7. neck dissection(87) Dr. RAHUL TIWARI

PRESENTED BY
Dr RAHUL TIWARI
2nd
Yr. MDS
Dept. of Oral and Maxillofacial Surgery
NECK DISSECTION
09/19/16 09:25 AM RT/7/NECK DISSECTION/87 1

Contents• Introduction
• What is neck dissection ?
• Cervical lymphatic – its drainage
• The rationale of neck dissection
• Studies on patterns of cervical lymphatic drainage
• Levels of lymph nodes, sublevels - their implications
• Clinical assessment and staging
• History of neck dissection
• Classification
• Surgical anatomy
• Types of incisions and procedures
• Complications
• Future

Introduction
• Surgery is the oldest and the most reliable
form of treatment for oral malignancy.
• what is the need for the neck to be treated
in oral malignancy ????

What is neck dissection?
• The term "neck dissection" refers to the
removal of lymphnodes and lymphnode
bearing tissues of neck from the inferior
border of the mandible to the clavicle ,as a
treatment of head and neck malignancy

How does tumor spread ?
• Spread of disease of oral cavity to neck --
palpable lymphadenopathy.
• Systemic homogenous spread rarely occurs in
the lymphatics of the neck.
• early eradication of local and regional disease can
prevent future systemic metastasis.

Division of neck levels by sublevels
•

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

Cervical lymphatics

Risk for nodal metastasis
• Various factors
– Site
– Size
– T stage
– Location of primary tumour
– Histomorphologic characteristics of primary tumor

Risk of nodal metastases increases in relation to
location of the primary tumor

Work-up and staging
TNM ( TUMOR –NODE – METASTASIS)
SYSTEM

TNM STAGING
• First reported by Pierre Denoix in the 1940s.
• The International Union against cancer (UICC) and
AJCC eventually adapted the system
• It is important to realize that the TNM staging system
is simply an anatomic staging system
• TNM Staging describes tumor burden in only two
dimensions

A study of correlation of tumor thickness with
risk of occult nodal metastasis –Spiro et al*
*Spiro RH,Huvos AG, Wong GY ,Spiro JD, Strong EW .Predictive
value of tumor thickness in SCC confined to the tongue and floor of the
mouth Am J Surg 1986; 152: 345-350

T staging for tumors of the lip and oral
cavity – AJCC 2002
• TX – Primary tumor cannot be assessed
• T0 – No evidence of primary tumor
• Tis – carcinoma in situ
• T1 – Tumor 2 cm or less in greatest dimension
• T2 – Tumor >2cm but not >4cm in greatest dimension
• T3 – Tumor >4cm in greatest dimension
• T4a
– Lip – Tumor invades through cortical bone, inferior alveolar nerve, floor
of the mouth, or skin of face (i.e, chin or nose).
– Oral – Tumor invades through cortical bone, into deep (extrinsic)
– Cavity – Muscle of tongue (genioglossus, hyoglossu, palatoglossus, and
styloglossus), maxillary sinus, or skin of face.
• T4b – Tumor involves masticator space, pterygoid plates, or
skull base and/or encases internal carotid artery.09/19/16 09:25 AM RT/7/NECK DISSECTION/87 14

AJCC/UICC (2002) Staging system for cervical lymph
nodes
NX – cannot be assessed, N3a – greater than 6cm , N3b-extn into
supraclavicular fossa

Stage grouping for all head and neck sites except the
nasopharynx and thyroid AJCC (2002)
AJCC cancer staging manual, 6th
Edition, 2002.09/19/16 09:25 AM RT/7/NECK DISSECTION/87 16

Patterns of cervical lymphatic metastasis
• lymphatic flow in the neck - consistent pattern -
upper neck and then to the lower neck.
• This orderly lymphatic flow has been demonstrated by
the work of Fisch and Sigel*
*Cervical lymphatic system as visualized by lymphography  Annals of
Otology, Rhinology and Laryngology 73: 869-872.

