neck dissections

1. NECK DISSECTIONS
BY
Dr Priyanka Malekar
Dept of surgical oncology
24/6/2017

2. Outline
1. ANATOMY OF NECK
2. LYMPH NODE LEVELS
3. STAGING OF CANCER
4. TYPES OF NECK INCISIONS
5. TYPES OF NECK DISSECTIONS
6. COMPLICATIONS

3. ANATOMY OF NECK
 The LOWER BORDER
OF THE MANDIBLE&
 The SUPRASTERNAL
NOTCH and the
UPPER BORDER OF
CLAVICLE.

4. FASCIAL LAYERS OF NECK
Superficial cervical fascia
- Platysma
• Deep cervical fascia
– Superficial layer
• SCM, strap muscles, trapezius
– Middle or Visceral Layer
• Thyroid
• Trachea
• esophagus
– Deep layer (also prevertebral fascia)
• Vertebral muscles
• Phrenic nerve

6. Superficial Fascia- Platysma
• Origin – subcutaneous tissues of infra and
supraclavicular regions
• Insertion – 1) depression muscles of the
corner of the mouth, 2) base of the mandible
• Nerve: Cervical branches of fascial nerve
• Artery: Submental and suprascapular arteries

7. Function –
1) wrinkles the the neck
2) depresses the corner of the mouth
3) increases the diameter of the neck
4) assists in venous return
Surgical considerations
– Increases blood supply to skin flaps
– Absent in the midline of the neck
– Fibers run in an opposite direction to the SCM

8. PLATYSMA

9. PLATYSMA
STERNOCLEIDOMASTO

10. DEEP CERVICAL FASCIA
• SCM:
Origin –
1) medial third of the clavicle (clavicular head)
2) manubrium (sternal head)
Insertion – mastoid process
Nerve supply – spinal accessory nerve (CN XI)
Blood supply –
1) occipital a. or direct from ECA
2) superior thyroid a.
3) transverse cervical a.

11. SCM
LATERAL RETRACTION OF SCM
EXPOSES SUBMUSCULAR RECESS

12. • OMOHYOID :
• Origin – upper border of the scapula
• Insertion –
1) via the intermediate tendon onto the clavicle and first rib
2) hyoid bone lateral to the sternohyoid muscle
• Blood supply – Inferior thyroid a.
• Function –
1) depress the hyoid
2) tense the deep cervical fascia

13. SUPERIOR BELLY OF OMOHYOID
INFERIOR BELLY OF OMOHYOID

14. • Surgical considerations
– Absent in 10% of individuals
– Landmark demarcating level III from IV
Inferior belly lies superficial to
• The brachial plexus
• Phrenic nerve
• Transverse cervical vessels
Superior belly lies superficial to
• IJV

15. • TRAPEZIUS
• Origin –
1) medial 1/3 of the sup. Nuchal line
2) external occipital protuberance
3) ligamentum nuchae
4) spinous process of C7 and T1-T12
• Insertion –
1) lateral 1/3 of the clavicle
2) acromion process
3) spine of the scapula
• Function – elevate and rotate the scapula and
stabilize the shoulder

16. TRAPEZIUS
Surgical considerations
– Posterior limit of Level V neck dissection
– Denervation results in shoulder drop and winged scapula

17. • DIGASTRIC MUSCLE
• Origin –
1. anterior belly :digastric fossa of the mandible (at the
symphyseal border) –(N:- mandibular br)
2. Posterior belly: mastoid process of temporal bone ( N :-
fascial N)
• Insertion –
hyoid bone via the intermediate tendon
• Function –
1) Opens the jaw when masseter and temporalis are relaxed

18. ANTERIOR BELLY OF DIGASTRIC M
POSTERIOR BELLY OF
DIGATSTRIC M

19. • Surgical consideration
Posterior belly is superficial to:
• ECA
• Hypoglossal nerve
• ICA
• IJV
Anterior belly
• Landmark for identification of mylohyoid for dissection of the
submandibular triangle

