2004 WebMD, Inc. All rights reserved.

ACS Surgery: Principles and Practice

2 HEAD AND NECK

6 NECK DISSECTION 1

NECK DISSECTION

Miriam N. Lango, M.D., Bert W. OMalley, Jr., M.D., F.A.C.S., and Ara A. Chalian, M.D.

Preoperative Evaluation

In the majority of cases, cancer in the neck is a metastasis from

a primary lesion in the upper aerodigestive tract, though metastases from skin, thyroid, and salivary gland neoplasms are
also encountered. Lymphomas often present as cervical
lymphadenopathy.
When a patient presents with a suspicious lesion in the neck, a
careful history and physical examination should be performed,
along with a thorough evaluation of the aerodigestive tract aimed
at locating the source of possible metastatic disease. Fine-needle
aspiration (FNA) of the neck mass should then be done to determine whether the mass is malignant. FNA can often differentiate
between epithelial and lymphoid malignancies, and this differentiation will guide subsequent workup. The reported sensitivity of
FNA ranges from 92% to 98%; the reported specificity, from
94% to 100%.1,2
If FNA reveals the presence of atypical lymphoid cells, an excisional lymph node biopsy should be performed to supply the
pathologist with a large enough sample to allow full typing of the
tissue. An excisional biopsy may also be performed if the FNA is
negative or indeterminate, the surgeon suspects a malignancy,
and the rest of the physical examination yields negative results.
Routine excisional biopsy of neck masses for diagnostic purposes
is not recommended, however, because it may result in tumor
spillage into the wound and complicate subsequent definitive
resection.
Once the presence of an epithelial malignancy is established,
the primary site of the lesion must be determined if it is not
apparent on initial physical examination. Imaging studies (e.g.,
computed tomography and magnetic resonance imaging) may be
helpful in locating the source of a cervical metastasis. Positron
emission tomography (PET) detects lesions with increased metabolic activity but has the limitation of being unable to detect
lesions smaller than 1 cm in diameter. Primary lesions greater
than 1 cm in diameter usually are easily identified on physical
examination and other imaging studies; thus, PET scans are of
limited value in this setting. In any patient with metastatic cervical adenopathy thought to originate in the upper aerodigestive
tract, panendoscopy and biopsy with general anesthesia are
mandatory for locating and characterizing the primary source of
the tumor and ruling out the presence of synchronous lesions.
The most common occult primary sites are the base of the
tongue, the tonsils, and the nasopharynx. In 5% to 10% of
patients who present with a metastatic node, the primary lesion is
never found despite extensive workup.
INCIDENCE AND IMPACT OF NECK METASTASES

Cutaneous Squamous Cell Carcinoma

The incidence of cervical metastases is governed by many factors. Cervical metastases from cutaneous squamous cell carcinomas are rare, occurring in 2% to 10% of cases. However, certain
lesionsthose that are greater than 2 cm in diameter; are recur-

rent; are deeper than 6 mm; involve the ear, the temple, or the
classic H zone; occur in an immunocompromised patient; or are
poorly differentiatedhave a significant occult metastatic rate,
ranging from 20% to 60%. The presence of cervical metastases
reduces 5-year survival to about 32%,3 which suggests that early
intervention for high-risk cutaneous lesions, involving regional
lymphadenectomy, sentinel lymph node (SLN) biopsy, or irradiation of at-risk lymph node basins, may be warranted.
Salivary Gland Neoplasms
With salivary gland neoplasms [see 2:2 Oral Cavity Lesions],
the incidence of cervical metastases is related to the histopathology as well as the size of the tumor. The most aggressive salivary
gland lesions are squamous cell carcinoma, carcinoma ex pleomorphic adenoma, adenocarcinoma, and salivary ductal carcinoma. Patients with these lesions often have cervical metastases at
presentation that warrant a therapeutic neck dissection [see Table
1]. How best to manage occult cervical salivary gland metastatic
disease is controversial. The occult metastatic rate for aggressive
lesions ranges from 25% to 45%. For such lesions, a selective
neck dissection is typically incorporated into the surgical
approach.4
Metastatic Well-Differentiated Thyroid Cancer
Cervical lymph node metastases are present in 10% to 15% of
patients with well-differentiated thyroid carcinoma. The impact
of nodal metastases on local recurrence and survival has not been
established. Other factors (e.g., age, sex, tumor extent, and distant metastases) appear to have a greater effect on prognosis.
Nevertheless, in the presence of clinically apparent nodal disease,
a formal neck dissection is advised: so-called cherry-picking operations or limited lymph node excisions result in higher rates of
recurrence.5
Squamous Cell Carcinoma of the Upper Aerodigestive Tract
With upper aerodigestive tract squamous cell carcinomas, the
incidence of cervical metastases is related to the site of the primary lesion, the size of the tumor, the degree of differentiation,
the depth of invasion, and a number of other factors. A significant proportion of head and neck cancer patients who harbor
clinically silent primary tumors of the base of the tongue, the
tonsils, or the nasopharynx initially present with cervical
adenopathy [see Table 1]. These sites lack anatomic barriers that
limit tumor spread and are supplied by rich lymphatic networks
that facilitate metastasis. In contrast, patients with glottic and lip
cancers are more likely to present early, without clinical
adenopathy.
The presence of cervical metastases negatively affects prognosis and has been associated with increased recurrence rates and
reduced disease-free and overall survival.The presence of clinical
adenopathy decreases survival by 50%. Metastatic tumors that
rupture the lymph node capsulea process known as extracapsular spread (ECS)are biologically more aggressive. Patients

