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The importance of identifying the presence larised in the English world in the mid-20th
of metastatic neck disease with head and century by Etore Bocca, an Italian otola-
neck cancer is recognised as a prominent ryngologist, and his colleagues 5.
factor determining patients’ prognosis. The
current available techniques to identify Fascial compartments allow the removal
disease in the neck all have limitations in of cervical lymphatic tissue by separating
terms of accuracy; thus, elective neck dis- and removing the fascial walls of these
section is the usual choice for management “containers” along with their contents
of the clinically N0 neck (cN0) when the from the underlying vascular, glandular,
risk of harbouring occult regional metasta- neural, and muscular structures.
sis is significant (≥20%) 1. Methods availa-
ble to identify the N+ (cN+) neck include Anatomical basis
imaging (CT, MRI, PET), ultrasound-
guided fine needle aspiration cytology The basic understanding of fascial planes
(USGFNAC), and sentinel node biopsy, in the neck is that there are two distinct
and are used depending on resource fascial layers, the superficial cervical fas-
availability, for the patient as well as the cia, and the deep cervical fascia (Figures
local health service. In many countries, 1A-C).
certainly in Africa and Asia, these facilities
are not available or affordable. In such Superficial cervical fascia
circumstances patients with head and neck
cancer whose primary disease is being The superficial cervical fascia is a connec-
treated surgically should also have the tive tissue layer lying just below the der-
neck treated surgically. mis. Surgically it is indistinct from the
fatty tissue that surrounds it. The neck is
Employing fascial planes as a concept to one of the few places where it splits to
perform excision of neck nodal areas is surround the muscles of facial expression.
based on specific anatomic concepts regar- The space deep to this layer contains fat,
ding the relationship between the lympha- neurovascular bundles and lymphatics. It
tic structures and their distribution within does not constitute part of the deep neck
the tissues of the neck 2-4. It is crucial that space system.
the anatomical description of the fascial
layers is reviewed as its understanding is Deep cervical fascia (Figures 1A-C)
essential to understand the rationale and
surgical technique of the procedure. The deep cervical fascia encloses the deep
neck spaces and is further divided into 3
This technique for performing a neck dis- layers, the superficial, middle and deep
section was proposed by Osvaldo Suárez, layers of the deep cervical fascia.
an Argentinean professor of anatomy and
otolaryngologist, in the early 1960s; he Superficial layer of deep cervical fascia
proposed the term “vaciamento ganglionar (Figure 1A)
functional” or “functional neck dissection” The superficial layer of the deep cervical
2, 3
. While he himself only published his fascia arises posteriorly from the vertebral
work in Spanish, this procedure was popu- spinous processes and ligamentum nuchae.
It surrounds the entire neck, splitting to
enclose the trapezius muscle, the omo- posterior triangle of the neck, and anterior
hyoid muscle, parotid gland, sternocleido- to the vertebral bodies, it provides a base
mastoid muscle and the strap muscles. on which the pharynx, oesophagus, and
Anteriorly this fascia is attached to the other cervical structures glide during swal-
hyoid bone. The inferior attachments of the lowing and neck movements.
fascia are the acromion of the scapula, the
clavicle and the sternum. The fascia The cervical plexus emerges from between
remains split in two layers until it attaches the scalene muscle bundles. The phrenic
to the sternum; thus, the superficial layer nerve crosses obliquely on the anterior sur-
attaches to the anterior surface of the face of the anterior scalene muscle from
sternum and posterior layer to the posterior lateral to medial and lies deep to the pre-
surface of the sternum. vertebral fascia. The cervical and brachial
nerve plexuses and the sympathetic trunk
1A are invested by the prevertebral fascia,
which forms the floor of the lateral triangle
of the neck. The consequences of elevating
the prevertebral fascia during neck dissect-
tion, beyond merely increasing the devas-
tation wrought by the surgical exercise,
can be severe. If this fascia is raised, there
is risk of injuring what lies deep in the
fascia, notably the cervical and brachial
plexus, the sympathetic trunk, and the
phrenic nerve.