20. DIVISIONS OF NECK
• Anterior triangle
• Suprahyoid region: submental triangle
submandibular triangle
• Infrahyoid region: muscular triangle
carotid triangle
• Posterior triangle

22. Suprahyoid triangle
Submental triangle
• Lies below the chin and is
bounded laterally by
anterior bellies of digastric,
and inferiorly by the body
of hyoid bone
• Covered by skin,
superficial fascia and
investing fascia
• Floor－mylohyoid muscles
• Contents－submental
lymph nodes

23. digastric
(posterior belly)
stylohyoid
Mylohyoid

24. Submandibular triangle
• Bounded by anterior and posterior bellies of digastric and
lower border of the body of the mandible
• Floor－ mylohyoid, hyoglossus and middle constrictor of
pharynx
• Contents－submandibular gland, facial a., v., hypoglossal n.
and v., lingual n., submandibular ganglion and submandibular
lymph nodes

26. • Why we remove submandibular gland in neck
dissection?

27. • Level I of neck includes pre- glandular and post glandular
nodes and pre – post vascular LN
• Submandibular gland has no intraparenchymal LN
• Tumour involvement in the submandibular gland must be
through extension from locally involved LN or primary tumour.
• Cases has been reported for preservation of submandibular
gland in early stage lower lip carcinomas

28. Infrahyoid triangles
Carotid triangle
sternocleidomastoid,
superior belly of omohyoid
and posterior belly of
digastic muscles
• Floor－prevertebral fascia
and lateral wall of pharynx
• Contents－common carotid
a. and its branches, internal
jugular v. and its tributaries,
hypoglossal n. with its
descending branches, the
accessory and vagus nerves,
and part of the chain of
deep cervical lymph nodes

29. Muscular triangle
• Bounded by midline of the
neck, superior belly of the
omohyoid and anterior
border of the
sternocleidomastoid.
• Floor－prevertebral fascia
• Contents－sternohyoid,
sternothyroid, thyrohyoid,
thyroid gland, parathyroid
gland, cervical part of
trachea and esophagus

30. Lateral regions of neck
• Bounded by posterior
border of
sternocleidomastoid,
anterior border of trapezius
and middle third of clavicle
• Divided by inferior belly of
omohyoid into occipital and
supraclavicular triangles

31. contents
Arteries:
1. Subclavian (3rd part)
2. Superficial cervical &
suprascapular
(branches of
thyrocervical trunk, a
branch of 1st part of
subclavian artery
3. Occipital, a branch of
external carotid artery

32. Nerves:
 Branches of cervical
plexus
 Spinal part of accessory
nerve
 Brachial plexus

33. Occipital triangle
• Bounded by posterior border of
sternocleidomastoid, anterior
border of trapezius and superior
border of inferior belly of
omohyoid
• Floor－prevertebral fascia and
scalenus anterior, scalenus
medius, scalenus posterior,
splenius capitis and levator
scapulae
• Contents
– Accessory n.emerges above the
middle of the posterior border of
sternocleidomastoid and crosses
the occipital triangle to trapezius
– Cervical and brachial PLEXUS

34. Supraclavicular triangle
• Bounded by posterior border of
sternocleidomastoid, inferior
belly of omohyoid and middle
third of clavicle
• Floor－prevertebral fascia and
inferior parts of scalenus
• Contents
– Subclavian v. and venous
angle
– Subclavian a.
– Brachial plexus

35. Marginal mandibular nerve
• Most commonly injured
dissection level Ib
• Landmarks:
– 1cm anterior and inferior to
angle of mandible
– Mandibular notch
• Subplatysmal
• Deep to fascia of the
submandibular gland
• Superficial to facial vein
• It lowers lip & corner of mouth
down and laterally

