Extensive soft-tissue tumors involving the facial region have historically been challenging to treat with regard to craniofacial reconstruction. Complete resections of these tumors have not been performed due to concerns over intraoperative facial nerve injury. Extensive soft-tissue tumors can involve a variety of tumors and vascular lesions, such as neurofibroma, lymphangioma, and malformations in the veins and lymphatic system. These can lead to varying degrees of facial sagging, bulging, and asymmetry, and may cause functional loss due to nerve or vital organ compression. Facial nerve preservation and optimization of facial appearance are critical components of facial tumor surgery.

Traditionally, excisional approaches have been widely adopted to manage massive facial tumors, from conservative methods to radical procedures (Ford, 1983; Hivelin et al., 2010; Kulbersh and Hochman, 2011; Singhal et al., 2014). Excisional approaches directly address the tumor mass and are considered more appropriate for obtaining long-lasting results (Hivelin et al., 2010). Some authors have emphasized the importance of aesthetic subunits, through placing scars in the deepest expression lines, and optimizing aesthetic outcomes by matching the contralateral side (Hivelin et al., 2010; Singhal et al., 2014). The excision amount varies from conservative to radical, depending on the surgeon's perspective. The main difficulties with excisional approaches include tumor involvement in the inferior third of the face, where en-bloc resection is limited owing to the parallel course of the marginal mandibular nerve along the mandibular border.

The suspension technique has been proposed as an alternative method for addressing the sagged tissue and minimizing the scars with a facelift approach (Acartürk et al., 2009). Massive tumors in the cheek — the most commonly affected region — eventually lead to loss of support in the midface and progressive lower-lid ectropion. Excisional approaches do not always guarantee sufficient debulking to preserve the facial nerve and potentially leave some tumor mass, with considerable gravitational pulls. Although some authors have proposed the suspension technique to manage massive facial tumors, most studies have been based on subcutaneous lift or fascial suspension (Khan and Frame, 1994; Friedrich et al., 1998). Several concerns regarding the long-term stability and loss of elasticity due to tumor involvement in the undermined flap have limited the application of the suspension technique for reconstruction. To address these issues, a deep-tissue plane can be used to create a durable support and provide sustainable flaps, simultaneously debulking the tumor mass in the superficial layer.

Our study assessed a stepwise solution for managing extensive hemifacial tumors. First, indocyanine green (ICG)-assisted visualization of the facial nerve allowed safe dissection during tumor debulking (Kwon et al., 2019). Second, a deep-plane facelift technique was performed to resolve soft-tissue redundancy. The study aimed to assess the functional and aesthetic outcomes in patients undergoing deep-plane facelift to treat extensive hemifacial tumors of varying etiology.