The incision is deepened to the areolar tissue plane just below the platysma muscle where an avascular space is reached. All active bleeding points are grasped with curved, pointed hemostats that are reflected upward or downward depending upon to which side of the incision they have been applied (Figure 6). Active bleeding and danger of air embolus may occur from accidental openings made into the anterior jugular vein if too deep an incision is made. Sharp dissection may be used alternately with blunt gauze dissection to facilitate the freeing of the upper flap (Figures 7 and 8). Usually, a small blood vessel will be encountered, high up beneath the flap on either side, which will produce troublesome bleeding unless it is ligated (Figures 8 and 9). The dissection goes up to the thyroid notch, exposing all of the thyroid cartilage, as well as down to the suprasternal notch. Outward and downward traction is then applied to the lower skin flap as it is freed from the adjacent tissue down to the suprasternal notch (Figure 9). At the very lowest part of the wound, care should be taken to avoid damage to the communicating arch connecting the two anterior jugular veins. If the veins or the arch is entered, the descending branches of the anterior jugular vein should be ligated below the level of the communicating arch in order to minimize the chance of air embolism (Figure 9).