Once beyond 3cm above the angle on the posterior margin of the dissection, it is safe to deepen the plane to bare the prevertebral muscles. Rest of dissection is carried out as routine radical neck dissection. 1957; Bocca E, Pinataro O & Sasaki C T 1980 and Ariyan 1986. Modified extended Kocher incision for total thyroidectomy with lateral compartment neck dissection - a critical appraisal of surgical access and cosmesis in 31 patients. But lymph nodes are found within parotid. After evaluation of his early failures, he found that a block resection of all of the lymph node-bearing tissue of the neck … Depending on the extent and location of the disease the appropriate procedure is chosen. The submandibular prevascular and retrovascular lymph nodes are in close proximity to the nerve and they must be carefully dissected out from it. This is a surgery to remove the lymph nodes in your neck area. When the skin flap is elevated in this region, the skin flaps stops at the lower border of the mandible since the skin and the platysma are leaving the operating field to overlie the facial muscles. Inadvertent arterial injury might result in serious. It is invested by superficial layer of the deep cervical fascia, which splits into two laminae to cover the superficial and deep surfaces of this muscle. Caudally it divides into the sternal and clavicular heads to attach on the sternum and the clavicle. No cardiac or GIT dysfunction is known to result from transection of the vagus. Lymph Node Dissections of the Neck Anuradha R. Bhama Geeta Lal Neck dissections encompass a wide variety of terminology and procedures. The modifications in bilateral dissections concern the skin incisions and the management of internal jugular vein. Morfit and Perzik 1952 demonstrated a case with simultaneous internal jugular vein ablation. McFee incision. “J” incision has a vertical incision extending from the mastoid apex to 2 cm above the clavicle along the back of the sternocleidomastoid muscle, then it is extended in horizontal plane and continued parallel to the bottom edge of the cricoid cartilage and it is stopped at the point where the sternocleidomastoid muscle is attached to the clavicle. N2 Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension. Duplicated Conley variant of triradiate incision can be used in these circumstances. L'incision de Mac Fee procure un excellent résultat cosmétique mais au prix d'une exposition chirurgicale moins bonne. Here the flap is raised inferiorly. It can also be identified deep to trapezius which is about 2 cm finger width above clavicle. This can be prevented by giving a posterior sigmoid curve to the vertical incision ( McFee 1960; Futrell and Cheretien 1976 ). Tri-radiate incision and its modification. In the symphyseal area clearance of the digastric muscle should be extended across the midline as far as the contralateral digastric muscle, making it possible to clear the submental nodes. Suarey 1963 discussed the rationale for this type of neck dissection. The effect of loosing sternocleidomastoid muscle on one side is cosmetic rather than functional. Occipital and external auricular branches of external carotid supply the upper lateral neck, the area between ramus of mandible and the sternocleidomastoid muscle. Cancers in certain locations spread to specific lymph node groups in predictable patterns. Modified Schobinger's incision is the most common incision used for neck dissection. Posterior triangle dissection is difficult ( Maran et al 1989, White et al 1993). Official report of the Academy’s Committee for Head and Neck Surgery and Oncology. Arch Otolaryngol Head Neck Surg 117:601–605 PubMed Google Scholar. The vagus lying between artery and vein is dissected free and retained. Unilateral loss of hypoglossal nerve function results in little disabilities. This flap most often gets cyanosed. Clearance of the neck is usually begun from the posterior triangle in the region of the posteroinferior angle. The structures concerned are the spinal accessory nerve, internal jugular vein and the sternocleidomastoid muscle. Baptist Downtown Southside Baptist South • Some swelling around the incision is normal. As the floor of the posterior triangle is cleared towards the posteroinferior angle the transverse cervical vessels are met passing across into trapezius that can be resected as a part of the dissection. Excellent cosmetic result ( McFee 1960, McNeil 1978). Eckert and Byars 1952 practised the first forms of the “J” incision. The carotid system contribute to 85% of cerebral blood flow, if occluded collateral flow must develop from the circle of Willis. The superficial layer of deep cervical fascia is divided at the junction of sternocledomastoid and anterior border of trapezius. it is ideal to visualise the anterior border of the trapezius from end to end for subsequent clearance. N0 No regional lymph node metastasis. The transverse incision curves gently 2-3 cm below the tip of mastoid process and runs medially towards the submental region approximately 2cm below the lower margin of the mandible. The omohyoid present just above the clavicle in the lower part of the triangle marks out a small subclavian triangle. This band should be sectioned. Tri-radiate incision & its modification. Sobol et al 1982, have described five pathological mechanism for cerberovascular complications following head and neck surgeries. The concept of neck dissection refers to systematic resection of lymph nodes from well-defined fascial compartments in the neck. In this study, types of skin incision used in neck dissections were defined, and the