The contributions of Sir Archibald McIndoe to surgery of the hand. , 1973, Annals of the Royal College of Surgeons of England.

[23]  J. Watson.  Trends in the treatment of burns. The influence of McIndoe. , 1971, Annals of the Royal College of Surgeons of England.

[24]  R. Honner,et al.  Dupuytren's contracture. Long term results after fasciectomy. , 1971, The Journal of bone and joint surgery. British volume.

[25]  Matthews Dn.  A tribute to the services of Sir Archibald McIndoe to plastic surgery. , 1967 .

[26]  D. Matthews.  A tribute to the services of Sir Archibald McIndoe to plastic surgery. , 1967, Annals of the Royal College of Surgeons of England.

[27]  N. Hughes,et al.  Dupuytren's contracture: a review of the late results of radical fasciectomy. , 1967, British journal of plastic surgery.

[28]  P. Jayes.  The establishment of the specialty of plastic surgery and its contributions to other specialties. , 1966, Annals of the Royal College of Surgeons of England.

[29]  Jayes Ph.  The establishment of the specialty of plastic surgery and its contributions to other specialties. , 1966 .

[30]  R. Ling.  THE GENETIC FACTOR IN DUPUYTREN'S DISEASE. , 1963, The Journal of bone and joint surgery. British volume.

[31]  G. Morley.  "Si Monumentum Requiris Circumspice": Plastic Surgery in War and Peace: The first McIndoe Lecture delivered at the Royal College of Surgeons of England on 7th December 1962. , 1963, Annals of the Royal College of Surgeons of England.

[32]  J. Vacek,et al.  NEUROGENIC ETIOLOGY OF DUPUYTREN'S CONTRACTURE. I. , 1963, Acta chirurgiae plasticae.

[33]  J. Vacek,et al.  NEUROGENIC ETIOLOGY OF DUPUYTREN'S CONTRACTURE. II. , 1963, Acta chirurgiae plasticae.

[34]  J. Hueston,et al.  The pathology of Dupuytren's contracture. , 1962, The Australian and New Zealand journal of surgery.

[35]  Hueston Jt.  Further studies on the incidence of Dupuytren's contracture. , 1962 .

[36]  Hueston Jt.  Digital Wolfe grafts in recurrent Dupuytren's contracture. , 1962 .

[37]  J. Hueston.  DIGITAL WOLFE GRAFTS IN RECURRENT DUPUYTREN'S CONTRACTURE , 1962, Plastic and reconstructive surgery and the transplantation bulletin.

[38]  J. Hueston.  LIMITED FASCIECTOMY FOR DUPUYTREN'S CONTRACTURE , 1961, Plastic and reconstructive surgery and the transplantation bulletin.

[39]  J. Hueston.  THE INCIDENCE OF DUPUYTREN'S CONTRACTURE , 1960 .

[40]  Luck Jv.  Dupuytren's contracture; a new concept of the pathogenesis correlated with surgical management. , 1959 .

[41]  J V LUCK,et al.  Dupuytren's contracture; a new concept of the pathogenesis correlated with surgical management. , 1959, The Journal of bone and joint surgery. American volume.

[42]  Broadbent Tr.  Dupuytren's contracture; observations on the pathology. , 1955 .

[43]  A. Bergeron,et al.  [Present trends in the treatment of burns]. , 1955, Acta Belgica de arte medicinali et pharmaceutica militari.

[44]  I. Hj.  [Dupuytren's contracture]. , 1953 .

[45]  E. Herzog.  The aetiology of Dupuytren's contracture. , 1951, Lancet.