1B
2
Middle layer of deep cervical fascia oral cavity, oropharynx, and supra-
(Figure 1C) glottis
• Can be performed simultaneously on
The middle layer of the deep cervical fas- both sides of the neck without in-
cia or “pretracheal fascia” has two divi- creasing morbidity
sions, muscular and visceral. The muscu- • May be considered when nodes measu-
lar division surrounds the strap muscles re < 2.5-3.0cms in greatest diameter,
(sternohyoid, sternothyroid, thyrohyoid, and are discrete and mobile (with cau-
omohyoid) and the adventitia of the great tion)
vessels. The visceral division surround the • Small aggregated or matted nodes that
constrictor muscles of the pharynx and are mobile (with caution)
oesophagus to create the buccopharyngeal
fascia and the anterior wall of the retro- Contraindications
pharyngeal space. Both the muscular and
visceral divisions contribute to the carotid • Large nodes > 3.0cms (usually fixed)
sheath. The middle layer also envelopes • Previously treated neck, either surgi-
the larynx, trachea, and thyroid gland. It cally or non-surgically
attaches to the base of the skull superiorly
and extends inferiorly as low as the peri- Should a surgeon be concerned that nodal
cardium via the carotid sheath. disease is exhibiting aggressive features
e.g. soft tissue invasion or fixity, then the
1C procedure should be converted to a “modi-
fied radical neck dissection”.
Surgical technique
To ensure oncologic safety, fascial plane The surgery is best performed by dissec-
surgery requires that all nodal disease be ting along the fascial planes with a scal-
confined within lymphatic tissues. pel; the fascial planes of the neck are
• Ideally suited to N0 necks at high risk mainly avascular and can be easily follow-
of harbouring occult metastases e.g. ed with the scalpel. It is essential that an
assistant apply firm countertraction on
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the tissues to permit easy, speedy and complete right sided neck dissection (ml:
effective surgical forward progressive pro- Midline; bm: Inferior border of mandible;
gress to be achieved. c: Clavicle; tm: Trapezius muscle; ga:
Greater auricular nerve; sc: Sternocleido-
Incisions and flaps mastoid muscle; sm: Strap muscles; pm:
Platysma muscle; ej: External jugular
The placement and type of skin incision(s) vein; aj: Anterior jugular vein; sg: Sub-
depend on the site of the primary tumour mandibular gland
and whether the primary tumour and the
neck are to be addressed synchronously, or Dissecting the sternocleidomastoid
whether the neck dissection is being per- (SCM) muscle
formed alone, and whether the neck dis-
section is to be unilateral or bilateral. Natu- This step completely unwraps the SCM
rally the personal bias of the surgeon from its surrounding superficial layer of
should also be considered. deep cervical fascia. Before approaching
the fascia of the SCM muscle, the external
After the skin incision, subplatysmal skin jugular vein is ligated and divided. Dissec-
flaps are elevated, preserving the super- tion of the SCM commences with a longi-
ficial layer of the cervical fascia. The tudinal incision in the fascia along the
limits of tissue elevation are similar to entire length of the muscle (Figure 3).
those of the classic radical neck dissection
(Figures 2A, B).
2A
5A
5
leases the muscle from its surrounding fas- Dissecting the submandibular triangle
cia.
The next step is to resect the submental
Including the posterior triangle of the neck and submandibular lymph nodes (Levels
in the dissection requires a combined ap- 1a, b). This level is at risk in patients with
proach, both posterior and anterior to the cancers of the oral cavity and oropharynx,
SCM muscle (Figure 7). but is unlikely to be involved in patients
with larynx, hypopharynx and thyroid can-
cers. The submandibular gland does not
need to be resected as, unlike the parotid
gland, there are no lymph nodes within the
substance of the gland 6.
