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1. Neck Dissections:
Classifications,
Indications, &
Techniques

2. INTRODUCTION
Neck dissection is performed for the
surgical control of metastatic neck disease
in patients with squamous cell carcinomas
of the upper aerodigestive tract, salivary
gland tumors, and skin cancer of the head
and neck (including melanomas).
Neck dissection is also indicated for the
surgical control of metastatic carcinoma to
the neck when the nasopharynx and
thyroid are the primary sites.

3. Evolution of the neck dissection
1880 – Kocher proposed removing nodal
metastases

1906 – George Crile described the classic
radical neck dissection (RND)

1933 and 1941 – Blair and Martin
popularized the RND
 1953 – Pietrantoni recommended sparing
the spinal accessory nerves

4. Evolution of the neck dissection
1967 - Bocca and Pignataro described the
“functional neck dissection” (FND)
 1975 – Bocca established oncologic safety
of the FND compared to the RND
 1989, 1991, and 1994 – Medina, Robbins,
and Byers respectively proposed
classifications of neck dissections

5. Evolution of the neck dissection
 1991 – Official Report of the ‘Academy’s
Committee for Head and Neck Surgery
and Oncology’ standardized neck
dissection terminology

6. Surgical
Anatomy

7. Fascial layers of the neck
Superficial cervical fascia
Deep cervical fascia
– Superficial layer (investing
layer)
 SCM, strap muscles, trapezius

– Middle or Visceral Layer
(pretracheal fascia)
 Thyroid
 Trachea
 Esophagus

– Deep layer (prevertebral
fascia)
 Vertebral muscles
 Phrenic nerve
 Cervical & Brachial Plexus

8. MUSCLES
Platysma
SCM
Omohyoid
Trapezius
Digastric

9. MUSCLES
Platysma
Surgical considerations
– Increases blood supply to
skin flaps
– Absent in the midline of the
neck
– Fibers run in an opposite
direction to the SCM
SCM
Surgical considerations
– Overlies IJV, Has to be
retracted laterally to
exposes LN related to IJV

10. MUSCLES
Omohyoid muscle
Surgical considerations
 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
Trapezius
Surgical considerations
Posterior limit of Level V neck
dissection
Denervation results in shoulder
drop and winged scapula

11. MUSCLES
Digastric
Surgical considerations
Posterior belly is superficial
to:
ECA
Hypoglossal nerve
ICA
IJV
Anterior belly
Landmark for identification of
mylohyoid m. for dissection
of the submandibular triangle

12. NERVES
Marginal Mandibular Nerve
Should be preserved in neck
dissections
• Most commonly injured while
dissection at level Ib
• Found:
– 1cm anterior and inferior to
angle of mandible
– Deep to fascia of the
submandibular gland
(superficial layer of deep
cervical fascia)
– Superficial to adventitia of
the facial vein

13. NERVES
Spinal Accessory Nerve
Penetrates the deep surface
of the SCM
Exits posterior surface of
SCM deep to Erb’s point
Traverses the posterior
triangle ensheathed by the
superficial cervical fascia
and lies on the levator
scapulae
Enters the trapezius approx.
5 cm above the clavicle

14. Spinal Accessory Nerve
CN XI – Relationship with
the IJV

15. NERVES
Phrenic Nerve
Sole nerve supply to the diaphragm
Supplied by nerve roots C3-5
Runs obliquely toward midline on the
anterior surface of anterior scalene
Covered by prevertebral fascia
Lies posterior and lateral to the carotid
sheath

16. NERVES
Hypoglossal nerve
Lies deep to the IJV, ICA, CN IX,
X, and XI
Curves 90 degrees and passes
between the IJV and ICA
Surrounded by venous plexus
(ranine veins)
Iatrogenic injury

– Most common site - floor of the
submandibular triangle, just deep
to the duct
– Ranine veins

17. Thoracic duct
Conveys lymph from the entire
body back to the blood
– Exceptions:
Right side of head and neck, Rt. U
Ext, right lung right heart and
portion of the liver
– Begins at the cisterna chyli
– Enters posterior mediastinum
between the azygous vein and
thoracic aorta
– Courses to the left into the neck
anterior to the vertebral column.
–Enters the junction of the left
subclavian and the IJV

18. Thoracic duct

19. Staging of the
Neck nodes

20. Staging of the neck nodes
“N” classification – AJCC (1997)
Consistent for all mucosal sites except the
nasopharynx.
Nasopharynx and Thyroid have different
staging based on tumor behavior and
prognosis.
Based on extent of disease prior to first
treatment.

21. Staging of the neck nodes
--NxNx- Can not be assessed -- Can not be assessed -N0N0- No lymph node metastasis- No lymph node metastasis
--N1N1- Single, ipsilateral, <3cm -- Single, ipsilateral, <3cm -N2N2- Single, ipsilateral 3-6 cm or- Single, ipsilateral 3-6 cm or
multiple <6 cmmultiple <6 cm
*N2a- single, ipsilateral 3-6 cm*N2a- single, ipsilateral 3-6 cm
*N2b- multiple, ipsilateral none >6 cm*N2b- multiple, ipsilateral none >6 cm
*N2c- contra lateral/ bilateral, none >6 cm*N2c- contra lateral/ bilateral, none >6 cm
--N3N3- > 6cm- > 6cm

22. Lymph Node
Levels/Nodal
Regions

23. Lymph Node Subzones

24. Lymph node levels/Nodal regions
Level I: Submental & Submandibular.
 Levels II, III, IV: nodes associated with IJV within
fibroadipose tissue (posterior border of SCM and
lateral border of sternohyoid).
Level II: Upper third jugular chain, Jugulodigastric,
and upper posterior cervical nodes.
– Boundaries - hyoid bone (clinical landmark) or
carotid bifurcation (surgical landmark)

25. Lymph node levels/Nodal regions
 Level III: Middle jugular nodes

– Boundaries - Inferior border of level II to
cricothyroid notch (clinical landmark)
or omohyoid muscle (surgical
landmark).
 Level IV: Lower jugular nodes.

– Boundaries -inferior border of level III to clavicle.

26. Lymph node levels/Nodal regions
 Level V: Posterior triangle of neck
– Boundaries - posterior border of SCM,
clavicle, and anterior border of trapezius.
Level VI: Anterior compartment structures.
– Boundaries - Hyoid, supra sternal notch,
medial border of carotid sheath)
Level VII: Ant. mediastinal

27. Classification of
Neck
Dissections

28. Classification of Neck
Dissections
Academy’s classification
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

29. Classification of Neck
Dissections
 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).

30. Classification of Neck
Dissections
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.

31. Classification of Neck
Dissections
Medina classification (1989)
• 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.

32. Radical Neck Dissection
Definition
-All lymph nodes in Levels I-V including
Spinal-accessory nerve (SAN), SCM, and
IJV are removed.

33. EXTENT OF RADICAL NECK
DISSECTION

The margins of the The margins of the
dissectiondissection are are
Inferiorly- Inferiorly- the the clavicleclavicle
Superiorly- Superiorly- the the mandiblemandible
Posteriorly- Posteriorly- thethe anterior anterior
border of the trapeziusborder of the trapezius
Anteriorly- Anteriorly- thethe lateral lateral
border of the sternohyoid border of the sternohyoid
musclemuscle..

34. Radical Neck Dissection
Indications
– Extensive cervical involvement or matted
lymph nodes with gross extracapsular
spread and invasion into the SAN, IJV, or
SCM.

35. Modified Radical Neck
Dissection (MRND)
Definition
– Excision of same lymph node bearing regions as
RND with preservation of one or more
nonlymphatic structures (SAN, SCM, IJV)
– Spared structure specifically named.
– MRND is analogous to the “functional neck
dissection” described by Bocca.

36. MRND- Rationale
Lymphatics of neck- contained in fibroadipose
tissue within the aponeurotic partions c are
separate from SCM and IJV.
Aponeurotic coverings can be stripped from
these structure to preserve these.
SAC n. runs thro’ nodal bearing tissue of neck,
can only be preserved if LN’s are not closly
related to it.

37. EXTENT OF MODIFIED RADICAL
NECK DISSECTION

38. Modified Radical Neck
Dissection
Three types

39. MRND TYPE I: Preservation of
SAN

40. MRND TYPE II : Preservation of
SAN and IJV

41. MRND TYPE III: Preservation of SAN,
IJV, and SCM ( “Functional neck
dissection”).

42. Selective Neck Dissections
Definition
– Cervical lymphadenectomy with preservation of one or
more lymph node groups
RATIONALE:
– SND is designed to remove cervical lymph nodes at risk
of involvement by metastatic cancer, which is based on
site of primary cancer.
–The basic anatomic studies have demonstrated that
lymphatic drainage of mucosal sites of head and neck
follow relatively constant and predictable routes.

43. Selective Neck Dissections
Four common subtypes:
• Supraomohyoid neck dissection (SO)
• Posterolateral neck dissection (PL)
• Lateral neck dissection (L)
• Anterior neck dissection (A)
:

44. SND: Supraomohyoid type
Most commonly performed
SND
Definition
– En-bloc removal of cervical
lymph node groups I-III
– Posterior limit is the post.
border of the SCM
– Inferior limit is the omohyoid
muscle overlying the IJV
Indications
– Oral cavity carcinoma with
N0 neck

45. Extended supraomohyoid N D
In case of carcinoma of lateral border of
tongue involvement of level IV L. N. is
common, so level IV dissection should be
done in such case.

46. 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.

47. SND: Posterolateral Type
Definition
– En bloc excision of lymph
nodes in Levels II to V.
Indications
– Cutaneous malignancies
• Melanoma
• Squamous cell Ca
• Ca Thyroid
• Merkel cell carcinoma
– Soft tissue sarcomas of
the scalp and neck.

48. SND: Anterior Compartment
Definition
– En bloc removal of lymph structures Level VI
• Peri thyroidal nodes
• Pre tracheal nodes
• Pre cricoid nodes (Delphian)
• Para tracheal nodes along recurrent nerves.
– Limits of the dissection are the hyoid bone,
suprasternal notch and carotid sheaths
Indications
– Selected cases of thyroid carcinoma
– Parathyroid carcinoma
– Subglottic carcinoma
– Laryngeal carcinoma with subglottic
extension
– CA of the cervical esophagus

49. 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 usually
Preserved
Indications
– Carotid artery invasion
- dissection of mediastinal nodes and central
compartment for subglottic involvement, and
- removal of retropharyngeal lymph nodes for tumors
originating in the pharyngeal walls.

50. ANAESTHESIA AND POSITION
ANAESTHESIA –General Anaesthesia
with ETT.
POSITION-Place the patient in the supine
position with a shoulder roll extending the
neck. Elevate the upper half of the
operating table to a 30° angle.

51. INCISIONS
Can be performed through a number of incisions
The decision to use a certain incision will be
based on a number of factors which include:
Personal preference
Previous radiotherapy
Number of levels required to assess
Site of the primary tumor if that is being resected

52. INCISIONS
Half Apron Incision
Apron Incision

53. INCISIONS
Conley Incision
Double-Y Incision

54. INCISIONS
H Incision
MacFee Incision

55. INCISIONS
Y Incision
Modified Schobinger Incision

56. OPERATIVE
PROCEDURE

57. OPERATIVE PROCEDURE
The skin is prepared
in the standard
manner and the skin
incision marked out
using a marking pen

58. OPERATIVE PROCEDURE
Make the skin incision
through the platysma
and elevate the flap in
the subplatysmal
plane

59. OPERATIVE PROCEDURE
Identify and preserve
the marginal
mandibular nerve at
the superior aspect of
the flap.
Remove submental
fatty tissue and
displace it inferiorly

60. OPERATIVE PROCEDURE
Removal of Submental
and pregladular
Submandibular nodes
Removal of
submandibular glands
with duct and associated
lymph nodes

61. OPERATIVE PROCEDURE
Expose the
sternocleidomastoid
muscle and incise it
above the clavicle.
Identify the anterior
and posterior belly
of the omohyoid
with transection of
the omohyoid
posteriorly

62. OPERATIVE PROCEDURE
Identify the internal
jugular vein and
vagus nerve in the
lower aspect of the
neck before ligation of
the internal jugular
vein. Further identify
the carotid artery and
the vagus nerve.

63. OPERATIVE PROCEDURE
Open the supraclavicular
fatty tissue using blunt
dissection, either with a
finger or hemostat, with
identification of the
phrenic nerve and
brachial plexus
Dissect from inferior to
superior. Continue the
dissection along the
anterior border of the
trapezius. Preserve the
phrenic nerve and
brachial plexus.

64. OPERATIVE PROCEDURE
Separate the
surgical specimen
from the carotid
and vagus,
proceeding
superiorly, with
identification of
the hypoglossal
nerve

65. OPERATIVE PROCEDURE
Cut the
sternocleidomastoid
muscle superiorly
Identify the internal
jugular vein superiorly,
medial to the posterior
belly of the digastric
muscle. Dissect and
ligate

66. OPERATIVE PROCEDURE

67. OPERATIVE PROCEDURE
Irrigate with
isotonic sodium
chloride solution.
Maintain
hemostasis

68. OPERATIVE PROCEDURE
Insert drains (0.125-in
Hemovac or Jackson-
Pratt); usually, use 2 for
each side of the neck.
Close the wounds in
layers with 3-0 Vicryl
through the platysmal
flaps and skin with
staples or 4-0 nylon.

69. Postoperative details:
Maintain head elevation at a 30° angle.
Ensure that the Hemovacs or drains are functioning properly.
Ensure that drains are maintained on continuous suction until
they drain less than 20-25 mL in 24 hours.
Monitor for fever, bleeding, or hematoma formation in the
postoperative period.
Avoid atelectasis. Move the patient out of bed the day after
surgery with assistance. Encourage deep breathing and early
ambulation with assistance.
Monitor for possible fistula if the oral or upper digestive tract
was opened, particularly during the third or fourth postoperative
day.

70. Intraoperative Complications
Hemorrhage
Carotid sinus reflux
Pneumothorax
Air embolus
Nerve damage
Chylous fistula

71. Postoperative Complications
Hematoma
Wound infection
Skin flap loss
Salivary fistula
Facial edema
Carotid artery rupture

72. THANKS