ORIGINAL ARTICLE
Therapeutic robot-assisted neck dissection via a retroauricular or modified facelift
approach in head and neck cancer: A comparative study with conventional
transcervical neck dissection
Won Shik Kim, MD, Hyung Kwon Byeon, MD, Young Min Park, MD, Jong Gyun Ha, MD, Eun Sung Kim, MD,
Yoon Woo Koh, MDPhD,* Eun Chang Choi, MDPhD
Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea.
Accepted 20 December 2013
Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23595
ABSTRACT: Background. In a previous study of robot-assisted neck
dissection (RAND), we limited the indication for neck dissection in clinical
N0 head and neck cancer. The purpose of this study was for us to pres-
ent the comparison of the results of therapeutic RAND via a retroauricu-
lar or modified facelift approach with outcomes from conventional neck
dissection in clinical node-positive head and neck cancer.
Methods. This study involved a total of 53 patients who underwent neck
dissection for head and neck cancer. Operative and pathologic parame-
ters were assessed.
Results. The RAND and the conventional neck dissection group consisted
of 20 and 33 patients, respectively. The mean operative time for the
INTRODUCTION
Owing to the introduction of robotic surgical systems,
there have been changes in the surgical techniques used
to treat head and neck cancers.1 Robotic techniques can
be applied to both primary tumors and nodal metastasis
through transoral robotic surgery and robot-assisted neck
dissection (RAND), respectively.2–6 The initial RAND
trial was performed for the management of thyroid cancer
with lateral neck metastasis using the transaxillary
approach.7 We also reported a cadaveric study using
RAND via the transaxillary approach.8 However, compe-
tent clearance of neck levels I, IIB, and VA was limited
with the transaxillary approach; to avoid this, we
designed a transaxillary and retroauricular approach.4
With the accumulation of experience with the transaxil-
lary and retroauricular approach, we realized that the ret-
roauricular or modified facelift approach is sufficient for
RAND in head and neck cancer.6 In our feasibility study
of RAND, we limited the indications for elective neck
dissection to clinical N0 head and neck cancer.4,5,9 As
*Corresponding author: Y. W. Koh, Department of Otorhinolaryngology, Yonsei
University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752,
Korea. E-mail: ywkohent@yuhs.ac
Additional Supporting Information may be found in the online version of this
article.
RAND group was significantly longer than that of the conventional neck
dissection group. The mean number of retrieved lymph nodes in the
RAND group was not significantly different from the conventional neck
dissection group.
Conclusion. Therapeutic RAND via a retroauricular or modified facelift
approach was successful with satisfactory esthetic results in patients
with node-positive head and neck cancer. V
C 2014 Wiley Periodicals, Inc.
Head Neck 00: 000–000, 2014
KEY WORDS: robot-assisted neck dissection, head and neck cancer,
nodal metastasis, retroauricular approach, modified facelift approach
our experience with RAND increased, we saw the poten-
tial for therapeutic RAND in node-positive patients. In
this study, we compare the results of therapeutic RAND
via a retroauricular or modified facelift approach with
conventional neck dissection in head and neck cancer.
MATERIALS AND METHODS
Patients
This study included a total of 53 patients who under-
went therapeutic neck dissection for head and neck cancer
at the Department of Otorhinolaryngology, Yonsei Uni-
versity College of Medicine, Seoul, Korea, from May
2010 to July 2012. Study approval was obtained from the
Institutional Review Board. The inclusion criteria
included a biopsy-proven lymph node metastasis of head
and neck cancer, no previous treatment of head and neck
cancer except nasopharyngeal cancer, nodal metastases
with residual nodal architecture (extracapsular extension
under grade 3 in grading system of Lewis et al10) on pre-
operative imaging studies (invasion of the sternocleido-
mastoid [SCM] muscle, internal jugular vein [IJV], or
spinal accessory nerve [SAN] by pathologically involved
lymph nodes was not absolutely contraindicated), and
cases requiring unilateral modified radical neck dissection
(MRND). The exclusion criteria included unresectable
lymph node metastasis owing to suspected extracapsular
extension (eg, carotid encasement), cases requiring
HEAD & NECK—DOI 10.1002/HED MONTH 2014 1
KIM ET AL.
bilateral neck dissection, previous radiation or chemother-
apy except for nasopharyngeal cancer, or distant metasta-
sis. Except for some oropharyngeal and hypopharyngeal
cancers, in which we omitted the level I dissection, all
cases of neck dissection were performed for levels I–V.
