Functional Neck DissectionA Description of Operative TechniqueEttore Bocca, MD; Oreste Pignataro, MD; Clarence T. Sasaki, MD

\s=b\The operative technique involved infunctional neck dissection is described toclarify its stepwise execution. Recentinterest in functional preservation de-mands therapeutic techniques that are

oncologically reliable but not mutilating.The functional neck dissection seems tobe a reasonable alternative to radicalradiotherapy and a preferred alternative totraditional neck dissection in the controlof regional metastasis when disease inthe neck is either occult or still confinedto mobile lymph nodes.

(Arch Otolaryngol 106:524-527, 1980)

Radical neck dissection, first de-' scribed by Crile1 in 1906, is a

widely destructive procedure designedto remove tumor-bearing lymph nodesof the neck. In an attempt to removethe lymphatics as completely as possi¬ble, traditional neck dissection in¬cluded removal of the submaxillarysalivary gland, internal jugular vein,greater auricular and spinal accessorynerves, as well as digastric, stylo-hyoid, and sternomastoid muscles.

Accepted for publication Oct 16, 1979.From the Otorhinolaryngology Clinic, Univer-

sity of Milan, Milan, Italy (Drs Bocca and Pigna-taro), and the Section of Otolaryngology, Depart-ment of Surgery, Yale University School of Med-icine, New Haven, Conn (Dr Sasaki).

Reprint requests to Department of Surgery,333 Cedar St, New Haven, CT 06510 (Dr Sasa-ki).

The routine, radical removal of struc¬tures uninvolved by nodal diseaseremained largely unchallenged foryears, despite the anatomic and func¬tional deformities it produced.

In 1953, Pietrantoni,2 a strong advo¬cate of bilateral elective neck dissec¬tion, recommended sparing the spinalaccessory nerves and at least one

internal jugular vein. This break withsurgical tradition was first limited toelective neck dissections, but was laterextended to therapeutic dissectionswhen lymph nodes were enlarged butstill mobile.

On the basis of the anatomic andsurgical contributions of Suarez,1 Boc¬ca,4 in 1966, modified the traditionalneck dissection, radically revisingthose concepts historically identifiedwith the surgical treatment of region¬al metastasis. A staunch opponent ofconservative nodal stripping, Bocca5indicated the complete effectivenessof his surgical technique, which hedescribed in the Semon Lecture to theRoyal Society of Medicine in 1975. Hecalled this technique the functionalneck dissection, a procedure thatmade no concession to oncologie radi-cality and that was based on soundanatomic and surgical concepts.

The anatomic basis for functionalneck dissection has been described ingreat detail by others and thereforewill not be repeated. The purpose of

this communication is to clarify theoperative technique concerning theprocedure, which originated with Boc¬ca in Europe and which promises tobecome a preferred alternative to theclassical neck dissection or radicalradiotherapy when regional metasta¬sis is either strongly suspected or con¬

fined within palpable lymph nodes ofthe neck.

OPERATIVE TECHNIQUEThe total operative time for a unilateral

neck dissection varies from one to twohours.

1. In bilateral neck dissection, a superi¬orly based apron flap is preferred, whereasa hockey-stick skin incision may be usedwhen neck dissection is unilateral.

2. By raising skin flaps that include theplatysma muscle, generous exposure of thecervical structures is obtained (Fig 1). Careis taken to preserve the greater auricularand marginal mandibular nerves. Thepoint at which the greater auricular nerve

emerges from behind the sternomastoidmuscle (Erb's point) is an important land¬mark (arrow in Fig 1) because it indicatesthe superior extent of the supraclaviculardissection to be accomplished later. Theexternal jugular vein is temporarily pre¬served along its entire course, as is thesuperficial cervical fascia enveloping thesternomastoid muscle.

3. The external jugular vein is ligatedand divided superiorly (Fig 2). The superfi¬cial cervical fascia is now cut along theposterior border of the sternomastoid mus-

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ele. By forward retraction on the cut edgeof the fascia, the sternomastoid is "un¬wrapped." Minor bleeding from the musclebelly is controlled by electrocoagulation.The divided external jugular vein will now

form the apex of the supraclavicular fossadissection to which it remains attached.

4. Attention is now turned to thesuperior limit of the operative field. Thesuperficial cervical fascia is cut along thelower border of the submaxillary fossaagainst the lateral surface of the submaxil¬lary gland, preserving the marginal man¬

dibular nerve (Fig 3). By downward retrac¬tion on this fascia, nodal tissue may befreed from the submaxillary gland andlower pole of the parotid.

