LigaSure-assisted Retaining Ligament Release during Composite Deep Plane Face and Neck Lift: A Three-Sign Structured Framework

Complete release of the retaining ligaments during deep plane face and neck lift is essential for durable rejuvenation. This step demands particular caution to avoid nerve injury, however, as branches of the facial nerve course in close proximity to the retaining ligaments. During ligament release, surgeons currently rely on uncodified visual and tactile clues or separate neuromonitoring equipment which introduces an instrument change between identification and division. We describe a three-sign sequential identification framework in which the LigaSure vessel sealing system (Medtronic, Minneapolis, MN) serves as both the diagnostic probe and the division instrument, eliminating the need for an instrument change during ligament release in deep plane facelift. First, the Visual Assessment Test evaluates fiber direction and tissue character. Second, the LigaSure Tweak Test distinguishes excitable nerve from nonresponsive ligamentous tissue. Third, the Skin Tethering Test applies gentle traction to confirm a ligament's dermal insertion through visible skin dimpling. A structure is divided only when all three signs align with a ligamentous identity. This framework synthesizes individually described anatomic identification clues into a structured, reproducible, and teachable approach for what is described as the most challenging step of deep plane facelift.