All patients were presented with both surgical options,
including the advantages and disadvantages of each proce-
dure, and that the procedural cost of the RAND procedure
is about 7 times higher than that of conventional neck dis-
section. After this discussion, the patients themselves
decided whether RAND or conventional neck dissection
would be performed. The extra cost for RAND was paid by
the private insurance company in about 80% of patients in
the RAND group. The remaining 20% of patients, who had
no private insurance covering robot-related operations, paid
the extra cost out of their pockets.
The following variables were assessed: age, sex, body
mass index, primary site, permanent pathology, TNM
stage, operation time for neck dissection (time interval
from the incision for neck dissection to the removal of
the neck dissection specimen), estimated blood loss, num-
bers of retrieved and pathologic lymph node, total amount
and duration of drainage, hospital stay, and complications,
including seroma, hematoma, chyle leakage, skin flap
necrosis/dehiscence, orocervical fistula, and nerve inju-
ries. Scar satisfaction was measured at 3 months after sur-
gery and was evaluated on a scale from 1–5
(1 5 extremely dissatisfied; 2 5 dissatisfied; 3 5 average;
4 5 satisfied; and 5 5 extremely satisfied).11
Operative procedure of therapeutic robot-assisted neck
dissection
All operations were conducted by the senior author
(Y. W. K.) using a da Vinci robotic system (Intuitive
Surgical, Sunnyvale, CA). The strategy for RAND via a
retroauricular or modified facelift approach is depicted
schematically in Figure 1.
Skin incision and flap elevation
The patient was placed in the supine position with neck
extension. Either a retroauricular or modified facelift inci-
sion was used. A retroauricular incision was made around
the retroauricular sulcus and the hairline. A modified
facelift incision was extended from the retroauricular inci-
sion to the preauricular fold. The skin flap elevation was
performed under the platysma muscle. After the lateral
upper aspect of the SCM muscle was reached, the dissec-
tion procedure was directed toward the midline and
downward. (In cases that required SCM muscle sacrifice,
the mastoid attachment of the SCM muscle was cut with
a Bovie coagulator.) The dissection was continued medi-
ally to the opposite anterior belly of the digastric muscle,
inferiorly to the clavicle, and laterally to the anterior bor-
der of the trapezius muscle. After the flap elevation, a
self-retaining retractor (Sejong Medical Corp, South
Korea) was placed (see video, online only).
Neck dissection under direct vision via a retroauricular
or modified facelift approach
For cases in which level I dissection was performed,
the marginal mandibular nerve was identified first. Then,
2 HEAD & NECK—DOI 10.1002/HED MONTH 2014
FIGURE 1. Schematic drawing of retroauricular or modified face
lift approach. Levels IIB, VA, and the lateral aspect of the carotid
space in level IIA can be dissected under direct visualization
(blue field). Robot-assisted lower neck dissection (levels III, IV,
and VB) as well as robot-assisted upper neck dissection (levels
IA, IB, and the medial aspect of the carotid space in level IIA) can
be performed through retroauricular or modified face lift incision
(red and yellow fields, respectively). [Color figure can be viewed
in the online issue, which is available at wileyonlinelibrary.com.]
the perifacial lymphofatty tissues were dissected, and the
distal facial artery and vein were ligated. The fibroadi-
pose tissues inferior to the tail of the parotid gland were
dissected. Then, the dissection procedure was performed
along the inferior border of the submandibular gland, and
the posterior belly of the digastric muscle and the IJV
were identified. The SAN was then identified near the
IJV. For cases in which level I dissection was not per-
formed, the dissection procedure was initiated from the
inferior border of the submandibular gland. The entire
course of the SAN was skeletonized from the skull base
to the trapezius muscle. Levels IIB, VA, and the lateral
aspect of the carotid sheath in levels IIA and upper III
were dissected under direct vision.
