a. The Stair-step resection of scars of lesions, and the stair-step incision to expose and to carry out procedures such as the augmentation mammaplasty enable one to repair in a stair-step fashion with a sound layer closure. This makes for a safer wound closure, especially when there is tension on the edges, and makes exposure of foreign implants or grafts (such as breast prostheses, bone grafts, and cartilage grafts) less likely. Interruption of the continuity of the healing wound external to the graft or implant is not likely with this repair because it distributes and shares the tension in each layer.
b. This technique may be applied to any wound closure and in resection of superficial lesions or scars, as is demonstrated. The tissue usually keep their normal thickness to give a level skin surface, with less likelihood of spreading or depression of the scar line.
上段文字并不难理解，做了个参考翻译
a. 阶梯形切除瘢痕，阶梯状切开并暴露深层组织，例如隆乳术，这样，我们以同样阶梯形式缝合，可安全放心的闭合切口。这种切口修复方法相对更安全，特别是切缘张力较大时，阶梯状缝合使外源性植入物或自身移植物（如乳房假体、移植骨、软骨）更不容易外露。由于阶梯状缝合使张力能够分布并分散到不同的层面，切口在不同的层面修复，故植入或移植物几乎不可能外露。 b. 临床应用证实，该方法或许可拥有任何表浅伤口或瘢痕切口的修复。由于该方法降低了瘢痕的挛缩力的扩展或凹陷幅度，故愈合后局部组织通常可维持原来正常的厚度，保持一个平整的外观。
“阶梯形”切口应用
a. The inframammary and the ancillary incisions allow for an incision through the skin, then dissection downward, before penetrating more deeply to the retromammary area. This creates a stair-step type of approach, which permits a more thorough closure by pulling the subcutaneous fat flap down over the implant, to close beneath the lower skin flap. This stair-step repair gives a thick, secure closure over the implant and more nearly insures sound wound healing without danger of dehiscence of the wound. Obviously, this approach does not penetrate the breast tissue but skirts the underside (or the lateral side, for the axillary approach) of the breast.
b. The periareolar (marginal areolar) approach for the small breast allows the surgeon to dissect inferiorly or laterally around the margin of the breast in the subcutaneous plane and to approach the retromammary space without penetrating the breast tissue. This is definitely preferable to a division of the breast tissue.
c. The transareolar or periareolar approach may penetrate and divide the breast tissue. This transaction may cut across the ducts, creating cysts or blockage of the duct. This approach is not favored by the author for this obvious reason and because it creates additional scar tissue in the breast which is difficult to evaluate in future breast examinations. The hazard of decreased somewhat, particularly but the transareolar approach and the nipple-splitting incision.
Neither the technique of b nor c allows an adequate check for bleeding vessels and securing of these vessels, and for hemostasis one must depend primarily on insertion of packs or of pressure before insertion of the augmentation prosthesis. Though the marginal areolar incision leaves little scarring in most instances, a heavy scar in this area is much more disturbing to the patient than one in the axilla or in the inframammary area.
The Overlap Technique
a. For depressed scars, defects in the underlying deeper soft tissues, and depressions in the underling skeletal tissues, there may be a need to build up the soft tissue and increase its thickness. The actual overlap of the deeper tissues is carried out rather than bring them together in stair-step fashion as in Figure 1-6, or as a simple layer closure as shown in Figures 1-5. A resection is carried out both superficially and deeply as is required. Then the superficial and the deeper tissues are undermined separately to allow sliding together of the superficial tissues and overlapping of the deeper tissues.
b. This technique may be used to maintain or correct contour defects and to build up the thickness of the soft tissue when there are deficiencies of either soft tissue or underlying skeletal tissues. A layer repair is carried out as with all wound repairs. This technique can cause exaggeration of the fullness when there is firm underlying skeletal support of the soft tissues such as over the forehead.
Caveat 8: There Are Other Ways to Deal with Lines of Unequal Length Often in plastic surgery an ellipse is designed, but because of the configuration of the lesion, the limbs of the ellipse have different lengths. A triangle of tissue (as described above) is one solution, but there are occasions where this is not desirable. If the discrepancy between the limbs is not too big, differential suturing (“stealing stitches”)is all that is required. When there is a greater discrepancy in length, in principle, one line can be made longer or the other can be made shorter, or both methods can be used (Fig. 1).
Remember, dog-ears commonly arise from two situations: the angle of the ellipse is too obtuse,or the length discrepancy between the two limbs is too great to allow for a “stealing” stitch.
The corner suture is best initiated near an imaginary line that bisects the tissue opposite the tissue corner. This allows the pull of the tissue directly into the corner, and not off to one side. A plumb line drawn opposite the corner will help guide the start and finish of the corner stitch (Figure 6). The needle enters the skin next to the plumb line (1 to 2 mm from the line) about 6 to 8 mm from the corner. The needle passes to the wound edge about 4 to 6 mm from the corner. It enters into the wound at the depth of the deep dermis, not beneath the dermis.
The corner flap is elevated with Adson forceps (pick-ups), and the needle is passed from one edge of the flap to the opposite edge of the flap. The needle passes through the deepest portion of the flap dermis, about 4 mm from the corner tip. After passing through the corner, the needle can be placed backward in the needle holder. The needle then passes about 4 to 6 mm from the corner into the deep dermis of the opposite edge from where the needle previously passed. The needle exits the skin on the opposite side of the plumb line, 6 to 8 mm from the corner. The suture is tied gently, allowing the tip to fit snugly into the corner. If the suture is tied too tightly, the corner tends to buckle.
不规则创口“不等长或等高”创口缝合：
Figure 2. Schematic illustrating the principle of halving sutures. Simple interrupted sutures are used to bisect the side of excess tissue. Additional sutures are used to equally divide the two remaining halves of the defect. The process is repeated until the excess tissue is gradually divided among progressive halving sutures.
igure 3. Schematic illustrating suture placement in the running pleated technique. (A) More widely spaced sutures are placed on the side of excess
and more narrowly placed sutures on the shorter side of the defect (II). (
Differences in the depth of suture placement in the running pleated technique are illustrated. More superficial sutures are used on the side of excess tissue
and more deeply on the shorter side of the defect (II).