History of neck dissections

Dr George Crile (1864-1943)
In 1906 paper
“Exicision of cancer of the
head and neck ”
Gold standard procedure :
“Radical Neck dissection”

Dr. Hayes Martin (1892-1977)
In 1951 paper
“Neck Dissection”
“Routine prophylactic RND was
impracticle”

Historical perspective on neck
dissection
• RND should not be used for N0 neck, a
philosophy that is largely observed in 2006.
• Nahum et al described a syndrome of pain
following RND – “Shoulder Syndrome”*.
*Nahum AM, Mullally W, Marmor L : A Syndrome resulting from
radical neck dissection. Arch otolaryngol 74 : 82,1961

Historical perspective on neck dissection
• 1880 – Kocher –proposed removal of nodal metastasis
• 1906 – George crile –RND
• 1933 & 1941 – Blair and Martin popularised RND
• 1953 – Pietrantoni - recommended sparing SND
• 1967-- Bocca and Pignataro described FND
• 1975- Bocca established oncologic safety compared to
RND
• 1980- Ballantyne –concept of selective neck dissection

Classifications of neck
dissections

Concepts behind classification of neck dissection
• Based on 4 concepts
– RND is the standard basic procedure - against
which all other modifications are compared
- preservation of any non - lymphatic structures are
referred as MRND
- that preserves one or more groups or levels of LN`s
is referred to as a SND
- removal of additional LN groups or non lymphatic
structures relative to the RND – Extended neck
dissection

1. Radical neck dissection (RND)
2. Modified radical neck dissection (MRND)
3. Selective neck dissection (SND)
• Supraomohyoid type
• Lateral type
• Posterolateral type
• Anterior compartment type
4. Extended radical neck dissection
Academy's classification

MEDINA CLASSIFICATION(1989)
• Comprehensive neck dissection
1. Radical neck dissection (RND)
2. Modified radical neck dissection (MRND)
• MRND I – Preserves spinal accessory nerve.
• MRND II – Spinal accessory and sternocleidomastoid
muscle but sacrifices internal jugular vein.
• MRND III – Requires preservation of SAN,
sternocleidomastoid muscle and internal jugular vein
• Selective neck dissection (SND)
• Supraomohyoid neck dissection – I, II, III
• Jugular neck dissection – II, III, IV
• Anterior triangle neck dissection – I, II, III, IV
• Central compartment neck dissection – VI
• Posterolateral neck dissection – II, III, IV

Spiro’s classification
– Radical (4 or 5 nodes levels resected)
• Conventional RND
• MRND
• Extended RND
– Selective (3 node levels resected)
• SOHND
• Jugular dissection (level II-IV)
• Any other 3 levels
– Limited (no more than 2 node levels resected)
• Para tracheal node dissection
• Mediastinal node dissection
• Any other 1 or 2 node levels resected

AAO-HNS CLASSIFICATION*
1991 Classification 2001 Classification
* Neck dissection classification update-Revisions proposed by the American
Head and Neck Society and the American Academy of Otolaryngology-Head and
Neck Surgery.

Rationale of RND
• Understanding the anatomy of lymphatics of head and neck and
why we remove them
• Understanging the concepts of lymphnode metastasis
• Understanding the concepts of neck incisions
• Why we remove IJV ?
• Why we Remove the submandibular gland ?
• Why we remove the sternocleidomastoid muscle?
• Why we remove the spinal accessory nerve and when do we save
it ?
• The concept behind the ligation of carotid artery and internal
jugular vein

Surgical Anatomy

Radical neck dissection predominantly from behind forward
makes use of the anatomical fact that the IJV does not have
posterior branches

The main arteries of the neck and face

Incisions

Anatomy of the vascularization of neck
skin
• Kambic and Sirca 1967 stated that arterial
supply is in a vertical direction.
• descending branches: facial and occipital
artery
• ascending branches: transverse cervical and
supraclavicular arterial branches .

Studies on the anatomy of the
vascularization of neck skin
• Robertson et al 1985
“Arterial supply of the skin of the neck is
multifaceted ”
• four arterial branches pass from the platysma
muscle through to the top of the skin’s surface.
• platysma cutaneous arteries supplying skin are
in anastomosis with each other.

Studies on the anatomy of the
vascularization of neck skin
• Ariyan 1986 - anastomosis remain intact during
neck dissection while the platysma is dissected
from the skin.
• Hetter 1972, Freeland and Rogers 1975
alternative development of arterial supply even if
facial, occipital and transverse cervical are ligated.