Robot-assisted neck dissection technique
A dual-channel 30 endoscope was placed on the cen-
tral camera arm of the robotic system and inserted in an
upward direction. Maryland forceps and Harmonic curved
shears were placed on either side of the camera. The lym-
phofatty tissues between the anterior bellies of the digas-
tric muscle were detached with Harmonic curved shears.
The posterior belly of the digastric muscle was exposed
and the proximal facial artery was ligated. The subman-
dibular gland was dissected beneath the inferior border of
the mandible. The submandibular gland ganglion and
Wharton’s duct were ligated. Because the lateral aspect of
the carotid sheath was already dissected, only the medial
aspect of the carotid space in levels IIA and III was
addressed using the robot-assisted technique. The dissec-
tion was performed over the carotid sheath and extended
to levels IV and VB. The small branches of the IJV were
ligated with Harmonic curved shears, whereas large ones
were ligated with a Hem-o-lok Ligation System (Teleflex,
Durham, NC) by an assistant. In cases of SCM muscle
sacrifice, the sternal and clavicular heads of the SCM
 THERAPEUTIC ROBOT–ASSISTED NECK DISSECTION

TABLE 1. Clinical characteristics of the study patients. TABLE 2. Operative parameters.

Conventional neck Conventional

RAND dissection p neck
Characteristics (n 5 20) (n 5 33) value RAND dissection p
Characteristics (n 5 20) (n 5 33) value
Age, y, median (range) 62.5 (44–74) 63.0 (46–84) .953
Sex, M:F 17:3 30:3 .661 Operation time for 186 6 37 150 6 23 .000
Body mass index, kg/m2 23.5 6 4.5 22.2 6 3.9 .268 neck dissection, min
Neck length, cm* 79.9 6 8.9 80.1 6 6.6 .933 Estimated blood loss 259 6 76 239 6 71 .354
Neck circumference, cm† 35.3 6 3.0 34.6 6 3.2 .463 during neck
Primary site/TORS, no.‡ .158 dissection, mL
Oropharynx 12/8 20/7 Amount of drainage, mL 894 6 424 794 6 306 .327
Hypopharynx 4/4 6/5 Duration of drainage, d 9.7 6 4.0 8.2 6 2.0 .145
Nasopharynx§ 2/0 0/0 Hospital stay, d 17.0 6 8.1 15.5 6 7.8 .522
Major salivary gland 2/0 2/0 Free flap reconstruction 3 8 .503
Oral cavity 0/0 5/0 SCM muscle sacrifice 6 10 1.000
Pathology, no. IJV ligation 3 7 .725
Squamous cell carcinoma 17 29 .193 Intentional SAN sacrifice 2 3 1.000
Adenoid cystic carcinoma 0 2 Conversion to conventional 0 –
Mucoepidermoid carcinoma 0 1 neck dissection
Salivary duct carcinoma 2 0 Perioperative complications
Lymphoepithelial carcinoma 0 1 Seroma 4 5 .715
Undifferentiated carcinoma 1 0 Hematoma 2 1 .549
pT classification, no. Chyle leakage 2 4 1.000
T0:T1:T2:T3:T4 2:4:13:0:1 0:12:14:6:1 .449 Skin flap necrosis/dehiscence 0 1 1.000
pN classification, no. Orocervical fistula* 0 2 .521
N1:N2a:N2b 4:3:13 12:1:20 .173 Lingual nerve injury 0 0
Incision, no. Hypoglossal nerve injury 0 0
Retroauricular 3 – – Phrenic nerve palsy 0 0
Modified facelift 17 – SAN injury† 0 1 1.000
Transcervical – 33 Vagus nerve injury 0 0
Sympathetic trunk injury 1 0
Abbreviations: RAND, robot-assisted neck dissection; TORS, transoral robotic surgery.
