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6.8 Complications
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even plane laterally to the level of the anterior sternocleidomastoid muscle and inferiorly to the level
of the thyroid cartilage. The skin flap can be elevated from the platysma leaving all the fat on the
skin flap or the skin flap can be raised leaving 3cm
of fat on the flap with the remainder on the platysma. Ultimately, it is the surgeon’s choice. An even
layer of fat should be left on the platysma. This
avoids having to defat the elevated flaps, which can
sometimes result in uneven contour when they scar
back down to the platysma.
Once the fat to be resected is removed from the
platysma, the actual muscle belly is opened midline from the level of the submental incision to the
thyroid cartilage. This is done with cautery as the
muscle and subplatysmal fat are much more vascular, and not infiltrated with epinephrine solution
as compared to the supraplatysmal fat. Once the
muscle has been divided in the midline, the subplatysmal fat becomes visible and is shaved as necessary until it is flush with the anterior digastric
bellies. The dividing of the platysma muscle and
deep fat resection should extend down to the level
of the thyroid cartilage and laterally to the anterior
belly of the digastric muscle. At this point, maneuvers for contouring the deeper layers of the neck
can be carried out. Plication of the anterior digastric muscle bellies can be done, and conversely,
shaving can be done if they are bulky and contributing to the poor appearance of the medial neck.
The superficial lobe of the submandibular gland
can also be excised or partially excised for a
smoother-appearing submandibul ar triangle. It is
important to remember that anastomosing veins
from the internal jugular system are often encountered and should be avoided along the neck midline at the level of the hyoid.
Before the final platysmaplasty is performed, a
short postauricular incision is made behind the
ear to allow for the lateral and posterior most dissection of the subcutaneous neck flaps. This is especially useful in severe neck skin laxity patients,
where the entire cutaneous septa overlying the
sternocleidomastoid fascia should be divided as in
a full face and neck lif t. This posterior incision also
serves as a potential site for skin excision if needed
and can serve as a drain insertion site. Finally, we
choose to perform a corset platysmaplasty. With
two forceps, the horizontal laxity of the platysma
can be measured and marked with brilliant green.
Then, a 3–0 PDS suture can be used in a r unning
fashion to plicate the platysma from the chin to
the level of the thyroid cartilage. The same suture
can be run back superiorly to gather further excess
platysma, completing the stitch with a buried knot
superiorly. The incisions are closed by surgeon preference, although over time we have chosen to close
both of these potentially tense and mobile regions—
the submental and postauricular incisions—with
interrupted 4–0 Monocryl subcuticular and running 5–0 FAST sutures.
6.7 Postoperative Care
A 7-Fr channeled drain is used on each side of the
neck, exiting through the postauricular incision
site or adjacent to it. The patient is fitted with a
chin strap dressing that allows even coaptation of
the neck flaps to the platysma and minimizes dead
space for fluid collection. Patients are instructed to
wear this at all times aside from showering. The
drains are removed at 24 hours after surgery during routine follow-up on postoperative day 1. At
this time, as long as the drains have egressed less
than 30 mL in a 24-hour period, they are removed.
If they remain high, then we keep them in place
until they fall under that mark. On the first postoperative day visit, the patient’s dressing is also removed, and the contour of the neck skin is checked
for smooth inset and vector of pull. This is a time
for potential gentle manipulation and massage if
unevenness is noted, although whether it helps in
smoothing the contour is strictly anecdotal. The
neck dressing is to be worn at all times for 5 days
after surgery. At that point, it can be transitioned
to nighttime wearing for the following 2 weeks.
6.8 Complications
The most common complications encountered
after surgical neck lifting are results of judgment
or technical errors. Skin irregularit i es are often
the result of inadequate skin undermining, and
patients must be counseled on the need for potential revision postoperatively if this occurs.
Contour irregularities, on the other hand, are the
result of uneven fat resection in the supraplatysmal or subplatysmal plane. We advise fin ding a
uniform thickness on the neck lift flap as the surgeon begins the procedure, with constant checking to make sure the under min ing is even. W hat
fat remains on the platysma should then be resected. This minimizes the chances of contour
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Surgical Approach to Neck Rejuvenation
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irregularities as opposed to undermining a complete
adipocutaneous flap off of the platysma and then attempting to shave the skin flap uniformly. Irregularities will also have to be discussed with the patient
postoperatively for potential revision. Inadequate fat
resection is easier to manage, as it requires a redo
secondary procedure. Over-resection can result in a
skeletonized-appearing platysma and may require
fat grafting and skin redraping. Thus, it is much better to err on the side of conservative resection.