5. By upward retraction of the mandibu¬lar angle and posterior retraction of thesternomastoid muscle superiorly, fascia isstripped from the digastric and stylohyoidmuscles, exposing the spinal accessorynerve as it crosses the lateral cervical spaceto enter the sternomastoid muscle (Fig 4).To free the accessory nerve, tissue overly-

ing it is incised longitudinally along itsdirection. Potential node-bearing tissueand fascia surrounding the nerve is metic¬ulously dissected from the nerve trunk andslipped under it. This dissection, bestaccomplished with a needle-tipped electro-cautery, is carried medially to the levatorscapulae muscle, which forms the deep ormedial extent of this dissection. Dissectionwith the electrocautery needle minimizesbleeding and facilitates identification ofthe accessory nerve. With the electrocau¬tery turned to a low setting, injury to thenerve has never occurred. The occipitalartery, in close approximation to the acces¬

sory nerve, should be avoided if possible.Inadvertent injury to this artery causes

unnecessary bleeding that may obscureidentification of the nerve. Anterior andmedial to the accessory nerve, care shouldbe taken to identify and avoid injuring theinternal jugular vein at this level.

6. The superficial cervical fascia is nowdissected from the posterior border of thesternomastoid muscle (Fig 5). Retracting

this muscle anteriorly will expose the direc¬tion of the accessory nerve as it enters thetrapezius muscle, posteroinferiorly. Dissec¬tion of the supraclavicular fossa is carriedsuperiorly only as far as Erb's point, toprotect this portion of the accessorynerve.

7. The supraclavicular tissue, limitedposteriorly by the trapezius muscle andinferiorly by the clavicle, is dissectedmedially up to the brachial plexus of nervesthat rests on the prevertebral muscles. Thephrenic nerve and thoracic duct are care¬

fully preserved as the contents of thesupraclavicular fossa, including the exter¬nal jugular vein, are delivered anteriorlyunder the belly of the sternomastoid mus¬

cle (Fig 5).8. Superiorly in the neck, meticulous dis¬

section of potential node-bearing tissue iscarefully accomplished from around thethyro-lingual-facial venous trunk (Fig 6,black arrow). Inspection of the spacemedial to the venous trifurcation is neces¬

sary to avoid missing disease. The venous

Fig 1 —Skin flaps are raised deep to platysma muscle. Care mustbe taken to avoid injury to greater auricular (GA) and marginalmandibular (MM) nerves. External jugular vein (EJ) and superfi¬cial cervical fascia overlying sternomastoid muscle (SM) aretemporarily preserved. Note position of Erb's point (arrowhead).

Fig 2.—Superficial cervical fascia is cut along posterior border ofsternomastoid muscle and, with No. 15 blade, is dissectedanteriorly as muscle is "unwrapped." External jugular vein isdivided superiorly and left attached to contents of supraclavicularfossa.

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trifurcation may be resected if nodesmedial to this venous trunk are suspectedto contain metastatic tumor.

9. The specimen, now freed superiorly,posteriorly, and inferiorly, remains at¬tached to the internal jugular vein andcarotid artery (Fig 6). Final dissectionfrom these large vessels is easily accom¬

plished, resulting in complete removal of

all lymph-bearing tissues from the lateralaspect of the neck (Fig 7).

COMMENT

According to Bocca,5 the effective¬ness of functional neck dissection isfavorably compared to traditionalneck dissection in a report from the

Otorhinolaryngology Clinic of Milan,Italy, in 1975. Of 403 patients withlaryngeal cancer treated by tradi¬tional neck dissection, 70% of thosewith NO disease survived five years,whereas 44% of those with Nl-2 dis¬ease (mobile nodes) survived fiveyears. On the other hand, of 367

Fig 3.—Superficial cervical fascia is dissected from medial sur¬face of sternomastoid muscle. This fascia is now cut along lowerborder of submaxillary fossa against lateral surface of submaxil¬lary gland, protecting marginal mandibular nerve. Potentiallymph-bearing tissue is dissected from submaxillary salivarygland (SG) and lower pole of parotid gland (PG).