advantages, disadvantages and results of J incisions, which have been performed on 320 radical neck dissection patients in our clinic between 1985–1996, were compared with those of other incision types. This is the most common type of neck dissection. Efficacy of radical neck dissection is to be considered with adjuvant radiotherapy. View All Posts. The surgeon makes a cut (incision) in the neck to remove the lymph nodes. Here there is clearance of nodes from below the mandible to the clavicle involving submental, submandibular, jugular group of nodes and also nodes in the posterior cervical triangle. Concern with the effect of loosing these structures, particularly the spinal accessory, has resulted in fresh evaluation of the whole surgical approach to lymph node resections, with the aim of preventing the sequelae without compromising the therapeutic effectiveness. Injury to motor branches of cervical plexus can also result in shoulder disability. In Type I modified neck dissection spinal accessory nerve is preserved. This results in little disability and minimal cosmetic deformity. A reversed hockey stick incision was first described by Schobinger as a long anterior skin flap for radical neck dissection and was extended to block resection of oral cavity by Babcock & Conley and Disanayaka. Morfit and Perzik 1952 reported a case of bilateral simultaneous neck dissection without vein preservation. This operation is defined as the en bloc removal of the lymph node bearing tissue of one side of the neck including the nodes in level I to V, preserving the spinal accessory, the internal jugular vein and the sternocleidomastoid muscle. If this isn’t possible, you may need to have a computed tomography (CT) scan or ultrasound of your neck … The ‘posterolateral neck dissection’ consist of removal of suboccipital and retroauricular lymphnodes and nodes from regions II, III, IV and V. Medina & Byers 1989 stated that en bloc removal of the nodes at highest risk for metastasis is anatomically justified and it has the same therapeutic value as radical or modified neck dissection. These platysma cutaneous arteries while supplying a particular region of the skin are also in anastomosis with each other. Choosing a particular incision is important especially in the post irradiated neck area. Stripping is pursued upward to the insertion of the mylohyoid. Medina ( 1989 ) based on these two points classified neck dissection into comprehensive, selective and extended. It invests around the sternocleidomastoid and trapezius muscle. Dissection further exposes the inferior belly of omohyoid that once divided, the dissection is continued deeply as far as the prevertebral fascia overlying the brachial plexus and the scalene muscles. If nodes are found in level III then the dissection is extended to level IV below the omohyoid sacrificing the omohyoid muscle. The realisation that the spinal accessory is not in close proximity to the nodes involved by tumour and that its preservation does not compromise the oncological soundness of the operation. The front and the tip of the medial flap might become necrotic however this weakest point is behind the carotid artery bifurcation. ( Log Out / Bilaterally placed hockey stick incision permits the elevation of a superiorly based large skin flap and allows the deglovement of the whole neck. Dargent & Papillon 1945 and Skolnik et al 1967 were among the first to advocate the spinal accessory nerve preservation. From metastatic point, this group of lymphnodes receive drainage from the nasopharynx, in the upper portion it receives drainage from the subdigastric group of deep cervical lymphnodes. So preservation of the spinal accessory is vital for this function. The external carotid gives branches in neck. Internal jugular vein is sectioned between the upper and lower limits of the jugular group of lymph nodes and are removed along with the nodes. It unites with the anterior branch of the retromandibular vein to form the common facial vein which joins with internal jugular vein. According to this recovery of the skin on the anterior trapezius muscle is by descending branches of the facial and occipital artery while transverse cervical and supraclavicular arterial branches form the ascending branches. The facial and maxillary arteries arise anteriorly deep to digastric muscle while occipital artery arise posteriorly. Recovery of the scar in these folds are rapid and successful. Fleming and Petrie (1968), Miller and Bergstorm (1974) reported cases of internal carotid thrombus. It is important to manage this properly otherwise it might result in neurological deficit or death. Any of the neck dissections described above can be extended to remove either lymphnode groups or vascular neural or muscular structures not routinely removed in a neck dissection. It is associated with less post operative morbidity. At the angle of the mandible this line of section becomes continuous with the section line of the parotid. Included here are radical neck dissection and those modifications of radical neck dissections that were developed with the intention of reducing morbidity by preserving structures such as : internal jugular vein, spinal accessory nerve and sternocledomastoid muscle. In cases where curved horizontal incisions are used the incision continues as a smooth curve between the two extremities and the vertical incision starts from the lowest point of the curve. It is a paired “Y” incision. Above and parallel to its duct lies and lingual nerve. It should prevent the damage that can occur after the operation to the anatomical structures especially the