1.
Surgical Anatomy
&
Approaches To Neck
Dr. Sadaf Syed
MDS ‘OMFS”
Saraswati Dental College
Lucknow 2016.

2.
FASCIAL PLANES
1.

3.
Skin, Superficial Fascia, Platysma

4.
Deep Cervical Fascia Layers
A. Investing Layer
B. Muscular Pretracheal Layer
C. Visceral Pretracheal Layer
D. Prevertebral Laye

5.
The Neck And Its Divisions
• Anterior triangle
• Posterior triangle
2.

6.
Example of a chart

7.
Submental Triangle

8.
Submandibular Triangle

9.
CONTENTS

10.
The base of the submandibular
triangle consists mylohyoid and
hyoglossus muscles framed by the
stylohyoid muscle and the bellies of
the digastric muscle.
The lingual branch of the trigeminal
nerve (V) and the hypoglossal nerve
(XII) pass anterior between the two
deep flat muscles.
The submandibular ganglion lies
below the lingual nerve.
The marginal mandibular branch of the facial nerve (VII) lies a variable distance
below the margin of the mandible and is superficial to the facial vessels.
The facial branch of the external carotid artery passes deep to the stylohyoid
muscle and posterior belly of the digastric, crosses the submandibular triangle
and crosses the inferior margin of the mandible.

11.
Carotid Triangle

12.
 Thyrohyoid
 Hyoglossus
 Middle & inferior
pharyngeal
constrictor
Borders
Floor

13.
Contents

14.
Important Structures of the
Carotid Triangle

15.
Muscular Triangle

16.
Posterior Triangle

17.
Muscles

18.
Contents

19.
- Beclards - Pirogoff - Lessers
Three nearly forgotten anatomical triangles of the neck:
Triangles of Beclard, Lesser and Pirogoff and their
potential applications in surgical dissection of the neck
R. Shane Tubbs , Surgical and Radiologic Anatomy
January 2011, Volume 33, Issue 1, pp 53-57

20.
Cervical Lymph Nodes
3.

21.
Neck dissection classification update: revisions
proposed by the American Head and Neck Society and
the American Academy of Otolaryngology-Head
and Neck Surgery.
Robbins KT et.al Arch Otolaryngol Head Neck Surg 2002
Jul;128(7):751-8
In addition to the five standard levels , nodal levels
were subdivided into
 Ia , Ib
 IIa , IIb ( below & above Accessory Nerve )
 Va , Vb (below & above Accessory Nerve in posterior
triangle

22.
Contd...
Som PM et al. Imaging-based nodal classification for evaluation of neck metastatic
adenopathy. Am J Roentgenol. 2000 Mar;174(3):837-44.

23.
Drainage

24.
Normal layer wise
anatomy of the neck

25.
The plane beneath this
layer is easily separated
from the underlying
deep fascia
 Facilitates anatomic
dissection for thyroid
surgery and neck
dissection.

26.
The deep cervical
fascia splits to
encompass the SCM and
trapezius muscles,
forming a girdle around
the neck.
The cervical plexus
nerves and superficial
veins penetrate the deep
fascia.

27.
.
•The SCM and trapezius
comprise the outermost layer of
the deep cervical muscles.
•The SCM lie superficial to the
carotid sheath and are crossed
diagonally by the external
jugular vein.
•Central venous access via the
internal jugular vein can be
obtained at the posterior border
of the mid-portion of the
muscle

28.
 The narrow center of the
omohyoid muscle crosses the
jugular bulb at the base of the
neck.
 The strap muscles cover
the larynx and cervical
trachea and depress the
laryngeal apparatus.
 The neck has the largest
concentration of lymph nodes
( internal jugular )

29.
 IJV cross the carotids
superficially and diagonally in
their course from the jugular
foramen at the base of the
skull.
 Their large common facial
branch lies over carotid
bifurcation and must be
divided to gain access to the
latter structure.
 IJV converge with the
subclavians behind the heads
of the clavicles.

30.
 The cervical plexus and brachial
plexus nerves emerge between the
anterior and middle scalene
muscles.
 The subclavian artery usually
emerges through the same gap
caudal to the brachial plexus.
 The phrenic nerve descends
diagonally across the anterior
scalene to enter the chest at the
medial border of the first rib.
 The spinal accessory nerve
descends to the trapezius across
the posterior triangle of the
neck.

31.
The carotid sheaths
containing carotid artery,
internal jugular vein and
vagus nerve lie in the angle
formed by the deep lateral
muscles scalene and the
visceral compartment.
The common carotid
bifurcates at about the
level of the tip of the hyoid
cornu.

32.
Surgical Approaches

33.
 In 1906, George W. Crile of the Cleveland Clinic described
the radical neck dissection.The operation encompasses
removal of all the lymph nodes on one side along with the spinal
accessory nerve, internal jugular vein and sternocleidomastoid
muscle.
 In 1967 - Oscar Suarez and E. Bocca described a more
conservative operation which preserves spinal accessory nerve,
internal jugular v. and sternocleidomastoid muscle which further
improved the quality of life of patients post operatively.
History

34.
Radical Neck Dissection is
the standard basic procedure
for cervical lymphadenetomy
and all other procedures
represent one or more
modifications of this
procedure.
Modification of the radical
neck dissection preserves
of one or more non-
lymphatic structures, its
termed as Modified
Radical Neck Dissection
Preserves one or more
lymph node groups that are
routinely removed in the
radical neck dissection;
the procedure is termed a
Selective Neck Dissection
Involves removal of
additional lymph nodes or
non-lymphatic structures
relative to RND is termed
an Extended Radical Neck
Dissection.
GENERAL DESCRIPTION

35.
If one or more of three
structures, the SCM the
internal jugular vein, or
the spinal accessory
nerve, are spared, the
procedure is termed as
Modified Neck Dissection.
If all three are spared, the
procedure is called as
Functional Neck
Dissection.