There can be areas of fullness caused by seromas
or hematomas. Diligent intraoperative hemostasis
is the most assured way to combat this postoperative complication. However, if fluid collections do
occur, they should be aspirated immediately and
followed by consistent c om pres sion with a chin strap
dressing in order to allow collapse of dead space.
Finally, there can be submental ridging or fullness
that results from a poorly performed platysmaplasty.
Again, diligent intraoperative decision-making, and
constant palpation of the platysmaplasty to make
sure there is smooth transition from the menton to
the submental region, is imperative. If the muscle is
plicated poorly, dog-ears will most certainly show
through the neck skin. The bulges in this region can
also be the result of inadequate resection of digastric
hypertrophy or submandibular gland ptosis. Many of
these complications can be avoided by a thorough,
methodical operative routine that the surgeon will
come up with as he or she experiences more neck
lifting cases. Raising the patient’s back and head at
the end of the case prior to completion can also
allow the surgeon to see the “finished product” with
gravity in play. This is also an opportune time to
check for any of the aforementioned complications
or judgment errors.
6.9 Commentary by Dr. Zins
The anterior approach to the neck has been described by numerous authors including Feldman,
Knize, Ramirez, and myself. The operation requires
a submental incision only. No skin is excised. It is
not technically challenging; the recovery is rapid
and the results are consistent in properly selected
individuals. And yet I am repeatedly surprised that
when presenting this technique many plast ic surgeons remain unaware of its benefits and utility.
The procedure yields more consistent results
and has as rapid a recovery as minimally invasive
techniques such as Kybella and radiofrequency
devices. It requires only minimally more time,
effort, and expertise than isolated submental and
submandibular lipoplasty alone. The operation
should be in the armamentarium of every plastic
surgeon performing cosmetic surgery.
6.10 Expert Commentary by
Dr. Slavin
The authors’ meticulous attention to anatomical
detail is to be applauded, and it is clear that they
are masters of facelift anatomy. It is a careful analytical, anatomical, diligent approach that works
well in the authors’ hands. One of the keys to a
happy facelift patient is preventing skin irregularities and contour deformities, as highlighted by the
authors. Correcting skin irregularities can be a
time-consuming correction that requires complete
re-elevation of the skin flaps, so they are best managed at the time of the initial operation. Moreover,
when the fatty component of the deep compartment is causing contour irregularities, our preference is to excise it, particularly a nteriorly. In the
heavier (grade III– IV) necks, we agree with the
authors’ preferred management. I would add, we
are wary of liposuction on the neck in older
patients and restrict it to patients with grade I
laxity. In these young patients (in general, under
40), the need for skin excision can be obviate d
with thoughtful liposuction alone. With regard to
submandibular gland ptosis, it can be effective
initially to pexy the gland and in our practice, the
results with pexy of the gland have lasted 3 to
5 years.
6.11 Expert Commentary by
Dr. Lin
In an era where numerous devices for nonsurgical
soft-tissue tightening and injectables are available, I
agree that a direct open approach, for instance, to
the anterior neck is effective. By the time patients
have had several Kybella injections, which are often
painful, without enough improvement, a more
open approach is not only warranted but also likely
may have been indicated in the appropriate patient
at the outset. Wide undermining is key for smooth
redraping, and it is important to counsel the patient
on the potential recurrence of neck banding and
jowling over time.
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References
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70
7 Deep Plane Neck Lift Concepts and Technique
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Benjamin Talei, Hedyeh Ziai, and Daniel J. Gould
Abstract
Modern approaches to the neck involve different
concepts including distributed tension, platysmal
manipulation, and varying degrees of interventions
to the deep neck space. The benefit of a deep plane
approach lies in the ability to release tension in the
neck and face. Once the platysma has been released
from the components of the deep neck space and
surrounding tethering points, it can be repositioned
and redraped in a tension-free manner. Aside from
lifting, one must realize the importance of restoring
the deep space compartments internally. This provides improved contour restoration as well as a
tension-free excision of any excess skin, which consequently helps avoid earlobe-related complications,
widened scars, and an odd or pulled look. The deep
plane is a more logical and natural approach to lifting of the face and neck, lifting along the natural
anatomical glide planes.
