仔细观察瘢痕整形技艺大师，弗吉尼亚州福尔斯彻奇的Alfred F. Borges的W-整形术缝合操作，就会知道应该怎样更好的学习技艺。在全面认识到高超技艺的重要价值后，Borges4982年写道： 最佳的手术技术本身不是成功的保证，在一项手术后，要获得细小缝线瘢痕的决定因素之一，不是如此之多的有特点的缝合技术，而是切口是否与皮肤张力松弛线行走一致。
a. The Stair-step resection ofscars of lesions, and the stair-step incision to expose and tocarry out procedures such as the augmentation mammaplasty enableone to repair in a stair-step fashion with a sound layer closure.This makes for a safer wound closure, especially when there istension on the edges, and makes exposure of foreign implants orgrafts (such as breast prostheses, bone grafts, and cartilagegrafts) less likely. Interruption of the continuity of the healingwound external to the graft or implant is not likely with thisrepair because it distributes and shares the tension in eachlayer.
b. This technique may beapplied to any wound closure and in resection of superficiallesions or scars, as is demonstrated. The tissue usually keep theirnormal thickness to give a level skin surface, with less likelihoodof spreading or depression of the scar line.
a. The inframammary and the ancillary incisions allow for anincision through the skin, then dissection downward, beforepenetrating more deeply to the retromammary area. This creates astair-step type of approach, which permits a more thorough closureby pulling the subcutaneous fat flap down over the implant, toclose beneath the lower skin flap. This stair-step repair gives athick, secure closure over the implant and more nearly insuressound wound healing without danger of dehiscence of the wound.Obviously, this approach does not penetrate the breast tissue butskirts the underside (or the lateral side, for the axillaryapproach) of the breast.
b. The periareolar (marginal areolar) approach for the small breastallows the surgeon to dissect inferiorly or laterally around themargin of the breast in the subcutaneous plane and to approach theretromammary space without penetrating the breast tissue. This isdefinitely preferable to a division of the breast tissue.
c. The transareolar or periareolar approach may penetrate anddivide the breast tissue. This transaction may cut across theducts, creating cysts or blockage of the duct. This approach is notfavored by the author for this obvious reason and because itcreates additional scar tissue in the breast which is difficult touate in future breast examinations. The hazard of decreasedsomewhat, particularly but the transareolar approach and thenipple-splitting incision.
Neither the technique of b nor c allows an adequate check forbleeding vessels and securing of these vessels, and for hemostasisone must depend primarily on insertion of packs or of pressurebefore insertion of the augmentation prosthesis. Though themarginal areolar incision leaves little scarring in most instances,a heavy scar in this area is much more disturbing to the patientthan one in the axilla or in the inframammaryarea.
The OverlapTechnique
a. For depressed scars, defectsin the underlying deeper soft tissues, and depressions in theunderling skeletal tissues, there may be a need to build up thesoft tissue and increase its thickness. The actual overlap of thedeeper tissues is carried out rather than bring them together instair-step fashion as in Figure 1-6, or as a simple layer closureas shown in Figures 1-5. A resection is carried out bothsuperficially and deeply as is required. Then the superficial andthe deeper tissues are undermined separately to allow slidingtogether of the superficial tissues and overlapping of the deepertissues.
b. This technique may be used tomaintain or correct contour defects and to build up the thicknessof the soft tissue when there are deficiencies of either softtissue or underlying skeletal tissues. A layer repair is carriedout as with all wound repairs. This technique can causeexaggeration of the fullness when there is firm underlying skeletalsupport of the soft tissues such as over theforehead.
Caveat 8: There Are Other Ways to Deal with Lines of UnequalLength Often in plastic surgery an ellipse is designed, but because of theconfiguration of the lesion, the limbs of the ellipse have different lengths. A triangleof tissue (as described above) is one solution, but there are occasions where this is notdesirable. If the discrepancy between the limbs is not too big, differentialsuturing (“stealing stitches”)isall that is required. Whenthere is a greater discrepancy in length, in principle, one linecan be made longer or the other can be made shorter, or bothmethods can be used (Fig. 1). Remember, dog-ears commonly arise from two situations: the angle ofthe ellipse is too obtuse,or the length discrepancy between the twolimbs is too great to allow for a “stealing”stitch.