36. Hypoglossal nerve
• Motor nerve to the tongue
• • Cell bodies are in the
Hypoglossal nucleus of the
• Medulla oblongata
• • Exits the skull via the
hypoglossal canal
• • Lies deep to the IJV, ICA, CN
IX, X, and XI
• Iatrogenic injury
Most common site - floor of the
submandibular triangle, just deep
to the duct

37. Spinal accessory nerve
• Penetrates deep surface of
the SCM
• Exits posterior surface of
SCM deep to Erb’s point
• Traverses the posterior
triangle on the levator
scapulae
• Enters the trapezius about 5
cm above the clavicle
Hypoglossal N
Vagus N
Spinal Acc N

38. CN XI – Relationship with the IJV
Crosses the IJV
• Crosses lateral to the transverse process of
the atlas
• Occipital artery crosses the nerve
• Descends obliquely in level II (forms Level IIa and IIb

39. Phrenic nerve
• Sole nerve supply to
diaphragm
• Nerve roots C3-5
• Runs obliquely towards
midline on the anterior
surface of anterior scalane
• Covered by prevertebral
fascia
• Lies posterior and lateral to
carotid sheath
Phrenic ner

40. Lingual nerve

41. Thoracic duct
• Conveys lymph from entire body
back to blood
• Exception: right side of head &
neck, RUE, right lung & right side
of heart, and portion of liver
• Begins at cisterni chyli
• Enters post mediastinum
between azygous vein & thoracic
aorta
• Courses left into neck anterior to
vertebral vessels
• Enters junction of left subclavian
and IJV

42. Lymph nodes of neck
• Developed by Memorial Sloan-Kettering Cancer Center
• Ease and uniformity in describing regional nodal involvement
in cancer of the head and neck

43. Positions of neck nodes
1. Submental
2. Submandibular
3. Parotid / tonsilar
4. Preauricular
5. Postauricular
6. Occipital
7. Anterior cervical superficial
and deep
8. Supraclavicular
9. Posterior cervical

44. Level of LN
• Ia: submental triangle
• Ib: submandibular triangle
• II: Base of skull to bifurcation of
common carotid A
• III: Hyoid bone upto inferior
border of cricoid
• IV: inferior border of cricoid
cartilage to clavicle
• V: posterior traignle: below spinal
A N and transverse cervical
vessels
• VI: central compartment
• VII: mediastinal LN

45. The regional lymph node groups draining a specific
primary site as first echelon lymph nodes

46. Regional drainage

47. Staging of neck
• Nx: regional lymph node cannot be assessed
• No: no regional lymph nodes
• N1: mets in single ipsilateral lymph node, 3 cm or smaller in
greatest dimension and ENE –
• N2:
1. N2a: metastasis in single ipsilateral node larger than 3 cm but
not larger than 6 cm In GD and ECE-
2. N2b: mets in multiple ipsilateral nodes, none larger than 6
cm in GD ENE –
3. N2c: mets in bil or contralateral LN, none larger than 6 cm in
GD

48. • N3:
1. N3a: mets in a lymph node larger than 6 cm in greatest
dimension and ENE –
2. N3b: mets in any nodes with clinically overt ENE +, ENCc
Midline nodes: ipsilateral nodes
ENCc: defined as invasion of skin, infiltration of musculature, dense tethering or
fixation to adjacent structures or cranial nerves, brachial plexus, sympathatic trunk,
phrenic nerve invasion with dysfunction
Designation of U & L category : positive nodes above the cricoid cartilage : U
positive nodes below the cricoid cartilage : L

49. Classifications of neck dissection
• Standardized until 1991
• Academy’s Committee for Head and Neck Surgery
and Oncology publicized standard classification
system

50. • Academy’s classification
Based on 4 concepts
1) RND is the standard basic procedure for cervical
lymphadenectomy against which all other modifications are
compared
2) Modifications of the RND which include preservation of any
non-lymphatic structures are referred to as modified radical
neck dissection (MRND)