carotid artery. With any second neck dissection preservation of the vein is worth attempting and for shorter time lag from first neck dissection. Figure 2: Common types of neck dissection Comprehensive or therapeutic neck dissection involves surgical clearance of Levels 1-V and may either be a radical (RND) or modified (MND) neck dissec- tion. Create a free website or blog at WordPress.com. While in bilateral neck dissection Freund 1967 described an apron flap extending from one mastoid to other. The supraomohyoid neck dissection consist of the removal of nodal regions I. II and III. Compensatory veins appear to open up which are efficient enough to prevent the more undesirable changes and the process of compensation seems to occur with surprising speed. The incision used in the dissection of the neck are generally classified into – vertical and horizontal. Selection of incision for neck dissection is important to avoid complications such as. This series included large number of cases of uncontrolled primaries. The anterior triangle contains the cervical part of the aerodigestive tract – larynx and trachea, hypopharynx and oesophagus, thyroid and parathyroid gland; large neurovascular structure of carotid sheath; supra and infra hyoid muscles; associated lymphatic and neurovascular structures. The posterior triangle is bordered by the anterior border of the trapezius muscle, by the posterior margin of sternocleidomastoid muscle and by the middle third of the clavicle. ( Log Out / Skin flaps are raised upward to the level of the thyroid notch and downward to the sternal notch. Selective Neck Dissection ( SND ) (together with the use of parentheses to denote the levels or sublevels removed) – cervical lymphadenectomy with preservation of one or more lymph node groups that are routinely … Supraomohyoid neck dissection and the expanded supraomohyoid neck dissection consist of enbloc removal of nodal regions I, II and III. Here two horizontal incisions are used one in submandibular region and other in the suprascapular region. It extends from base of skull to the tubercles of the transverse process of all cervical vertebrae and is continuos along the vertebral surface of the vertebral column into the posterior mediastinum. Modified radical neck dissection. If digastric is retained dissection proceeds around it returning behind it to mylohyoid. The transverse cervical artery and suprascapular artery provide vasculature to the lower half of neck. It involves selective en bloc removal of only lymph node groups of neck depending on the location of the primary tumour which are most likely to contain metastasis. Once the sternocleidomastoid is divided dissection is proceeded medially over the scalenus anterior. Nodal tissues are found on the anterior, lateral and posterior aspects of the connective tissue sheath along the internal jugular vein. Most serious complications are vascular in nature. Type III: The spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle are preserved. Most dramatic injury is to the common carotid artery and its branches which occurs rarely during an orderly neck dissection. The routine removal of the spinal accessory was advocated by Blair and Brown (1933), who believed that the nerve has to be removed to decrease the operating time and increase the certainty of total neck node removal. It is traced to the superior root of ansa cervicalis that is divided. Hermanek, R. V. P. Hutter, L. H. Sobin & Ch Wittekind. Dissection is continued to reach the anterior branch of cervical plexus as they emerge at segmental intervals just posterolateral to carotid sheath. All the tissue on the side of the neck from the jawbone to the collarbone is removed. the internal jugular vein and deep jugular group is dissected forward. The suprahyoid muscles lying between the hyoid bone and the body of the mandible constitute a muscular framework of the mouth (Oral diaphragm). The upper border of the triangle is defined by deepening the dissection along the lower border of the mandible to the bone in front of the masseter. Region I – contains the lymphnodes of the submental and submandibular region. It is rarely indicated in the treatment of squamous cell carcinoma of the aerodigestive tract. Apron flap incision. Supraomohyoid neck dissection is indicated in the surgical management of patients with T2 to T4 N0 or Tx N1 oral cavity tumours and when palpable nodes less than 3 cm, clearly mobile and located in either level I or II. He found no recurrence of neuromas after treatment by resection high ligation and local instillation of triamcinole. Martin (1951) championed the concept that a cervical lymphadenectomy for cancer was not adequate unless all the lymph node bearing tissues of one side of the neck were removed and that this was not possible unless the spinal accessory nerve, the internal jugular vein and the sternocleidomastoid muscle were included in the resection. Exposure of the carotid artery following neck dissection. Increased intracranial pressure may occur, that can lead on to cerebral edema, impaired neurologic function, and blindness stroke. Clearance of lower part of posterior triangle proceeds medially past the brachial plexus seen emerging between the two scalenes but safe behind the fascia until the dissections clearly impeded by sternocleidomastoid and this is then divided close to its sternal and clavicular insertions taking care to avoid damage to the internal jugular vein. Other risks for neck dissection surgery are: 1 Numbness in the skin and ear on the side of the surgery, which may be permanent 2 Damage to the nerves of the cheek, lip, and tongue 3 Problems lifting the shoulder and arm 4 Limited neck movement 5 Drooping shoulder on the side of the surgery 6 Problems talking or swallowing 7 Facial droop Constant suction should be maintained during the early post operative and bulky external compression drainage applied. Fascia and fascial planes are important in neck dissection as these help in recognising proper tissue planes. In 30-50% of patients with cancer of the thyroid gland, the cancer spreads to the surrounding lymph nodes in the neck. They empty into the deep jugular chain of lymphatics. To prevent haematomas meticulous hemostasis should be attained and prior to closure at least two medium drainage catheter should be placed in the supraclavicular fossa and posterior triangle. Cervical metastasis whose primary has recovered on treatment. 