36.
Committee For Head & Neck Surgery And Oncology Of
American Academy Of Otolaryngology

37.
Medina classification (1989)

38.
–
.
Classification of neck dissection: variations on a new theme.
Spiro R : Am J Sur.1994 Nov;168(5):415-8.

39.
INCISIONS

40.
Modified Schobinger Lateral Utility incision Lahey’s

41.
Hockey-stick incision for neck dissection combined with
parotidectomy

42.
Apron flap with lateral extensionsWide apron flap

43.
Conleys incision

44.
Double Y H Incision

45.
MacFee Incision Y incision

46.
Radical Neck Dissection

47.
All tissue between the
lower border of the
mandible and the clavicle.
Between the anterior
edge of the trapezius and
the anterior midline.
 From the underside of
the platysma to the deep
muscular fascia.
The carotids, brachial
plexus, phrenic and vagus
nerves are normally
preserved except when
directly invaded

48.
The investing layer of
cervical fascia (incorporating
sternocleidomastoid and
trapezius muscles) is
exposed along with jugular
vein branches and cervical
plexus nerves.
The marginal mandibular
branch of the facial nerve
may or may not be visualized
along the edge of the
mandible beneath the upper
flap.

49.
To preserve the marginal
mandibular branch and
prevent the corner of the
mouth from drooping,
the external facial artery
and anterior facial vein
are divided about a
centimeter below the
mandible and the
upper cut ends tacked to
the platysma of the upper
flap forming a sling and
lifting the nerve out of
harm's way.

50.
The insertions of the SCM and
the posterior belly of the
omohyoid muscle are divided
along the upper margin of the
clavicle and the investing fascia is
opened posteriorly to the
trapezius and anteriorly to the
midline.
Supra clavicular nerves,
underlying transverse cervical
vessels and external jugular vein
are divided and the underlying
lymphatic-containing areolar
tissue is swept upward.
The bulb of the internal jugular
vein and the brachial plexus
come into view.

51.
The internal jugular vein is
divided above the clavicle and the
vein reflected upward with the
overlying muscles and lymph
nodes.
It also involves opening the
areolar carotid sheath.
The underlying vagus and phrenic
nerves are identified and
preserved.
Posteriorly, the investing fascia is
opened along the border of the
trapezius and the accessory
nerve lying on the levator
scapulae muscle is divided and
reflected upward.

52.
The upper end of the SCM
muscle is divided near the
mastoid process.
The upper end of the
accessory nerve and the
internal jugular vein are
divided as high as possible
and lymph nodes are
removed
The hypoglossal nerve ,
beneath the posterior belly
of the digastric muscle and
preserved.

53.
The submandibular gland is mobilized, preserving
the lingual nerve and removed

54.
The boundaries of the
RND with removal of
node-bearing tissue,
along with the SCM
muscle, the internal
jugular vein, and the
spinal accessory nerve.
The platysma layer and
skin are re-approximated,
sutured and suction
drains placed.

55.
Modified Neck Dissection

56.
In the majority of cases
requiring wide lymph
node dissection, the
modified radical neck
dissection is chosen.
The area covered by a
Modified Neck
Dissection is shown.

57.
A modified neck
dissection is begun by
elevating the skin flaps
beneath the platysma
anteriorly and
posteriorly, exposing
the deep cervical
fascia, external jugular
vein and cervical
plexus cutaneous
branches.

58.
The deep cervical fascia
is incised along the
dashed lines, dividing
greater auricular nerve
and external jugular
vein.

59.
The fascia of the
submandibular triangle
is dissected downward,
taking care to stay below
the marginal mandibular
nerve. The SCM is
dissected off the deep
layer of investing fascia
and retracted
posteriorly.

60.
The submandibular
gland may be resected
in continuity with the
specimen in order to
include periglandular
nodes

61.
The fascia and nodes of
level II are dissected from
the mastiod downward,
exposing the internal
jugular vein at the skull
base, and the spinal
accessory nerve entering
the upper part of SCM

62.
Since all 3 structures
are preserved, this is
a functional neck
dissection
The SCM is retracted
posteriorly, and the
nodal tissue of the
posterior triangle (level
V) is dissected from
posterior to anterior,
dividing the omohyoid
and cervical plexus
cutaneous branches.

63.
The lateral neck
dissection outlined
here includes levels II
through IV.

64.
A supraomohyoid
dissection includes levels I
through III.

65.
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66.
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68.
THE NECK AND ITS DIVISIONS
The neck is clinically divided into :

69.
Submandibular Triangle
(The Digastric or Submaxillary triang
Borders
 Anterior and posterior bellies of the digastric mus
anteriorly and infero-posteriorly, respectively.
 The superior aspect is bordered by the lower bord
mandible.
Contents

70.
Levels

71.
 Radical neck dissection is the standard basic procedure for
cervical lymphadenectomy, and all otherprocedures represent
one or more modifications of this procedure.
 When the modification of the radical neck dissection involves
preservation of one or more non-lymphatic structures, the
procedure is termed a modified radical neck dissection
 When the modification involves preservation of one or more
lymph node groups that are routinely removed in the radical
neck dissection; the procedure is termed a selective neck
dissection .
 When the modification involves removal of additional lymph
node groups or non-lymphatic structures relative to the radical
neck dissection, the procedure is termed an extended radical
neck dissection.