The vasculature can be summarized into
• upper neck region - anterior to the angle of
mandible - branches of facial and submental
arteries.
• upper lateral neck - the area between ramus of
mandible and the sternocleidomastoid muscle-
Occipital and external auricular branches of
external carotid .
• Lower half of neck - The transverse cervical artery and
suprascapular artery
• Large platysma-cutaneous branches and branches
of superior thyroid supplying the front middle
portion of the neck.09/19/16 09:25 AM RT/7/NECK DISSECTION/87 42

Incisions
• Incisions classified into
– Vertical
– Horizontal
• The incisions used for neck dissections are
– Tri-radiate incision and its modification
– Hayes martin double ‘Y’ incision
– McFee incision

Incisions for neck dissections

Basic needs of an incision are
• Good exposure of the neck and primary disease
• Ensure viability of the skin flaps. Avoid acute
angles
• Protect carotid artery even in the cases of
wound infection
• Facilitate reconstruction
• Adapt to the condition of patient esp after
radiotherapy
• It should be cosmetically acceptable

Differences between incisions
Transverse incision Vertical incision
Have cosmetic advantage as
they follow natural skin
folds of the skin
Disadvantages because they
intersect to the natural skin
folds of the skin and the
vascular supply of the neck
Recovery of scar tissue in
these folds are rapid and
successful
They tend to contract along
their long axis – leads to
deformity and restricted
action.
Easy to modify

Tri-radiate incision and its
modifications
• Advantages
– Incision provides good
exposure to surgical site.
• Disadvantages
– Flap necrosis is high due to
disruption of vasculature of
skin flaps
– Occurrence of flap
separation at the trifurcation
site.

Modification of Tri-radiate incision
• Schobinger (1957)
• Cramer & Culf (1969)
• Conley (1970)

Schobinger (1957)
‘vertical limb instead of
being straight should be
curved posteriorly ’

Conley (1970)
• Suggested a
posteriorly curving
vertical incision rather
than a horizontal
incision

Hayes Martin Incision
• It is a paired ‘Y’ incision.
• Here the submandibular
component is met by a
vertical limb which below
becomes continuous with
an inverted ‘Y’ in the
suprascapular region.
• This flap most often gets
cyanosed.
• Flap necrosis and carotid
exposure is more in this
type of incision.

McFee Incision
• It avoids a vertical limb.
• Two horizontal incisions
are used one in
submandibular region
and other in the
suprascapular region.

Advantages Disadvantages
Excellent cosmetic result (McFee 1960,
McNeil 1978)
Exposure is not good (Hetter 1972)
There is no lessening of vascularity in
the centre of the flap (Ariyan 1986)
It is not suitable for bilateral
simultaneous neck dissection (Chandler
and Ponzoli 1969)
There is no angle intersection in
incision (McFee 1960)
Operating period is long (McFee 1960)
Post operative wound recovery is rapid
(McFee)
Posterior triangle dissection is difficult
(Maran et al 1989, White et al 1993)
Suitable in necks receiving radiotherapy
and in peripheral vascular disease
(Maran et al 1989)
Difficulty may arise while working
under the bridge flap
Recovery of flap excellent due to wide
bipedicled flaps (Stella & Brown 1970,
Daniel & McFee 1987)
In short neck it might be difficult to
distinguish between the front tip of the
incision from that of the tracheostomy.

Apron flaps
• Described by Latyschevsky and
Freund 1960.
• Only a horizontal incision from
mastoid to mentum gently curving
inferiorly upto upper border of the
thyroid cartilage is used.
• 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

Hockey stick incision
• Lahey et al (1940) described.
• Modified for RND by Eckert
& Byars 1952.
• It has a longitudinal and
transverse incision
• B/L hockey stick incision
allows the deglovement of
the whole neck.

Radical neck dissection

Radical neck dissection
• Current indications for classical radical neck dissection.
– N3 disease
– Multiple gross metastases involving multiple levels.
– Recurrent metastatic disease in a previously
irradiated neck.
– Grossly apparent extranodal spread with invasion of
the spinal accessory nerve and /or internal jugular
vein at the base of the skull
– Involvement of accessory chain lymph nodes by
metastatic disease.