Temporary mouth 4 3 .405
* Neck length was determined as the vertical distance from the mandible angle to the upper corner deviation
border of the clavicle in the coronal image of neck CT. Satisfaction of scar 3.6 6 1.1 2.8 6 1.1 .023
†
Neck circumference was measured preoperatively using measuring tape. Adjuvant therapy
‡
TORS cases for primary resection.
§
Salvage RAND was performed for the management of nodal recurrence in nasopharyngeal
CCRTx 13 21
cancer. RTx 6 9
Median follow-up, mo 8.0 9.3 .456
Nodal recurrence 0 2 .521
muscle were cut with Harmonic curved shears. The lym-
Abbreviations: RAND, robot-assisted neck dissection; SCM, sternocleidomastoid muscle; IJV,
phatic or thoracic ducts were ligated with vascular clips. internal jugular vein; SAN, spinal accessory nerve; CCRTx, concurrent chemoradiotherapy;
After the specimen was removed, a closed suction drain RTx, radiotherapy.
* Orocervical fistula in cases of oropharyngeal cancer.
was placed (see video, online only). †
Unexpected SAN injury or resection.

Conventional neck dissection via a transcervical

approach
Conventional therapeutic neck dissection, including lev-
els I–V or II–V, was performed via a modified Scho-
binger or hockey-stick incision depending on the primary
sites by 2 senior authors (Y. W. K. and E. C. C.).
Statistical analysis
Statistical analyses were performed using the t test, the
chi-square test, Fisher’s exact test, or the Mann–Whitney
U test. Two-sided p values of < .05 were considered stat-
istically significant.
RESULTS
The RAND group consisted of 20 patients with a
median age of 62.5 years. The conventional neck dissec-
tion group consisted of 33 patients with a median age of
63.0 years. Other clinicopathologic characteristics were
not statistically significantly different by group (Table 1).
The operative parameters of each group are shown in
Table 2. The mean operative time for neck dissection in
the RAND group was longer than that in the conventional
neck dissection group (186 minutes vs 150 minutes;
p 5 .000). The mean estimated blood loss during neck
dissection in the RAND group and the conventional neck
dissection group was 259 mL and 239 mL, respectively.
The mean amount of drainage in the RAND group and
the conventional neck dissection group was 894 mL and
794 mL, respectively. The mean drainage duration was
9.7 days in the RAND group and 8.2 days in the conven-
tional neck dissection group. The mean hospital stay was
17.0 days in the RAND group and 15.5 days in the con-
ventional neck dissection group. Free flap reconstructions
were performed in 3 cases in the RAND group and 8
cases in the conventional neck dissection group. The
SCM muscle was removed in 6 and 10 cases in the
RAND group and the conventional neck dissection group,
respectively. The IJV ligation was performed in 3 and 7

HEAD & NECK—DOI 10.1002/HED MONTH 2014 3

KIM ET AL.
TABLE 3. Retrieved and pathologic lymph nodes according to neck level.
Retrieved lymph node per neck dissection
I*
II 12.60 6 4.71
III
IV
V 9.80 6 5.85
Total 40.75 6 12.92
Pathologic lymph node per neck dissection
I*
II
III
IV
V 0.35 6 1.18
Total
Abbreviation: RAND, robot-assisted neck dissection.
* The data for level I are collected from 10 and 22 cases of RAND and conventional neck dissection, respectively, which encompassed level I dissection.
