To avoid bleeding, a vertical incision is placed exactly in the midline of the neck between the sternohyoid muscles, extending from the thyroid notch to the level of the sternal notch. All bleeding points are controlled by the application of hemostats. The tissues on either side of the incision are lifted up so that the incision is not carried directly through into the thyroid gland (Figure 13). The blunt handle of the knife is inserted beneath the exposed sternohyoid muscles (Figures 14 and 15). At this point the loose fascia over the thyroid gland should be picked up with forceps and incised with the scalpel in order to develop a cleavage plane between the thyroid gland and the sternothyroid muscle (Figures 16, 17, and 18). This is one of the most important steps in a thyroidectomy. Many difficulties may be encountered unless the proper cleavage plane is entered at this time. When the fascia of the sternothyroid muscle has been completely incised and reflected, the blood vessels in the capsule of the thyroid gland are clearly visible (Figure 18). After the proper cleavage plane is developed, the sternohyoid and sternothyroid muscles are pulled outward from the thyroid gland by means of a retractor, so that any unusual blood vessel communication between the sternothyroid muscle and the thyroid gland can be clamped and ligated (Figure 18). Once the surgeon is working in the proper cleavage plane, the delivery of the gland may be facilitated by inserting the two forefingers side by side to the outer edge of the thyroid gland and separating them, thus freeing the gland without injuring blood vessels (Figures 19 and 20). If an effort is made to free the entire lateral surface of the gland by finger dissection, it must be remembered that in some instances the middle thyroid vein is quite large and may be torn accidentally by this maneuver, resulting in troublesome bleeding.