6
flected inferiorly while the gland is retrac-
ted superiorly (Figure 9).
The specimen is reflected inferiorly and The SAN runs within the “soft tissue” of
the fascia over the digastric and stylohyoid the neck, so that one must divide the tissue
muscles is incised from the midline to the overlying the nerve, rather than to follow a
tail of the parotid gland. Following the fascial plane. Dissecting the SAN is usual-
posterior belly of the digastric muscle the ly performed with scissors rather than a
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scalpel because of the loose consistency of 11C
the tissue in this area and the restricted ac-
cess. The SCM muscle is retracted poste-
riorly and the posterior belly of the
digastric muscle is retracted superiorly
with a retractor. It is important to identify
the entire SAN between the SCM muscle
and the internal jugular vein (IJV). Usually
the IJV lies immediately behind the
proximal portion of the nerve. Occasion-
ally the nerve may go behind the vein or
even cross it (Figures 11 a – c).
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scm
scm
zius muscle in a medial direction including Figure 13: Anterior view of the anatomic
the lymphatic contents of the supraclavi- landmarks of the right supraclavicular
cular fossa. At the upper margin of this fossa. ( BP: Brachial plexus; pn: Phrenic
area is where damage to the SAN is most nerve; tc: Transverse cervical artery; sn:
likely to occur. Supraclavicular branch of cervical plexus;
oh: Omohyoid muscle retracted inferome-
The omohyoid muscle is next identified; its dially)
fascia is dissected off the muscle so that is
may be removed with the contents of the Dissecting the deep cervical muscles
posterior triangle. The muscle may be tran-
sected if necessary but may be retracted As the dissection proceeds medially to-
inferiorly to identify the transverse cervical wards the carotid sheath, several branches
vessels deep to the omohyoid muscle. of the cervical plexus are found over the
deep muscles of the neck (Figures 14 and
The deep layer of the cervical fascia over- 15A).
lying the levator scapulae and scalene
muscles now comes into view. The brach- Optimal shoulder function may be preser-
ial plexus is easily identified because it ved if the deep branches of the 2nd, 3rd, and
appears between the anterior and middle 4th cervical nerves are preserved, as they
scalene muscles (Figure 13). may communicate with the SAN. There
are also similar anastomoses from the 3rd,
Remaining superficial to the scalene fascia 4th and 5th cervical nerves to the phrenic
(deep layer of the cervical fascia) prevents nerve – these should also be preserved.
injuring the brachial plexus and the phrenic Preservation of these nerves is best achie-
nerve. Dissection proceeds medially until ved by keeping the dissection superficial to
the anterior border of the SCM muscle is the scalene fascia.
reached. The muscle is retracted posterior-
ly and the dissection is continued anterior Continuing the dissection posterior to the
to the muscle towards the carotid sheath. carotid sheath carries a high risk of
damage to the sympathetic chain.
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cimen is grasped with haemostats and
retracted medially, while the surgeon uses
a gauze pad in the non-dominant hand to
pull laterally over the deep cervical mus-
cles.
Figures 15A, B: Dissecting carotid sheath Following release of the internal jugular
vein from its fascia, the dissection pro-
Dissecting the carotid sheath ceeds medially over the carotid artery. The
specimen is now completely separated
This part of the dissection is best executed from the great vessels, remaining attached
with a knife while applying adequate coun- only to the strap muscles.
tertension to the tissues. The surgical spe-
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Dissecting the strap muscles At this point the specimen is almost free
and any remaining vessels - arteries or
This may be the last step or may already veins - should be ligated and divided un-
have been performed at an earlier stage of less required for some other procedure
the operation, depending on the preference such as anastomosis of a free flap!
surgeon or the location of the primary tu-
mour. The midline of the neck constitutes Dissecting the central compartment
the medial margin of the neck dissection.