Fig 4.—Spinal accessory nerve is identified by strong upwardretraction on mandible and posterosuperior retraction of sterno¬mastoid muscle. Tissue overlying nerve is incised along itsdirection. As nerve is freed, surrounding fascia and soft tissue ispassed anteriorly beneath nerve trunk. A good deal of importanceis placed on meticulous dissection around this nerve, such thatthe deep margin of this compartment is cleaned to the levatorscapulae muscle. Occipital artery, passing in close proximity toaccessory nerve, should be avoided. Care must be taken toidentify internal jugular vein, located anterior to accessorynerve.

Fig 5.—Superficial cervical fascia is now dissected from posteriorborder of sternomastoid muscle. Contents of supraclavicularfossa are dissected from trapezius muscle posteriorly, acrossclavicle inferiorly, and deep to, but not including, brachial plexus(BP) overlying prevertebral muscles. This dissected block oftissue, marked superiorly by Erb's point, is delivered anteriorlydeep to sternomastoid muscle. As this dissection proceedsanteriorly, care must be taken to preserve the phrenic nerve andthoracic duct low in the neck.

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Fig 6.—Careful dissection of fascia from internal jugular vein (IJ)and carotid artery (CA) is accomplished, paying specific attentionto thyro-lingual-facial venous trifurcation high in neck. Thistrifurcation is either divided and included in neck specimen, orspace behind it is carefully inspected for possible nodal disease(black arrow).

Fig 7.—Completed neck dissection should now have preservedmarginal mandibular (MM) and greater auricular (GA) nerves,internal jugular vein (IJ), carotid artery (CA), vagus and sympa¬thetic nerves, as well as phrenic nerve and brachial plexus (BP).Sternomastoid (SM) and omohyoid (OH) muscles remain intact.

patients treated by functional neckdissection, 89% of patients with NOdisease and 48% of patients with Nl-2disease survived five years. No pa¬tient received adjuvant radiotherapy.Such a favorable comparison wouldindicate, therefore, that functionalneck dissection fulfilled the require¬ments of oncologie safety while avoid¬ing unnecessary mutilation.

It should be apparent that function¬al neck dissection has nothing in com¬

mon with the mere stripping of lymphnodes. Rather, it is a complete dissec¬tion of the lateral cervical space, ana¬

tomically confined by a fasciai enve¬

lope, and itself containing the majorcervical lymphatics.5 The preservationof major nerves, vessels, and muscledoes not appear to compromise onco¬

logie safety. Functional preservationof the neck presents undeniableadvantages:

1. It avoids unjustified conse¬

quences of the traditional neck dissec¬tion, including dropped shoulder, skel-

étal pain, limitations of neck and limbmotion, and widespread cutaneousanesthesia.

2. Bilateral dissection may be per¬formed simultaneously without dan¬ger of abrupt venous congestion intra-cranially.

3. It provides a reasonable alterna¬tive to radical radiotherapy of theneck, when the preferred treatment ofthe primary tumor is surgical. Thus,the untoward biologic consequences ofradiation are avoided entirely, with¬out resorting to the mutilation of tra¬ditional neck dissection.

4. When the preferred treatment ofthe primary tumor requires combinedsurgery and radiation, functional neckdissection may alter the decision forneck irradiation in patients with NOdisease. Indeed, it may alter the man¬

ner in which adjuvant radiation isdelivered in patients with Nl-2 dis¬ease.

It is our opinion that N3 disease(fixed nodes) represents an absolute

contraindication to functional neckdissection. However, previous radia¬tion to the neck is not considered a

contraindication to this procedure.It is hoped that the essential points

of this technique have been adequate¬ly described at a time when increasinginterest in functional preservation isboth demanded by the patient andrequired by the physician.

This study was supported by a grant to DrSasaki from the International Union AgainstCancer.

References

1. Crile G: Excision of cancer of the head andneck. JAMA 47:1780-1786, 1906.

2. Pietrantoni L: Il problema chirurgico dellemetastasi linfoghiandolari del cancro della lar-inge. Arch Ital Otol, suppl 14, 1953.

3. Suarez O: El problema de las metastasislinfaticas y alejadas del cancer de laringe e

hipofaringe. Rev Otorrinolaryngol Santiago23:83-99, 1963.

4. Bocca E: Supraglottic laryngectomy andfunctional neck dissection. J Laryngol 80:831-838,1966.

5. Bocca E: Critical analysis of the techniquesand value of neck dissection. Arch Ital OtolRinol Laryngol 4:151-158, 1976.

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