51. • Academy’s classification
3) Any neck dissection that preserves one or more groups or
levels of lymph nodes is referred to as a selective neck
dissection (SND)
4) An extended neck dissection refers to the removal of
additional lymph node groups or non-lymphatic structures
relative to the RND

52. • Academy’s classification(1991)
1) Radical neck dissection (RND)
2) Modified radical neck dissection (MRND)
3) Selective neck dissection (SND)
• Supra-omohyoid type
• Lateral type
• Posterolateral type
• Anterior compartment type
4) Extended radical neck dissection

53. • Medina classification (1989)
– Comprehensive neck dissection
• Radical neck dissection
• Modified radical neck dissection
– Type I (XI preserved)
– Type II (XI, IJV preserved)
– Type III (XI, IJV, and SCM preserved)
– Selective neck dissection

54. Spiro’s classification
– Radical (4 or 5 node levels resected)
• Conventional radical neck dissection
• Modified radical neck dissection
• Extended radical neck dissection
• Modified and extended radical neck dissection
– Selective (3 node levels resected)
• SOHND
• Jugular dissection (Levels II-IV)
• Any other 3 node levels resected
– Limited (no more than 2 node levels resected)
• Paratracheal node dissection
• Mediastinal node dissection
• Any other 1 or 2 node levels resected

55. • Indications:
1. Presence of clinically positive N1, N2a, N2b & N3 nodes
2. Extra nodal spread (including skin involvement)
3. Recurrence after RT treatment
4. Selective neck dissection in No neck where higher risk of
micrometastasis

56. • Contraindications:
1. Uncontrolled primary lesion
2. Involvement of internal / common carotid artery
3. Presence of distant metastasis.
4. Poor anaesthetic risk patient.

57. Most commonly used neck incision:
transverse incision

58.  TYPES
- Criles incision
- Apron incision
-Half apron incision
-Conley incision
-Double Y incision
-H incision
-Macfee incision
- Y incision
-Modified Schobinger incision
-Schobinger

59. CRILES

60. APRON FLAP
B/L HOCKEY STICK

61. Basic needs of neck incisions
1.Good exposure of the neck and primary disease.
2. Ensure viability of the skin flaps. Avoid acute angles
3. Protect carotid artery even in the cases of wound infection.
4. Facilitate reconstruction Example, if pectoral muscle is used a
lower limb should be near the clavicle to enable flap
accommodation.
5. It should be cosmetically acceptable.

62. Criles incision
• ADVANTAGES:
• Easy to perform
• Maximum exposure to repair field
• DISADVANTAGES:
• Trifurcation point is prone for delayed healing
• Vertical limb of this incision overlies carotid
artery.compromised healing results in exposure of carotid
vessels
• Unsightly scar later forms contracture band

63. MACFEE

64. • Hyes Martin:
• Disadvantage:
• This flap most often gets
cyanosed.
• Flap necrosis and carotid
exposure is more in this
type of incision.
• Apron flaps:
• Advantages
– Carotid artery is well
protected
– Protects the descending
arterial recovery
• Disadvantages
– It will damage the ascending
arterial and venous recovery
– Venous congestion and
oedema might develop at the
bottom corner

65. Radical neck dissection
• Removes
– Nodal groups I-V
– SCM, IJV, XI
– Submandibular gland, tail of
parotid
• Preserves
– Posterior auricular
– Suboccipital
– Retropharyngeal
– Periparotid
– Perifacial
– Paratracheal nodes

66. Modified radical neck dissection
• Removes
– Nodal groups I-V
• Preserves
– SCM, IJV, XI (any combination)
– TYPE I MRND
• Indications
– Clinically obvious lymph node
metastases
– SAN not involved by tumor
–Intraoperative decision
–
Spinal acc N

67. Spinal ACC N
IJV
TYPE II MRND
Spinal Acc N
SCM
IJV
TYPE II MRND
Rarely planned
– Intraoperative tumor found adherent
to the SCM, but not IJV and SAN
Nodes not within muscular
aponeurosis or glandular capsule
(submandibular gland)
NO neck
( functional neck dissection)