Keywords: deep plane facelift, deep plane neck lift,
direct neck lift, facial rejuvenation
Key Points
●
Deep plane neck lif t involves release from the
deep facial cervical structures.
●
Tension is released, then soft tissues are redistributed with a deep plane neck lift.
●
Re-compartmentalization is a key concept in
neck contour restoration in all dimensions.
●
There are danger zones to avoid risk of depressor
anguli oris (DAO) weakness or facial paralysis.
●
With the release of tension, the skin closure is
tension free and the appearance is distinctly
natural.
7.1 Patient Considerations,
Indications, and Contraindications
7.1.1 Patient Considerations
To properly understand deep plane lifting, a better
understanding of prior and modern techniques is
required.
que for neck lifting is the deep plane lift with full
release and tension-free suspension.
1,2,3,4,5
In our opinion, the optimal techni-
4,5,6,7
Patient complaints about the neck typically precede those of the face.
accelerated aging relative to the remainder of the
face for a variety of reasons. With age, each side of
the face gravitates and descends into the neck in a
pendular fashion, meaning an additive effect of
bilateral descent may occur in the neck. This direction of aging continues over the sternum and
clavicles, causing changes in skin quality and loss
of radiance over time. Additionally, midline vertical descent may occur in the submentum. Drooping in the neck may occur with or without skin
laxity. Volume excess may also be present during
youth or it may worsen with age. Superficial to the
platysma, we typically only consider subdermal or
supraplatysmal fat. Maintenance of a layer of fat is
essential to avoid visible banding and a deflated
appearance in the skin. The submandibular glands
commonly descend with age, although hypertrophy may be present in a subset of patients as well.
Bulging of the anterior belly of the digastric may
be present from hypertrophy in some cases or
from incorrect vector of pull in revision cases. In
some patients, aberrant excess volume lateral to
the hyoid may exist. This could be from fatty or
lymphatic tissue and in some cases glandular tissue presenting as an anterior and medial extension
of the lower pole of the submandibular gland.
With age, the parotid glands tend to bulge outward as the strength of overlying encapsulation
from the superficial musculoaponeurotic system
(SMAS) and platysma diminishes. The tail of the
parotid may become more prominent as well,
blunting gonial angle definition substantially. On
the face, the lateral cheek may become hollower as
the soft tissue of the cheeks descends in a pendular fashion. The physician must analyze the characteristic changes noted in each individual face to
plan the most appropriate course of action. If the
cervicomental distance appears short, the physician must determine if it should be lengthened
internally by contouring around the lifting against
the hyoid or by performing chin augmentation. All
too often, gratuitous chin augmentation is performed to camouflage issues with inadequate lifting. In some cases, prominent dentition may lead
the practitioner to believe that chin augmentation
would provide better balance. In many of these
8
The neck may experience
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Deep Plane Neck Lift Concepts and Technique
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cases, the female patient may become more masculinized when all that was needed was a more
thorough neck surgery. Rather than adding volume to the chin, one m ight benefit more from
gently excavating the pre- and peri-hyoid region
to create depth without hollowing. Blunting of
the cervical angle may also be addressed this way
by contouring the deep cervical fascia.
Aging and lifting of the neck need to be understood in three dimensions in order to perform
adequate treatments. The surgeon must restore
depth and contour to a neck that has aged outward, anteriorly and inferiorly. Hence, the vectors
of lifting should be inward, posterior, and superior
all at once. Releasing the neck in a deep plane
allows the surgeon to manipulate the platysma as
a sling or hammock around deep compartments,
using the submandibular gland zone and lateral
hyoid as the fulcrum for submental and lateral
neck lifting. Vectors of suspension must always follow the natural anatomy. In the face, the cheek
mostly ages along the vector of the zygomaticus
musculature, perpendicular to the nasolabial folds.
Hence, lifting occurs in the opposite direction. In
the neck, the lateral platysma ages around the hyoid and must be lifted vertically in the direction of
the posterior digastr ic muscle to avoid residual
laxity or improper pull on the anterior belly of the
digastric. Lateral lifting of the platysma may cause
a bulge in the submandibular triangle along the
line of the digastric. This is commonly and erroneously described as digastric muscle or submandibular hypertrophy. Realistically, deep plane release
and a proper vector of pull would have prevented
this from occurring.
