Is Dupuytren's contracture a cosmetic problem?

Dupuytren’s surgery- elective or cosmetic, or necessary?
Some patients are being denied Dupuytren’s surgery because their CCG classes it as a "cosmetic" procedure, and therefore not offered on the NHS. This is a step down from "elective" even. So what is the difference?
‘Elective’ is any surgery that can be planned in advance. 'Planned' surgery would be a better name, as 'elective' gives the impression the patient can choose whether to have the procedure done or not, and in many cases there isn't really a choice; not if the patient wants to remain alive, mobile, able to live independently and to work.. And quality of life (and QALYs and ICERs are important in the decision making of what procedure to offer on the NHS), so these things should matter in the decision makings of the CCGs.
Elective surgery tends to have a medical indication.
In many cases elective surgery is needed to give the patient the ability to live a normal or near-normal life again, to keep working and be independent. Think of patients who need a joint replacement, in constant pain, unable to walk any distance if it concerns hip or knee.
Electives can be life saving, like cardiac bypass surgery or the taking of biopsies to reach a diagnosis. But also a condition that causes the patient mental health problems can (and in the opinion of many should) be classed elective, even if it is only to change appearance and not to increase body function.
Cosmetic surgery is not medically necessary except maybe for the patient's self-esteem. The patient chooses to have a procedure done purely to change their appearance for cosmetic rather than medical reasons.
Cosmetic surgery is optional, and not classed as "elective" even.
Plastic surgery is done to normalise appearance AND FUNCTION of the body part. https://www.ambrdfcs.org/patient-resources/cosmetic-vs-plastic-surgery/ Therefore plastic surgery by definition belongs in the "elective" group.
So where does Dupuytren’s surgery fall in this terminology?
Some CCGs are claiming Dupuytren’s is a cosmetic problem. Maybe it is, in the early stages. But that is not the stage when surgeons would operate normally anyway, the nodular stage is best not touched with a knife as you would risk exacerbating the disease.
What about at a later stage, when the finger(s) are starting to contract? Common guidelines are to operate at 30-40 degrees contracture at the MCP joint, or ANY PIP joint contracture. This is not only because of the problems these contractures will cause the patient, but also because the beneficial effect of surgery is greatest if done in those stages.
The problems Dupuytren patients experience everyday
At that stage, the patient will have functional problems. Gripping things, getting the hand in small openings (think purse, trouser pockets), wearing gloves (and cold weather is not good for Dupuytren’s hands- cold causes vasoconstriction causes poor perfusion, which is a risk factor in itself). Patients will be struggling doing their job in many cases, struggling using kitchen utensils, personal hygiene will become more difficult. Typing on a keyboard or using a computer mouse will not be possible anymore for some. Doing up buttons or tying shoelaces gets to be a problem. Looking after the (grand)children can become difficult, or even stroking them over the head with one or more bent fingers that poke rather than stroke.
Is this still a cosmetic problem, if it limits what a patient can do in everyday life, if the patient can’t open doors or a bottle of water, can’t hold the steering wheel of the car properly, can’t hold a toothbrush or use scissors to open a bag of pasta?
Dupuytren’s causes a functional deficit
Dupuytren’s is a functional problem, a physical condition that deteriorates over time, affects the use of one (or both) hands, and needs treatment. And that treatment in many cases is surgery. Performed by a qualified hand surgeon, to get the best possible chance of functional fingers again.
After all, being able to use your hands is not a question of cosmetics, patients want functional hands (or at least as much as possible) and will gladly put up with a scar or two if it means being able to put your hand (almost) flat on the table again.
That means Dupuytren surgery is plastic, and not cosmetic.