cases in the RAND group and the conventional neck dis-
section group, respectively. Intentional SAN sacrifice was
done in 2 and 3 cases in the RAND group and the con-
ventional neck dissection group, respectively. No cases in
the RAND group were converted to the conventional
neck dissection. In the RAND group, there were 4 cases
of postoperative seroma, 2 cases of hematoma, 2 cases of
chyle leakage, and 4 cases of temporary mouth corner
deviation. Bleeding focuses in the 2 cases of hematoma
were the skin flap and external jugular vein. Although the
RAND procedure was performed concurrently with trans-
oral robotic lateral oropharyngectomy in 8 patients with
oropharyngeal cancer, no orocervical fistulas occurred in
these patients. There was an unexpected sympathetic
trunk injury in 1 case of the RAND group, which devel-
oped during the dissection of a lymph node that adhered
to the carotid sheath. In the conventional neck dissection
group, there were 5 cases of postoperative seroma, 1 case
of hematoma, 4 cases of chyle leakage, 1 case of wound
dehiscence, 2 cases of the orocervical fistula, 1 case of
SAN injury, and 3 cases of temporary mouth corner devi-
ation. Regardless of the neck dissection method, all
seroma and hematoma cases were resolved with needle
aspiration and compression. All cases of the chyle leak-
age were successfully managed with a fat-free diet and a
compressive dressing over the supraclavicular fossa. All
patients with mouth corner deviation recovered within a
few months.
Scar satisfaction scores were significantly higher in the
RAND group than in the conventional neck dissection group
(p 5 .023). The decision for adjuvant therapy was dependent
on the margin positivity of the primary tumor, multiplicity
of lymph node metastasis, and evidence of extracapsular
spread of the lymph node metastasis. The median follow-up
periods were 8.0 months in the RAND group and 9.3 months
in the conventional neck dissection group. Nodal recurrence
was not reported in the RAND group until the last follow-
up. However, 2 patients in the conventional neck dissection
group developed nodal recurrence.
The number of retrieved lymph nodes by neck level
and the number of pathologic lymph nodes identified in
4 HEAD & NECK—DOI 10.1002/HED MONTH 2014
RAND (n 5 20) Conventional neck dissection (n 5 33) p value
5.19 6 3.06 6.96 6 3.51 .091
13.3 6 4.95 .609
7.85 6 4.22 9.82 6 5.58 .153
6.35 6 3.39 6.64 6 3.58 .772
7.94 6 5.12 .248
44.39 6 13.99 .488
0.19 6 0.75 0.30 6 0.72 .645
2.15 6 2.13 1.70 6 1.69 .424
0.75 6 0.72 1.12 6 1.54 .316
0.50 6 1.47 0.24 6 0.83 .479
0.21 6 0.86 .653
3.90 6 4.73 3.52 6 3.83 .760
each dissection are given in Table 3. The mean number
of total retrieved lymph nodes in the RAND group
(40.75 6 12.92) was not significantly different from the
conventional neck dissection group (44.39 6 13.99;
p 5 .488). The mean number of total pathologic lymph
nodes of the RAND group (3.90 6 4.73) showed no sig-
nificant difference from that of the conventional neck dis-
section group (3.52 6 3.83; p 5 .760).
DISCUSSION
The surgical techniques used in head and neck surgery
are on the verge of substantial technological innovation.
An enormous body of evidence indicates that the appro-
priate application of robotic surgery in head and neck
cancer is feasible and effective.2,3,12,13
Radical neck dissection has been the treatment of
choice for the management of clinically obvious neck
metastasis of head and neck cancer since Crile14 first
reported a systematic approach to neck dissection. There-
after, radical neck dissection has evolved into various
modified techniques, including an MRND which pre-
serves one or more nonlymphatic structures, such as the
SAN, IJV, and SCM muscles.15 The data examining the
feasibility of selective neck dissection in the management
of N1 head and neck cancer are well documented in the
literature.16–18 Based on our previous study, we would
not dissect level I in the comprehensive neck dissection
of patients with oropharyngeal or hypopharyngeal carci-
noma with clinically node-positive neck, especially below
nodal stage N2a.19 However, despite the trend toward
focusing on minimizing morbidity, the oncologic safety
of the approach is of primary importance. On the other
hand, in the treatment of head and neck cancer, quality of
life is still an important concern. Disfiguring neck scars
and subsequent psychological trauma to the patient can
be detrimental and should be avoided if possible.
Terris et al20 developed the technique of modified face-
lift incision for parotidectomy, and the feasibility of
robotic thyroidectomy via modified facelift was recently
reported by the same group.21 Based on that, we added

modified facelift or retroauricular to the transaxillary
approach, and we named this hybrid approach transaxil-
lary and retroauricular.4 With increasing experience with
the RAND procedure via the transaxillary and retroauricu-
lar approach, we realized that omitting the transaxillary
approach for neck dissection was feasible, and we now
complete neck dissection via the retroauricular or modi-
fied facelift alone.