The surgeon must analyze the neck from all
directions. From the anterior view, the width and
circumference of the neck should be diminished to
maintain proper depth relative to the jawline. One
may use the image of placing a hand around the
neck and squeezing in order to narrow the radius of
the internal angle of the neck extending from the
mastoid to the hyoid to the contralateral mastoid.
This will assist the surgeon in envisioning the
changes needed in order to restore depth and recompartmentalize the deep space components in
the neck while avoiding untoward pull and tension.
7.1.2 Indications
Patients with laxit y, drooping, sloping, or aging of
the neck are deep plane neck lift candidates. Jowl
formation often indicates that drooping and aging
in the face and neck have occurred. Some patients
may present with an obtusely angled neck from a
very young age. These patients are candidates as
well if they would not benefit adequately from liposuction or radiofrequency (RF) treatments. Ptosis
of the submandibular triangle and submandibular
glands typically requires vertical vector deep plane
lifting to correct. Skin laxity may or may not be
present. Platysmal banding may also be treated
with deep plane neck lifting by treating the platysma from a midline or lateral approach. In some
cases, the deep cervical fascia may contribute to
banding and this may be treated as well during a
neck lift. Patients with prior face or neck lifting
with inadequate results or those who have aged
out of their prior lifts are also good candidates for
this procedure.
7.1.3 Contraindications
There are few contraindications to deep plane neck
lift as a method. Prior neck surgeries, including
parotidectomy, are not contraindications although
greater care must be taken with these patients.
There are relative contraindications to neck lifting
in general, such as uncontrolled hypertension,
blood thinners, and generalized anxiety disorder,
but this is not the desired scope of this chapter.
7.2 What Technique to Use and
Why?
The authors recommend a modified extended vertical vector deep plane face and necklift in patients
with soft-tissue ptosis and skin laxity. It is incorrect to assume that younger patients would benefit from miniature forms of lifting as they typically
have denser tissues and require more substantial
release of tension to obtain a noticeable result and
avoid scarring. If it appears as though drooping
has occurred in the neck without any substantial
skin excess, an internal neck lift may be performed.
An internal neck lift encompasses a lateral and midline platysmaplasty through minimal access incisions and is typically combined with Profound RF—a
bipolar RF treatment to improve skin tightness and
quality.
It is very important to consider the threedimensional aspects along with the contrary lifting that is required to re-compartmentalize the
submandibular contents and lift the neck naturally
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7.3 Technique
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and effectively. As the face and neck descend with
age, the major salivary glands commonly protrude
and descend as well. The platysmal drape can be
manipulated to resuspend the submental contents
and restore the submandibular angulation while
also lifting the lower neck across the clavicle.
Although most authors discuss the vertical vectors
of lifting only, it is of equal or greater importance
to understand the depth of lift that is required to
achieve thebest result. The contents of the submandibular region and gonial angle tend to lateralize
with age; hence, upon lifting, they must be internalized. Internalization and deepening of the lateral
platysma insertion upon lifting results in a much
more substantial improvement of the gonial angle,
submentum, and submandibular triangle. Although
a small percentage of the population experiences
anterior digastric muscle and submandibular gland
hypertrophy, the majority of patients solely demonstrate ptosis. What most surgeons perseverate
about as being digastric hypertrophy and submandibular gland enlargement is more likely bulging
and residual ptosis caused by inadequate lifting or
improper vector utilization. This chapter will
explain a proper and effective technique.
7.3 Technique
We perform two differing techniques to lift the
neck using a deep plane technique. Younger patients without skin excess or need for skin excision
may undergo an internal neck lift, which in our
practice is combined with the Profound RF treatment to obtain skin quality improvements. Patients
with more laxity and skin excess may undergo a
more substantial face and neck lift. Releasing and
lifting the face along at the same time as the neck
allows a much more substantial and fluid lift of the
neck, with less need for compensatory techniques.
7.3.1 Deep Plane Face and Neck
Lift
A 2-cm submental incision is placed in the submental line. The position of the crease is delineated by
drawing a line around the internal border of the
mandible, meaning in some patients the line may
be straight and in others it may be curved. The incision should always sit in this line, at the junction of
the mentalis and platysma, allowing surgical access
to the entire platysma. Naturally existing creases
that do not fall within this line should not be used.