2014 Feb;40(1):27-31. doi: 10.5125/jkaoms.2014.40.1.27. Tri-radiate incision and its modification. The posterolateral neck dissection is indicated in the treatment of melanomas, squamous cell carcinomas or other skin tumours with metastatic potential such as the merkel cell carcinomas that originate in the posterior and posterolateral aspects of the neck and occipital scalp. See our Privacy Policy and User Agreement for details. He showed a 77 % tumour control but 1-yr. survival rate was 15%. Neck dissection is either a component of a primary resection or a procedure unto itself. Significant scar contracture of the cervical flap incisions may occur if wound dehiscence has occurred or if the vertical limb of a cervical incision is placed more than 4cm anterior to the border of the trapezius muscle. Injury to brachial plexus is uncommon and may be avoided by undermining the posterior triangle of the neck and visualizing the entire brachial plexus prior to transection or to clamping of the posterior triangle fat. Plane of dissection is along the prevertebral muscle behind carotid sheath. Occasionally larger lymphatics are recognised as distinct channels in the lower part of the neck but more often they are noticed when they are divided and clear fluid is seen to well up into the wound. In order to make incision for tracheostomy the transverse part of the incision is displaced superiorly and there by run across the anterior lower neck. ( Stella & Brown 1970, Daniel & McFee 1987 ). Grandon and Brintnall 1960 popularised this type of incision. Tissue between the anterior bellies of digastric is dissected off the midline raphe of mylohyoid. Each operation is tailored to the illness and the suspected degree of metastasis. This nerve has to be protected during neck dissection. PMID: 22943672 [PubMed - indexed for MEDLINE] Publication Types: Letter; MeSH Terms. This increases the risk of flap necrosis in the tips of the flap. When there is clearly identifiable plane of dissection between the tumour and the nerve. The incisions used for neck dissection are. The superior thyroid artery arises below the greater cornu, the lingual artery arises below the level of digastric and the ascending pharyngeal arises posteriorly. Neck dissection is done superficial to this plane to avoid damage to the cervical, brachial plexus and phrenic nerve. The thoracic duct is at risk when dissection is carried low down on the left side of the neck. Below and parallel to the duct runs the hypoglossal nerve with hypoglossal venous plexus. Region IV includes nodes in lower jugular as well as scalene and supraclavicular lymphnodes that are located deep to lower third of sternocleidomastoid muscle. Within one finger-breadth cranial and parallel to the vein, the great auricular nerve crosses the posterior surface of sternocleidomastoid muscle from Erb’s point ( the midpoint along the posterior margin of the sterrnocleidomastoid muscle). The fascia and fascial planes of the head and neck were described in detail in the 1930s by Coller & Yglesius (1937) and by Grodinsky & Holyoke (1938). Your surgeon will discuss with you the details of the operation you are having. However, it is often performed as just one part of a bigger cancer operation. The cervical lymphatic system is divided into superficial and deep chains. The dissection is carried along the carotid sheath. for neck dissection must have defined anatomical . The veins stays superficial to the gland, running downwards and backwards deep to platysma and the mandibular division of facial nerve. In the most general of surgeries, incisions (cuts or slices) are made near the crease of the ear or posttragally (behind the tragus), as in a facelift, and continued behind the ear. Epub 2014 Feb 25. Abduction of shoulder becomes limited. It has good cosmetic result as the incision gets covered in the hair line and clothing. In cases of primary in larynx and hypopharynx where the submandibular triangle is at low risk of containing metastases. ‘J’ incision. Bilateral loss of function may occur in laryngectomy with resection of base of tongue cancer and would result in severe crippling of the swallowing function. Several types of incision can be used for LND of patients with PTC, including a hockey stick incision, an apron incision, a single transverse incision, a modified MacFee incision, or a modified Schobinger incision [6, 7]. Paratracheal and pretracheal nodes are removed in carcinoma of transglottis and subglottis, cervical oesophagus, trachea and thyroid carcinoma. Other classifications of neck dissections are Medina Classification and Spiros Classification. Four flaps are thus created, the base of each extending to the limit of the neck dissection on each side.
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