uninvolved (subclinical skin involvement occurs in ~50% of cases) recurrent disease. similar to a limited fasciectomy, the dermofasciectomy removes diseased cords, fascia, and the overlying skin. typically, the excised skin is replaced with a skin graft, usually full thickness, consisting of the epidermis and the entire dermis. in most cases the graft is taken from the antecubital fossa (the crease of skin at the elbow joint) or the inner side of the upper arm. this place is chosen because the skin color best matches the palm's skin color. the skin on the inner side of the upper arm is thin and has enough skin to supply a full-thickness graft. the donor site can be closed with a direct suture. the graft is sutured to the skin surrounding the wound. for one week the hand is protected with a dressing. the hand and arm are elevated with a sling. the dressing is then removed and careful mobilization can be started, gradually increasing in intensity. after this procedure the risk of recurrence is minimised, but dupuytren's can recur in the skin graft and complications from surgery may occur. segmental fasciectomy with/without cellulose segmental fasciectomy involves excising part(s) of the contracted cord so that it disappears or no longer contracts the finger. it is less invasive than the limited fasciectomy, because not all the diseased tissue is excised and the skin incisions are smaller. the person is placed under regional anesthesia and a surgical tourniquet is used. the skin is opened with small curved incisions over the diseased tissue. if necessary, incisions are made in the fingers. pieces of cord and fascia of approximately one centimeter are excised. the cords are placed under maximum tension while they are cut. a scalpel is used to separate the tissues. the surgeon keeps removing small parts until the finger can fully extend. the person is encouraged to start moving his or her hand the day after surgery. they wear an extension splint for two to three weeks, except during physical therapy. the same procedure is used in the segmental fasciectomy with cellulose implant. after the excision and a careful hemostasis, the cellulose implant is placed in a single layer in between the remaining parts of the cord. after surgery people wear a light pressure dressing for four days, followed by an extension splint. the splint is worn continuously during nighttime for eight weeks. during the first weeks after surgery the splint may be worn during daytime. less invasive treatments studies have been conducted for percutaneous release, extensive percutaneous aponeurotomy with lipografting and collagenase. these treatments show promise. percutaneous needle fasciotomy needle aponeurotomy is a minimally-invasive technique where the cords are weakened through the insertion and manipulation of a small needle. the cord is sectioned at as many levels as possible in the palm and fingers, depending on the location and extent of the disease, using a 25-gauge needle mounted on a 10 ml syringe. once weakened, the offending cords can be snapped by putting tension on the finger(s) and pulling the finger(s) straight. after the treatment a small dressing is applied for 24 hours, after which people are able to use their hands normally. no splints or physiotherapy are given. the advantage of needle aponeurotomy is the minimal intervention without incision (done in the office under local anesthesia) and the very rapid return to normal activities without need for rehabilitation, but the nodules may resume growing. a study reported postoperative gain is greater at the mcp-joint level than at the level of the ip-joint and found a reoperation rate of 24%; complications are scarce. needle aponeurotomy may be performed on fingers that are severely bent (stage iv), and not just in early stages. a 2003 study showed 85% recurrence rate after 5 years. a comprehensive review of the results of needle aponeurotomy in 1,013 fingers was performed by gary m. pess, md, rebecca pess, dpt, and rachel pess, psyd, and published in the journal of hand surgery april 2012. minimal follow-up was 3 years. metacarpophalangeal joint (mp) contractures were corrected at an average of 99% and proximal interphalangeal joint (pip) contractures at an average of 89% immediately post procedure. at final follow-up, 72% of the correction was maintained for mp joints and 31% for pip joints. the difference between the final corrections for mp versus pip joints was statistically significant. when a comparison was performed between people aged 55 years and older versus under 55 years, there was a statistically significant difference at both mp and pip joints, with greater correction maintained in the older group. gender differences were not statistically significant. needle aponeurotomy provided successful correction to 5° or less contracture immediately post procedure in 98% (791) of mp joints and 67% (350) of pip joints. there was recurrence of 20° or less over the original post-procedure corrected level in 80% (646) of mp joints and 35% (183) of pip joints. complications were rare except for skin tears, which occurred in 3.4% (34) of digits. this study showed that na is a safe procedure that can be performed in an outpatient setting. the complication rate was low, but recurrences were frequent in younger people and for pip contractures. extensive percutaneous aponeurotomy and lipografting a technique introduced in 2011 is extensive percutaneous aponeurotomy with lipografting. this procedure also uses a needle to cut the cords. the difference with the percutaneous needle fasciotomy is that the cord is cut at many places. the cord is also separated from the skin to make place for the lipograft that is taken from the abdomen or ipsilateral flank. this technique shortens the recovery time. the fat graft results in supple skin. before the aponeurotomy, a liposuction is done to the abdomen and ipsilateral flank to collect the lipograft. the treatment can be performed under regional or general anesthesia. the digits are placed under maximal extension tension using a firm lead hand retractor. the surgeon makes multiple palmar puncture wounds with small nicks. the tension on the cords is crucial, because tight constricting bands are most susceptible to be cut and torn by the small nicks, whereas the relatively loose neurovascular structures are spared. after the cord is completely cut and separated from the skin the lipograft is injected under the skin. a total of about 5 to 10 ml is injected per ray. after the treatment the person wears an