Dissection is initiated sharply, opening a plane
directly over the platysma, while ensuring a fatty
layer is left attached to the skin. Liposuction is performed in some cases, although fat must be left in
situ on the underside of the dermis to avoid crepiness of the skin and prominent muscle banding in
the future. Elevation of the flap is then continued
down toward the top of the thyroid cartilage using
a lighted Aufricht elevator and blunt spreading dissection with a Kaye facelift scissor. The platysmal
borders are then identified in order to determine
the degree of laxity. Intraplatysmal deep cervical
fascia may be excised without subplatysmal fat reduction. The platysma is then elevated bilaterally
over the anterior belly of the digastric muscles,
continuing to the lateral hyoid. There may be
dense ligamentous attachments at the lateral cervical angle around the lateral hyoid that require
sharp dissection.
At this point, the submental and submandibular
compartments are assessed for potential reduction.
Lateral reduction should always be performed first
to avoid any relative central hollowing. The anterior
belly of the digastric may be reduced if it appears to
be bulging. A laryngeal mask airway may cause artificial bulging. Digastric reduction may be performed
by stripping the top layer of the digastric using
bipolar electrocautery. This may cause postoperative
myositis for 2 to 3 weeks. The volume around the
lateral hyoid is then assessed. A pocket of fat and
lymphoid tissue on the lateral borders may be reduced. In some cases, the submandibular gland may
be pushing toward or caudal to the lateral hyoid.
This inferior or medial pole of the gland may be
delivered gently out of the capsule and reduced if
needed. Only judicious reduction should be performed to avoid hematoma, seroma, sialocele, and
nerve damage.
Using a substantial vertical vector deep plane lift
obviates the need for submandibular gland excision in the large majority of patients. Intermittent
irrigation is regularly performed during submandibular gland reduction to minimize heat dispersion around the motor nerves. Damage to medial
cervical branches may occur if the surgeon is not
careful. The central fat compartment may then be
reduced minimally only if needed. It is best to
leave fullness in the central compartment to avoid
hollowing and cobra neck deformities. The fullness
will flatten as a corset platysmaplasty is performed. A horizontal fasciotomy is then performed
through the prehyoid deep cervical fascia to relieve
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Deep Plane Neck Lift Concepts and Technique
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deeper contributions to banding and to allow better angulation through an obtuse cervicomental
angle. Overaggressive hollowing or reduction must
be avoided in the neck to prevent forming a rigid,
vacuous appearance in the neck. A youthful neck
should have adequate volume and smooth, soft
contours.
A corset platysmaplasty is then performed. The
goal should be to have the edges of the platysma
meet at the midline with a minimal amount of tension to avoid medialization of the jowls or future
dehiscence. Overtightening of the central neck will
also limit the amount of vertical lift possible.
5,9,10
The key is to try and balance the medial pull against
the lateral pull from the vertical neck lift, which
will be performed next. The fulcrum to consider is
the lateral hyoid at the junction of the anterior and
posterior bellies of the digastric muscle at the intermediate tendon and fibrous sling. Release of the
platysma from the anterior belly of the digastrics
helps avoid medialization and bunching of the digastrics. A buried 3–0 PDS may be placed at the cervical angle as the first suture. The primary author
advises against tacking to the deeper fascia to avoid
tethering during swallowing and to avoid a choking
sensation, which may occur from impaired move-
ment or increased awareness of sensation. Several
other buried sutures are placed while advancing
from the cervical angle toward the submental incision (▶ Fig. 7.1).
It is important to remember that the proximal
platysma is most commonly dehiscent at midline
in its native state and that excessive approximation
may cause medialization of the jowls or require
subcutaneous release of the mandibular ligaments.
If the thyroid–laryngeal complex is prominent, the
platysma must remain intact in front of the
thyroid cartilage as well to avoid exaggeration of
Adam’s apple and cervical angle when lifting. Back
cuts of the platysma around the cervical angle are
advised against to avoid a harsh or angular appearance. If severe or recurrent banding is present,
lower platysmal myotomies may be performed.
Partial myotomies are sufficient and avoid stepoffs and bleeding from violating the external jugular venous system. The cavity is then irrigated with
a dilute sodium hypochlorite solution (0.057%),
which appears to have gentle hemolytic, antibruising, and anti-inflammatory benefits.
