_Plastic operations_ may be conducted under the same principles as those which guide the surgeon in the treatment of cicatricial contractions from burns or other causes. In cases of contraction at the metacarpo-phalangeal joint, where the skin is greatly involved, I have made a transverse incision through the integument and fibrous cord at the root of the finger and filled up the wide gap left on extending the joint by the transplantation of a flap from the side of the digit. (Fig. 5.) The dissection of the flap must be carefully conducted in order to avoid injury to the digital nerves. The result is usually good and permanent. In some cases it might be permissible to carry the plastic principle still further by the transplantation of a flap on the Tagliacotian principle from the chest or upper arm or any other convenient point; or the more simple resource of grafting, after the manner of Thiersch, may be employed with advantage, as it has been proved to have a remarkable effect in lessening cicatricial contraction. [Illustration: FIG. 5. Diagram showing lateral flap transplanted into gap left by division of the contracted band, with the superjacent integument at the level of the inter-digital web.] Of these various procedures I believe that the best operation in most cases is the subcutaneous plan. It is speedy and safe, the immediate results are very satisfactory, the risks of relapse are in my experience less than in the open method, and in the event of a recurrence the other lines of treatment are still available. The open operation involves a more extensive surgical injury, and although it will usually do well under antiseptic precautions, there is a greater risk of casualties. It is perhaps most applicable to the slighter cases, in which the whole of the disease can be removed, but it may also be employed where the subcutaneous plan has failed. The plastic operations are most useful in the traumatic forms, and in those cases of true Dupuytren’s contraction where the skin is so far involved that full or satisfactory extension is impossible. The method I have suggested produces an immediate result, and under ordinary circumstances a long after-treatment is unnecessary, because the flap of integument does not tend to contract. The larger operation can only be called for in very severe cases, where all other measures have failed. It is not certain in any given example whether the surgeon will be successful in giving lasting relief to the patient. Were it simply a question of dividing or excising a common cicatricial band, there is no reason why the result of every well-devised operation should not be permanent; but experience shows that even with the greatest care it is occasionally difficult to prevent a return of the condition which gave rise to the deformity in the first place—that is, a growth of new fibrous tissue which tends to contract. The main conclusions arrived at may be stated as follows: