modified radical neck dissection types

Throughout its more than 100 years of history, neck dissection has continuously evolved from a mutilating radical surgery to an elegant, anatomically bound ablation with minimal functional impact. The location of the nerve in relationship to the lower border of the mandible is variable; furthermore, this relationship may change depending on the segment of the nerve analyzed (anterior vs. posterior to the facial artery), as shown in, plane immediately superficial to the vessels and appear as a structure parallel to the mandible (, Neck Dissection for Salivary Gland Malignancies, History/Classification of Nodal Levels and Neck Dissections, Histopathologic Evaluation of Neck Dissections. Similarly, as it relates to the nomenclature and indications, the last decades have seen a significant degree of consolidation that has laid the foundation for a common understanding of its oncological and technical aspects. SOHND was done on the opposite side in five patients (primaries that have high propensity for bilateral metastasis) but no … The current nomenclature for the boundaries and contents of the nodal groups in the neck is summarized in Table 7.1 and illustrated in Fig. MODIFIED & RADICAL NECK DISSECTION. EJV, elevated jugular vein; GAN, greater auricular nerve; SCM, sternocleidomastoid muscle; SMG, submandibular gland. Modified radical neck dissections was defined as NDs of levels I to V with or without removal of other muscular, nervous, or vascular structures (both radical and modified radical NDs are included in the abbreviation MRND). Selective Neck Dissection for Oropharyngeal, Hypopharyngeal, and Laryngeal Cancer The lateral neck dissection is recommended for these sites. 16.1). If there is significant risk of carotid exposure (such as history of radiation or radical neck dissection), consider an elective interposition of myofascial pectoralis flap to protect these critical structures. Flap elevation with electrocautery may lead to abrupt nerve stimulation (especially in the coagulation setting), causing a violent trapezius contraction that brings the tissue toward the instrument, posing an exceptional risk. Anatomically, a modified radical neck dissection requires wide exposure of the anterior and posterior neck triangles, so the boundaries for skin flap elevation are the mandibular margin and tail of parotid superiorly, the clavicle inferiorly, the strap muscles medially, and the anterior border of the trapezius muscle posteriorly. 7.3) and are associated with the pioneers of the procedure. Selective neck dissection. Instead of removing nodes from all five zones, only selected nodes are removed, which preserves the most amount of tissue. Once the nerve is identified, antegrade and retrograde dissections are performed until it is released from underlying attachments, and it can safely be reflected cephalad. Regardless of the chosen approach, some common considerations are helpful in minimizing the risk of flap failure: • Skin flaps must be broad based to maximize blood supply. Although these were initially implemented in the context of the cN0 neck, they are more commonly being used for treatment of cN +. The effects of each of these muscles are as follows: • Depressor labii inferioris draws the lower lip downward (depresses) and laterally (irony). Shopping. Info. Table 7.1 Contents and boundaries of the lymphatic levels of the neck.23. Distally, the marginal nerve can anastomose with other branches of the facial nerve (most commonly buccal) to create a plexus that will innervate the perioral musculature. To fully expose the contents of level V, it is often necessary to drop an accessory limb from the main incision; ideally, this limb must merge with the main incision at a 90-degree angle to minimize the risk of tip necrosis. Furthermore, this may happen even if the patient is fully paralyzed. 7.6 Completed elevation of the skin flaps over the anterior triangle. Modified radical neck dissection involves removal of levels I through V, as in classical radical neck dissection, but with preservation of one or more of the key extranodal structures (spinal accessory nerve, sternocleidomastoid muscle, and internal jugular vein). A modified radical neck dissection, which is the most comprehensive form of functional neck dissection, entails the resection of the nodal groups I through V, and is still considered the standard of care for management of the cN + neck. SND (I-IV). Selective dissections are less effective and need further study. You can change your ad preferences anytime. Once the airway is secured, the bed is routinely turned 90 to 180 degrees. (b) Inferiorly based platysma flap. • Reoperative exposure (risk of ipsilateral or contralateral neck recurrence). Alternatively, the skin incisions may be performed with scalpel, prior injection with diluted lidocaine and epinephrine. Different types of incision such as the utility flaps, Schobinger flaps, MacFee, T-shaped, Y-shaped, double Y-, single, and double transverse incisions and their modifications have been described [,, ]. The superior boundary is formed by the sternocleidomastoid and trapezius muscles, the inferior boundary is the clavicle, the anterior (medial) boundary is the posterior border of the sternocleidomastoid muscle, and the posterior (lateral) boundary is the anterior border of the trapezius muscle. Selective neck dissection: each variation is depicted by “SND” and the use of parentheses to denote the levels or sublevels removed. As it relates to the classification of the procedure, the current nomenclature has not changed since 2002 ( Table 7.2) and modified radical neck dissection formally entails the resection of all lymphatic groups in the neck (I–V) with preservation of the IJV, SAN, and SCM. For bilateral ND consisting of an SND on one side and an MRND on … In this chapter, critical aspects of the surgical anatomy of the neck are reviewed, and the reader is presented with strategies to avoid common pitfalls in the execution of the procedure. For this reason, it is recommended that for patients undergoing bilateral neck dissection, lateral flaps are elevated first and subsequently addressing the anterior neck, once the correct plane has been established. modified radical neck dissection with preservation of the spinal accessory nerve). Refers to the removal of all lymph nodes by radical neck dissection with preservation of one or more of the non-lymphatic structures: i.e., the spinal accessory nerve, internal jugular vein and the sternocleidomastoid muscle. Modified radical neck dissection (Figure 4, Figure 5, and Figure 6) refers to the excision of all lymph nodes routinely removed by the radical neck dissection with preservation of 1 or more nonlymphatic structures (ie, the SAN, internal jugular vein, and SCM). Overall neck … The concept of neck dissection refers to systematic resection of lymph nodes from well-defined fascial compartments in the neck. 7.1. The head is extended and rotated to the opposite side; this maneuver not only provides the best exposure, but also brings the relevant anatomical structures to a more horizontal plane, significantly facilitating the dissection ( Fig. For purposes of lymph node dissection, the unilateral neck is classified by discreet anatomic subdivisions, or levels (Fig. Neck dissection may be (END) elective. Laser surgery is becoming more commonly used for excisional biopsies, debulking, and some types of resections (small tumors and vocal cord lesions). A partial neck dissection removes all or part of the lymph node chain(s), or at a minimum, a nodal mass. Mauricio A. Moreno In a recent literature review, Eckard reported a flap success rate ranging from 71 to 100%6 and concluded that most failures were related to history of previous radiation or ligation of the facial artery. 7.9); these will innervate the platysma muscle and may have an effect on preserving lip symmetry. The muscle, nerve, … The nerve is exposed to injury along its entire course in this area as it has a very superficial location and it is only protected by a thin fascial layer. The purpose of radical neck dissection is to remove lymph nodes and other structures in the head and neck that are likely or known to be malignant. The lymph nodes groups/levels typically removed depends on expected patterns of metastatic spread from a given primary site 2: Dissections are performed bilaterally if the primary lesion crosses the midline. Contents of level V below the level of anterior cricoid arch. The lymph nodes located anterior (medial) to the spinal accessory nerve. Selective Neck Dissection If the cancer is diagnosed early, a selective neck dissection may be an option. As the collective knowledge has matured, a more utilitarian approach is overwhelmingly favored by most surgeons; as such, modern-day incisions are usually apron-type or transversal incisions at a skin crease. This procedure is still the standard of care in the management of the cN + neck, although there is growing evidence supporting the role of selective approaches in this setting as well. The posterior (lateral) boundary is the vertical plane defined by the posterior edge of the submandibular gland. Keywords: neck dissection, modified, functional, technique, complications. While it has been largely replaced by other reconstructive options, the myocutaneous platysma flap should be part of the armamentarium of every head and neck surgeon, as it provides an elegant alternative for closure of small to medium sized intraoral defects, especially in patients with significant comorbidities. This is a time-tested approach that works well for most cases, but it has some limitations such as in cases where there is direct disease extension to the submental triangle, or significant nodal disease level Ib or in facial lymph nodes. A modified radical neck dissection spares the accessory nerve and/or the sternocleidomastoid muscle. Type III: The spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle are preserved. The most common types of neck dissection include selective (with removal of nodes at risk) and radical modified (with removal of all neck lymph nodes). Supraomohyoid 2. These were separately analyzed and the outcome was compared to those who had a standard total RND. The location of the nerve in relationship to the lower border of the mandible is variable; furthermore, this relationship may change depending on the segment of the nerve analyzed (anterior vs. posterior to the facial artery), as shown in Table 7.3. Although previously grouped by types (I through III), variation in practice makes it advisable to name explicitly the structures spared in a modified radical neck dissection (e.g. 128 (7): 751-8. Classification and terminology of neck dissection has not changed. Fig. Radical neck dissection (RND) – This involves the removal of Level I-V lymph nodes with the removal of the spinal accessory nerve (SAN), Internal jugular vein (IJV) and Sternocleidomastoid muscle (SCM). Radical neck dissection is the historical standard by which subsequent approaches are compared and defined. The nerve almost invariably (90%) courses as a single branch as it exits the parotid and throughout its course. While this surgery can be analyzed from multiple perspectives, this chapter will primarily focus on its anatomical and technical aspects, which are essential to perform this surgery safely, effectively, and efficiently. Harish K. Neck dissections: radical to conservative. 7.8). 7.5). The structure(s) preserved should be specifically named (eg, modified radical neck dissection with preservation of the SAN). Historically, there were named subtypes of selective neck dissections: Due to evolving practices, the 2001 classification omitted the named subtypes in favor of precise description with "SND" and parentheses denoting the levels removed, e.g. Care must be taken to ensure the head is not hanging, especially in older patients. The functional or modified radical neck dissection was developed in the 1950s and 1960s. The procedure was widely adopted and endorsed by prominent head and neck surgeons such as Vilray Blair and Hayes Martin and became the standard of care for neck management through the first half of the 20th century. Few studies, however, have attempted to assess the long-term oncologic outcomes of robotic MRND in these patients. 7.9 Illustration showing the anatomical relationship of the marginal and cervical branches of the facial nerve. Fig. There are multiple types of neck dissection that vary by the structures removed 1. Taking these points into consideration, the posterior elevation of skin flaps proceeds until the anterior border of the trapezius muscle is widely exposed ( Fig. In terms of elevation of skin flaps, in the posterior triangle there is also risk of injury of the SAN. At this point, skin flaps are elevated in the subplatysmal plane wide enough to expose all the anatomical landmarks and provide access to the nodal groups of interest. The radical neck dissection involves removal of all ipsilateral cervical lymph nodes from levels I through V, as well as the submandibular gland. Fig. It is performed when the cancer has spread widely in the neck. A modified radical neck dissection is defined as functional resection of the lymphatic levels I to V in the neck. In this chapter, critical aspects of the surgical anatomy of the neck are reviewed, and the reader is presented with strategies to avoid common pitfalls in the execution of the procedure. When an ultrasound-guided FNA has confirmed that a lymph node in the lateral neck area (outside the left or right carotid artery) contains cancer, a lateral neck dissection is necessary. The external jugular vein can also be used as a landmark; since the SLDCF invests the SCM and the vein, the plane of dissection is immediately superficial to the vessel. A modified radical neck dissection, which is the most comprehensive form of functional neck dissection, entails the resection of the nodal groups I through V, and is still considered the standard of care for management of the cN + neck. From the technical standpoint, patient selection and surgical planning are of outmost importance if this flap is to be attempted. The neck can be gently flexed to identify natural skin creases, which should also be marked. These will be, the vast majority of times, performed in the context of mucosal aerodigestive tract, salivary, cutaneous, or endocrine malignancies. A radical neck dissection removes the most tissue. The lymph nodes located around the lower third of the internal jugular vein extending form the inferior border of the cricoid cartilage (above) to the clavicle below. This procedure was pioneered by Suarez and Bocca, who were the first to understand the concept of nodal groups defined by fascial places during the second half of the last century. MODIFIED & RADICAL NECK DISSECTION Johan Fagan Neck dissection removes potential or proven metastases to cervical lymph nodes. It may spare some non-lymphatic tissue, such as some nerves, muscles, or blood vessels. Lateral 4. Decision points and critical aspects of the surgical anatomy will be addressed as the process is described, with the intention of contextualizing the information within the flow of the operation. Keywords: neck dissection, modified, functional, technique, complications. The facial vessels—and more specifically the facial artery—may be used as landmarks to identify the nerve, which will always be in a plane immediately superficial to the vessels and appear as a structure parallel to the mandible ( Fig. It is a complex operation and requires a sound knowledge of the 3-dimensional anatomy of the neck. It is a complex operation, and requires a sound knowledge of the 3dimensional - anatomy of the neck. While this surgery can be analyzed from multiple perspectives, this chapter will primarily focus on its anatomical and technical aspects, which are essential to perform this surgery safely, effectively, and efficiently.

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