extension splint for 5 to 7 days. thereafter the person returns to normal activities and is advised to use a night splint for up to 20 weeks. collagenase main article: collagenase clostridium histolyticum collagenase enzyme injection: before, next day, and two weeks after first treatment the cords are weakened through the injection of small amounts of the enzyme collagenase, which breaks peptide bonds in collagen. clostridial collagenase injections have been found to be more effective than placebo. in february 2010 the us food and drug administration (fda) approved injectable collagenase extracted from clostridium histolyticum for the treatment of dupuytren's contracture in adults with a palpable dupuytren's cord. (three years later, it was approved as well for the treatment of the sometimes related peyronie's disease.) in 2011 its use for the treatment of dupuytren's contracture was approved as well by the european medicines agency, and it received similar approval in australia in 2013. however, the swedish manufacturer abruptly withdrew distribution of this drug in europe and the uk in march 2020 for commercial reasons.(it now is promoted primarily as a dermatological treatment for cellulite aka "cottage cheese thighs"). collagenase is no longer available on the national health system except as part of a small clinical trial. the treatment with collagenase is different for the mcp joint and the pip joint. in a mcp joint contracture the needle must be placed at the point of maximum bowstringing of the palpable cord. the needle is placed vertically on the bowstring. the collagenase is distributed across three injection points. for the pip joint the needle must be placed not more than 4 mm distal to palmar digital crease at 2–3 mm depth. the injection for pip consists of one injection filled with 0.58 mg cch 0.20 ml. the needle must be placed horizontal to the cord and also uses a 3-point distribution. after the injection the person's hand is wrapped in bulky gauze dressing and must be elevated for the rest of the day. after 24 hours the person returns for passive digital extension to rupture the cord. moderate pressure for 10–20 seconds ruptures the cord. after the treatment with collagenase the person should use a night splint and perform digital flexion/extension exercises several times per day for 4 months. radiation therapy shows the beam's-eye view of the radiotherapy portal on the hand's surface, with the lead shield cut-out placed in the machine's gantry radiation therapy has been used mostly for early-stage disease, but is unproven. evidence to support its use as of 2017, however, was scarce —efforts to gather evidence are complicated due to a poor understanding of how the condition develops over time. it has only been looked at in early disease. the royal college of radiologists concluded that radiotherapy is effective in early stage disease which has progressed within the last 6 to 12 months. alternative medicine several alternate therapies such as vitamin e treatment have been studied, though without control groups. most doctors do not value those treatments. none of these treatments stops or cures the condition permanently. a 1949 study of vitamin e therapy found that "in twelve of the thirteen patients there was no evidence whatever of any alteration. ... the treatment has been abandoned." laser treatment (using red and infrared at low power) was informally discussed in 2013 at an international dupuytren society forum, as of which time little or no formal evaluation of the techniques had been completed. postoperative care postoperative care involves hand therapy and splinting. hand therapy is prescribed to optimize post-surgical function and to prevent joint stiffness. the extent of hand therapy is depending on the patient and the corrective procedure. besides hand therapy, many surgeons advise the use of static or dynamic splints after surgery to maintain finger mobility. the splint is used to provide prolonged stretch to the healing tissues and prevent flexion contractures. although splinting is a widely used post-operative intervention, evidence of its effectiveness is limited, leading to variation in splinting approaches. most surgeons use clinical experience to decide whether to splint. cited advantages include maintenance of finger extension and prevention of new flexion contractures. cited disadvantages include joint stiffness, prolonged pain, discomfort, subsequently reduced function and edema. a third approach emphasizes early self-exercise and stretching. prognosis dupuytren's disease has a high recurrence rate, especially when a person has so-called dupuytren's diathesis. the term diathesis relates to certain features of dupuytren's disease, and indicates an aggressive course of disease. the presence of all new dupuytren's diathesis factors increases the risk of recurrent dupuytren's disease by 71%, compared with a baseline risk of 23% in people lacking the factors. in another study the prognostic value of diathesis was evaluated. it was concluded that presence of diathesis can predict recurrence and extension. a scoring system was made to evaluate the risk of recurrence and extension, based on the following values: bilateral hand involvement, little-finger surgery, early onset of disease, plantar fibrosis, knuckle pads, and radial side involvement. minimally invasive therapies may precede higher recurrence rates. recurrence lacks a consensus definition. furthermore, different standards and measurements follow from the various definitions. notable cases chelsea handler (born 1975), american comedian, actress and writer tim herron (born 1970), american golfer prince joachim of denmark (born 1969) joanne harris (born 1964), british author jonathan agnew (born 1960), english cricketer john elway (born 1960), american football player nanci griffith (1953–2021), american singer, guitarist, and songwriter bill murray (born 1950), american actor and comedian bill nighy (born 1949), english actor mitt romney (born 1947), american politician misha dichter (born 1945), american pianist josé feliciano (born 1945), puerto rican musician, singer and composer bill frindall (1939–2009), english cricket player and statistician, who had a finger amputated. david mccallum (born 1933), scottish/british actor and musician paul newman (1925–2008), american actor and film director margaret thatcher (1925–2013), prime minister of the united kingdom ronald reagan (1911–2004), american president and actor andrew wyeth (1917–2009), american visual artist frank sinatra