We previously reported the feasibility of robot-assisted
supraomohyoid neck dissection for clinically node-
negative oral tongue cancer and documented the satisfac-
tory operative parameters obtained.9 These findings were
the foundation of the rationale for the MRND via the ret-
roauricular or modified facelift approaches used in this
study. The hindrance caused by clavicular prominence
during the levels IV and V dissection could be bypassed
because a superior-to-inferior dissection was performed in
a retroauricular or modified facelift approach. Moreover,
an abbreviated transaxillary incision allowed for shorter
operating times and better results in terms of cosmesis
and invasiveness.
Retrieval of lymph nodes in the RAND group was not
significantly different from that in the conventional neck
dissection group. Satisfaction with the resulting scar was
significantly higher in the RAND group than in the con-
ventional neck dissection group.
In addition to the use of robotic surgical systems, the
more important new contribution of our method is the
shift in the incision from an anterior neck incision to ret-
roauricular or modified facelift incisions. With this inci-
sional shift, we can expect not only aesthetic superiority
but also the avoidance of postoperative lymphedema, the
prevention of wound dehiscence (especially in the trifur-
cation incision), and evasion of direct radiation to the
skin incision in case of adjuvant radiotherapy. Based on
the normal anatomic subcutaneous lymphatic channel of
the head and neck, the transverse incision in the anterior
neck can significantly disrupt lymphatic drainage, which
is generally prevented by the use of retroauricular of
modified facelift incisions. We confirmed a decreased
rate of postoperative lymphedema in the RAND group
(data are not shown), and plan to examine the postopera-
tive lymphedema results in a follow-up study.
RAND has potential weaknesses in terms of technical
complexity and its learning curve compared with conven-
tional neck dissection. We recommend that only those
surgeons who are experienced with endoscopic surgeries
perform RAND. Another disadvantage of RAND is the
longer operation time for neck dissection compared to the
conventional procedure. We evaluated the learning curve
in the RAND group, as depicted in Figure 2. It is clear
that the operation time for neck dissection in the RAND
group decreased with the accumulation of experience.
The most significant concern regarding the RAND pro-
cedure is the oncologic safety in the management of
obvious cervical metastasis. RAND should be considered
only in selected patients who have signs of nodal metasta-
sis with residual nodal architecture in preoperative stud-
ies. However, intraoperative findings indicated IJV
adhesion with lymph node metastasis in some cases.
Nevertheless, we were successfully able to perform IJV
ligation or dissect lymph nodes from IJV in all cases of
THERAPEUTIC ROBOT–ASSISTED NECK DISSECTION
FIGURE 2. Learning curves for robot-assisted neck dissection via
a retroauricular or modified face lift approach. The operation
time for neck dissection decreased with the accumulation of
experience. [Color figure can be viewed in the online issue, which
is available at wileyonlinelibrary.com.]
IJV adhesion. Specimen handling in the limited space of
the retroauricular or modified facelift approach can be
overcome by the refined movement possible with the
robotic instruments. By handling tissue meticulously and
not holding the specimen too tightly, it is not different
from the conventional technique in terms of safety from
tumor seeding. Up until the latest follow-up, no cases of
infield nodal recurrence were reported in the RAND
group.
Therapeutic RAND via an retroauricular or modified
facelift approach was feasible with satisfactory esthetic
results in patients with node-positive head and neck can-
cer. This RAND technique via a retroauricular or modi-
fied facelift approach may be successfully applied to
selected cases by an experienced surgeon. Although this
surgical novelty may not be widely applied given the
increased costs and long learning curve, the RAND tech-
nique via a retroauricular or modified facelift approach
may be successfully applied to selected cases by an expe-
rienced surgeon.
Acknowledgment
The authors thank D. S. Jang for his excellent support
with the medical illustrations.
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