During dissection of the central compart-
This the superficial layer of the deep cervi- ment (Level VI), the recurrent laryngeal
cal fascia is incised in the midline from the nerves must be identified and followed
upper border of the surgical field to the upwards to the larynx and downwards to
sternal notch. The anterior jugular vein is the upper mediastinum. The lobe of the
identified, ligated, and divided at both ends thyroid, if being preserved, makes such
of the surgical field. The fascia is now dis- surgery difficult, as preservation of the
sected from the underlying strap muscles. parathyroid glands is extremely important
The dissection starts at the upper part of with its functioning blood supply.
the surgical field and continues in a lateral
and inferior direction. The sternohyoid and Closure of wound
omohyoid muscles are completely freed
from their fascial coverings (Figures 16 A, The neck is carefully inspected for bleed-
B). ing points and retention of sponges etc.
The entire wound is irrigated with saline
16A (Figure 17).
16B
Figure 16: (A) Dissection of strap muscles. Figure 17: Image of the right neck after a
(B) Artist’s view of dissection of the fascia neck dissection. Note the preserved sub-
covering the strap muscles mandibular gland
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The skin is closed in two layers over a 5. Bocca E, Pignataro O, Sasaki CT,
large suction drain. The platysma is Functional neck dissection. A descrip-
sutured with absorbable buried sutures, and tion of operative technique. Arch Oto-
the skin closure with skin clips. laryngol 1980; 106: 524-7
6. Dhiwakar M, Ronen O, Malone J, et al.
Comment Feasibility of submandibular gland pre-
servation in neck dissection: a prospec-
While the term functional neck dissection tive anatomic-pathologic study. Head
has not been included in more recent Neck 2011;33-(5): 603-9
classifications of neck dissection, the
procedure as described is eminently suited Copyright
to elective selective neck dissections
(Level I, II, III and IV) and for therapeutic Figures reproduced with permission of
selective neck dissections for N1 necks. THIEME
Video Authors
• Download: Functional neck dissection
technique Patrick J Bradley, MBA FRCS
• YouTube: Emeritus Honorary Professor of Head and
https://www.youtube.com/watch?v=sdq Neck Oncologic Surgery
QxbZMLlA Nottingham University Hospitals
Queens Medical Centre Campus
Other Open Access Atlas neck dissection
chapters: Nottingham, England
pjbradley@zoo.co.uk
• Modified and radical neck dissection
technique
Javier Gavilán, MD
• Selective neck dissection operative Professor and Chairman
technique Department of Otolaryngology
La Paz University Hospital
References Autonomous University of Madrid
Madrid, Spain
1. De Bree R, Takes RP, Castelijns JA, javier.gavilan@salud.madrid.org
Medina, JE, Stoeckli SJ, Mancuso AA,
Ferlito A. (2015). Advances in diag- Editor
nostic modalities to detect occult
lymph node metastases in head and Johan Fagan MBChB, FCS(ORL), MMed
neck squamous cell carcinoma. Head Professor and Chairman
Neck, 37(12), 1829-39 Division of Otolaryngology
2. Gavilán J, Herranz J, Martin L, Func- University of Cape Town
tional neck dissection: the Latin ap- Cape Town, South Africa
proach. Operative Techniques in Oto- johannes.fagan@uct.ac.za
laryngology 2004;15: 168 -75
3. Ferlito A, Gavilán J, Buckley J, et al.
Functional neck dissection: fact and
fiction. Head Neck 2001; 23; 804-8
THE OPEN ACCESS ATLAS OF
4. Gavilán J, Heranz J, De Santo LW, OTOLARYNGOLOGY, HEAD &
Gavilán C: Functional and selective NECK OPERATIVE SURGERY
neck dissection. New York Thieme, www.entdev.uct.ac.za
2002
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The Open Access Atlas of Otolaryngology, Head &
Neck Operative Surgery by Johan Fagan (Editor)
johannes.fagan@uct.ac.za is licensed under a Creative
Commons Attribution - Non-Commercial 3.0 Unported
License
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