The vertical portion of the lift is performed next
in the form of a combined deep plane face and
neck lift. The face and neck are treated as a single
74
Fig. 7.1 (a– c) A demonstration of the authors’ approach to the neck. The submental
access allows for deep plane neck dissection
to fully release the platysma from the
Submental incision
Digastric muscle
Submental fat
Submandibular
gland
Hyoid bone
Platysma
Thyroid cartilage
a
digastrics while accessing the submental fat
compartment for reduction if needed and
the submandibular glands as well. This is
followed by several key steps to deepen the
cervicomental angle including division of the
deep cervical fascia in a horizontal incision
above the thyroid cartilage.
(Continued)
7.3 Technique
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Fig. 7.1 (b, c) (Continued)
Resected fat
Partially resected
gland
Horizontal
fasciotomy
Hyoid bone
b
Corset
platysmaplasty
Occasional
partial myotomy
c
c
unit to allow a more substantial and fluid lift.
Access is achieved through a temporal tuft incision
extending around the helical root. Incisions within
the hairline are avoided as this will result in elevation and retroplacement of the sideburns and an unnatural lengthening of the lateral cheek. Temporal
tuft incisions heal exceptionally well if tension is
avoided upon closure and skin excision between the
lateral canthus and the anterior limb of the incision.
The temporal skin ages in the inferior vector, so lateral skin excision w ould only provide unwanted tension. The incision may then proceed in a pretragal or
retrotragal fashion. A pretragal incision is preferred
if the patient has an ear with strong architecture
including a prominent auricular incisura. The incision is then carried in the postauricular crease, traversing to the posterior hairline at the point the
mastoid f lattens, and the temporalis muscle inserts.
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Deep Plane Neck Lift Concepts and Technique
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This continues down the posterior hairline for 3 to
4 cm in most patients. Again, incisions hidden within
thehairlineareavoidedastheytendtocausedistortion, scarring, and limitations in vertical lifting
(▶ Fig. 7.2).
The skin is then incised and elevated using a no.
10 blade scalpel and then proceeding with microdissection scissors. The surgeon holds tension with
an Anderson Bear Claw retractor, while the assistant holds counter-tension. Transillumination may
be used to maintain uniform flap thickness. A thin
layer of fat is left on the reticular dermis to avoid
compromising the blood supply of the subdermal
plexus in this random flap. Dissection is carried up
to the modified deep plane entry point shown in
the figure. The entry point is delineated preoperatively by performing a “sailboat modification”
upon the classic deep plane entry point. This
allows a greater preservation of SMAS on the elevated flap, resulting in improved vascularity,
greater ease of dissection, and a lower rate of skin
and muscle irregularities in the upper lateral
cheek.
The postauricular skin is then elevated in the
same fashion in a subdermal plane. Upon reaching
the border of the sternocleidomastoid (SCM)
muscle, blunt dissection may be used to continue
in the preplatysmal plane. A lighted facelift retractor (BriteTrac) is used to provide retraction and
lightning, while Steven’s Kaye scissors are used to
bluntly separate the subdermal fat from the preplatysmal fascia. Dissection is carried anteriorly
until the submental cavity is connected to the lateral dissection space. Inferiorly the dissection typically stops at the horizontal plane of the thyroid or
cricoid cartilage to avoid vascular compromise of
neck skin. If tethering or dimples are present at
the conclusion of lifting, these should be released.
The deep plane dissection is performed next.
The Anderson Bear Claw retractor is used to
place tension along the border of the facial platysma. A gentle and deliberate incision is made using
a no. 10 blade scalpel until the deep glide plane is
exposed. The lateral platysmal border is scored in
a broad, serial fashion until the areolar plane is
slightly visible. Dissection is then carried out with
blunt spreading with the Steven’s Kaye scissors.
Gentle spreads are performed in the mostly avascular plane immediately deep to the platysma. A
thin areolar fat plane typically exists under the
platysma and the tip of the scissors may be gently
pushed forward into this without damaging the
platysma. The flap is raised anteriorly until reaching the facial artery. Extending past this may cause
76
Fig. 7.2 A demonstration of the standard
temporal tuft and periauricular incisions with
landmarks. Importantly, the authors do not
recommend violating the hairline, as a deep
plane approach offsets tension, and thus the
risk of a scar is particularly low. Addressing
the critical concept of tension is the best way
to prevent a scar. One key benefit of the
deep plane approach is that the deep plane
work offloads the tension and then excess
skin is removed. There is no pulling of skin
Temporal
tuft
Mastoid processNot past lobe
and no tension on the skin.
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