Operative steps in the functional neck
dissection

Incision

Dissection of the posterior triangle begins at the
anterior border of trapezius

Dissection of the posterior triangle medially leads to exposure
of brachial plexus, phrenic nerve and cutaneous roots of the
cervical plexus

Specimen reflected posteriorly and anterior flap elevated to
expose the sternal head of SCMM

Sternocleidomastoid muscle is detached from the sternum and
clavicle and retracted cephalad to expose the carotid sheath

Internal jugular vein is ligated and divided after common
carotid and vagus nerve is exposed and retracted medially

Dissection proceeds cephalad along the carotid sheath up the
skull base

The upper skin flap is now elevated preseving the mandibular
branch of the facial nerve

Surgical field following RND

Two suction drains inserted

Contra indications for RND
• Uncontrollable cancer of the primary site
• Evidence of distant metastasis
• Fixed nodes unchanged by radiotherapy or
chemotherapy
• Life expectancy of less than 3 months

Supraomohyoid neck dissection

Indications for supraomohyoid neck
dissection
• Cancers of oral cavity that are N0 clinically
• Discreet N1 lesions can also be treated

Jugular neck dissection

Posterolateral neck dissection

Extended radical neck dissection

Complications of RND
• Intra operative problems
• Post operative problems
• Late complications

Intra-operative problems
• Injury to prenic nerve
• Injury to vagus nerve
• Brachial plexus injury
• Common carotid injury
• Internal carotid injury
• Hypoglossal nerve injury
• Lingual nerve injury

Post operative problems
• Haemorrhage
• Lymph leak
• Dysphagia
• Carotid blow out
• Facial edema

Complications of ligating bilateral internal
jugular vein simultaneously

Late complications
• Shoulder droop
• Shoulder pain
• Brachial neuralgia
• Neuroma
• Strictures

Five-year survival rates in patients undergoing
classical radical neck dissection and modified radical
neck dissection preserving the spinal accessory nerve

Indications for postoperative radiation
therapy to the neck
1. Gross residual disease following neck dissection
2. Multiple positive lymph nodes in the neck
3. Extracapsular extension by metastatic diseae
4. Perivascular or perineural invasion by tumor
5. Other ominous findings such as tumor emboli in
lymphatics, cranial nerve invasion, or extension of
disease to the base of the skull.

Future of neck dissections
• Sentinel lymph node biopsy
• Endoscopic neck dissections

Sentinal lymph node biopsy

conclusion
Knowing the surgical anatomy is
very important
before starting any surgical procedure.

References
• Charles W. Cummings, John M. Fredrickson, Lee A. Harker,
Charles J. Krause, David E. Schurller. Neck Dissection.
Otolaryngology- Head and neck surgery. Vol. II, 2nd edition.
1993: 1649-1672.
• Ian A. McGregor, Frances M. McGregor. Neck dissection.
Cancer of the face and mouth – Pathology and management
for surgeons. Churchill Livingstone.1986: 282- 320.
• Ian T. Jackson. Inrtra oral tumour and cervical lymphadenectomy.
Grabb & Smith’s Plastic Surgery. Sherrel J. Aston, Robert W.
Beasley, Charles H. M. Thorne. 5th edition. Lippincott-
Raven . 1997 : 439 –452.
• L. H. Sobin & Ch Wittekind. TNM Classification of malignant
tumours. 5th edition. UICC, A John Wiley & Sons Inc.
Publication. 1997.. Surg. 1999: 28 : 197 – 202.09/19/16 09:25 AM RT/7/NECK DISSECTION/87 85

• P. Hermanek, R. V. P. Hutter, L. H. Sobin & Ch
Wittekind. TNM atlas. Illustrated guide to the TNM /
pTNM classification of malignant tumours. 4th edition.
Springer. 1997.
• Aydin Acar, Gürsel Dursun, Ömer Aydin,Yücel Akbaş.
J incision in neck dissections. The journal of Laryngology
and otology. 1998: 112: 55 - 60.
• Susumu Omura, Hiroki Bukawa, Ryoichi Kawabe,
Shinjiro Aoki, Kiyohide Fujita. Comparision between hockey
stick and reverse hockey stick incision: gently curved single linear
neck incisions for oral cancer. Int. J. Oral Maxillofac

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7. neck dissection(87) Dr. RAHUL TIWARI

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