68. Selective neck dissection
• Definition
– Cervical lymphadenectomy with preservation of one or more
lymph node groups
– Four common subtypes:
• Supraomohyoid neck dissection
• Posterolateral neck dissection
• Lateral neck dissection
• Anterior neck dissection

69. • Also known as an elective neck dissection
• Rate of occult metastasis in clinically negative neck 20-30%
• Indication: primary lesion with 20% or greater risk of occult
metastasis

70. supraomohyoid
Most commonly performed SND
• Definition
– En bloc removal of cervical lymph node groups I-III
– Posterior limit is the cervical plexus and posterior border of the SCM
– Inferior limit is the omohyoid muscle overlying the IJV
• Oral cavity cancers with No
• T2-T3 No – if intraoperative suspicion of mets at level II – III then
level IV clearance: extended SOHND

71. B/L SOHND
• Anterior tongue
• Oral tongue and FOM that approach the midline
– SOHND + parotidectomy
• Cutaneous SCCA of the cheek
• Melanoma (Stage I – 1.5 to 4mm) of the cheek

72. SND lateral type
• Definition
– En bloc removal of the jugular lymph nodes including Levels II-
IV.
• Indications
N0 neck in carcinomas of the oropharynx, hypopharynx,
supraglottis, and larynx

73. SND posterolateral
Definition
– En bloc excision of lymph bearing tissues in Levels II-IV and
additional node groups – suboccipital and postauricular.
• Indications
– Cutaneous malignancies
• Melanoma
• Squamous cell carcinoma
• Merkel cell carcinoma
– Soft tissue sarcomas of the scalp and neck

74. SND anterior compartment
Definition
– En bloc removal of lymph structures in Level VI
• Perithyroidal nodes
• Pretracheal nodes
• Precricoid nodes (Delphian)
• Paratracheal nodes along recurrent nerves
– Limits of the dissection are the hyoid bone, suprasternal notch
and carotid sheaths

75. • Indications
– Selected cases of thyroid carcinoma
– Parathyroid carcinoma
– Subglottic carcinoma
– Laryngeal carcinoma with subglottic extension
– CA of the cervical esophagus

76. Extended neck dissection
Definition
– Any previous dissection which includes removal of one or more
additional lymph node groups and/or non-lymphatic structures.
– Usually performed with N+ necks in MRND or RND when
metastases invade structures

77. • Indications
– Carotid artery invasion
– Other examples:
• Resection of the hypoglossal nerve resection or digastric muscle,
• dissection of mediastinal nodes and central compartment for
subglottic involvement, and
• removal of retropharyngeal lymph nodes for tumors originating in
the pharyngeal walls.

78. Complications
• 4 TYPES
- INTRA OP
- IMMEDIATE POST OP
- LATE POST OP
- DELAYED COMPLICATIONS

79. Intraoperative
• Inadvertent injury to local blood vessels and
nerves .
-marginal mandibular N.
- Spinal accessory N.
- Cervical plexus
- Brachial plexus
- Thoracic duct injury .

80. Immediate post op
• Haemorrhage: Needs evaluation of the extent of bleeding
and occasionally may need re-exploration.
• Lymph leak: When the drainage is of milky fluid and is
persistently high >100ml /day after 2days.A possibility of
lymph leak has to be considered.

81. • Carotid blow out: A dreaded complication that occurs
secondary to wound break down. If exposed the carotids have
to be covered using vascularised flaps.
• Facial oedema: A common occurrence usually settles down in
4-6 weeks.

82. Late complications
• Wound infection
• Fistulae
• Devitalisation of the reconstructed flap
DELAYED COMPLICATIONS
• Dysphagia ( CN V,IX, X, XI)
• Shoulder weakness
• Trismus

83. THANK YOU