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2 HEAD AND NECK

6 NECK DISSECTION 2

Table 1 Incidence of Cervical Metastases in

Selected Head and Neck Cancers
Tumor
Cutaneous squamous cell carcinoma
Salivary gland malignancies
Mucoepidermoid carcinoma (highgrade)
Adenoid cystic carcinoma
Malignant mixed tumor
Squamous cell carcinoma
Salivary duct carcinoma
Acinic cell carcinoma
Metastatic well-differentiated thyroid
cancer
Squamous cell carcinoma of upper
aerodigestive tract
Alveolar ridge
Hard palate
Oral tongue
Anterior pillar/retromolar trigone
Floor of mouth
Soft palate
Tonsillar fossa
Tongue base
Bilateral

ACS Surgery: Principles and Practice

Incidence of Cervical Adenopathy

2%10%

30%70%
8%
25%
46%
50%
40%
10%15%

30%
10%
30%
45%
30%
44%
76%
78%
20%

who have palpable cervical lymphadenopathy with ECS manifest

a 50% decrease in survival compared with those who have palpable cervical lymphadenopathy without ECS.6 In addition,
about 50% of clinically negative, pathologically positive neck
specimens exhibit ECS. Clinically negative, pathologically positive, and ECS-positive specimens are associated with a high risk
of regional recurrence and distant metastases.7-9 The presence of
ECS in lymph node metastases may in fact be the single most
important prognostic factor in patients with head and neck cancer. Identification of this patient subset may be the most important benefit of elective neck dissection, in that it allows these
patients to be offered adjuvant therapy. Nonrandomized studies
have found that both disease-specific and overall survival are significantly improved when these high-risk patients are treated
with adjuvant postoperative chemoradiation.10 However, randomized clinical trials are needed to confirm the clinical benefits
of adjuvant chemoradiation in this setting.
Whereas anatomic and pathologic factors (e.g., ECS) have
long been known to predict tumor behavior, it is only comparatively recently that the impact of comorbidity has been well characterized.When patients are stratified by tumor stage, those with
comorbidities fare worse. In fact, the impact of comorbidity on
overall survival is greater than that of tumor stage or treatment
type.10,11 In addition, comorbidity is associated with both
increased frequency and increased severity of surgical complications.These factors may be important in treatment selection and
patient counseling. To date, comorbidity has not been incorporated into clinical staging of head and neck cancer patients.
STAGING OF NECK CANCER

Staging of the neck for metastatic squamous cell carcinomas of

the head and neck is based on the TNM classification formulated
by the American Joint Committee on Cancer (AJCC) [see 2:2
Oral Cavity Lesions]. The N classification applies to cervical
metastases from all upper aerodigestive tract mucosal sites except

the nasopharynx; it also applies to metastases from major salivary

gland and sinonasal malignancies but not to metastases from
cutaneous or thyroid malignancies, which use an alternate staging
system.
The purpose of staging is to characterize the tumor burden of
an individual patient. Accordingly, an effective staging system
should incorporate factors known to have prognostic and therapeutic significance, thereby facilitating planning of therapy and
appropriate patient counseling. In addition, it should attempt to
standardize reporting so that meaningful cross-institutional comparisons can be obtained. A staging system ideally should also be
simple to apply while still incorporating biologically important
factors that permit accurate patient stratification in prospective
clinical trials. Precise characterization and differentiation of tumors facilitate identification of those patients who are most likely to benefit from treatment.
The TNM staging system does not include a number of factors that are known to have an impact on prognosis, such as the
presence or absence of ECS and the pattern of lymphatic spread.
Nonanatomic factors (e.g., comorbidity, immune status, and nutritional status) have a strong impact on survival as well but are
also not incorporated in the current staging system. In general,
TNM staging has been found inadequate for use in clinical
trials.12
The limitations of clinical staging of the neck are well described.The addition of imaging to clinical examination improves
diagnostic sensitivity but not specificity. Imaging is particularly
useful after chemoradiation because of the difficulty of clinical
examination in this setting. Pathologic review of neck specimens
remains the gold standard for anatomic staging. The addition of
ultrasound-guided FNA of neck nodes yields enhanced diagnostic accuracy in cases where the neck is clinically negative but the
radiologic findings are positive. This approach is employed to
select patients for neck dissection in a number of centers, particularly in Europe; whether it provides more accurate staging than
alternative methods, such as SLN biopsy, remains to be determined. Results from the First International Conference on
Sentinel Node Biopsy in Mucosal Head and Neck Cancer
revealed that SLN biopsy of the clinically negative neck has a sensitivity comparable to that of a staging neck dissection.13 In general, imaging modalities appear to be neither sufficiently sensitive
nor sufficiently specific in the evaluation of the clinically negative
neck. Uptake of 2-deoxy-3 [18F] fluoro-D-glucose, as measured
by PET scans, is undetectable in small foci of cancer in the clinically negative neck.14
Proper staging is important for stratification of patients into
risk categories on the basis of tumor biology, so that high-risk
patients may be appropriately selected for clinical trials or offered
adjuvant therapy and other patients may be spared unnecessary
treatment. Until accurate methods of assessing the clinically negative neck are developed, selective neck dissection will be performed to treat the neck when the occult metastatic rate is
expected to be higher than 20%.
INDICATIONS FOR NECK DISSECTION

The classic indication for neck dissection is for treatment of

metastatic carcinoma in the neck, most frequently deriving from
a mucosal site in the upper aerodigestive tract. Over time, the
indications for neck dissection have changed. With wider use of
chemoradiation therapy for head and neck cancer, treatment of
metastatic disease in the neck has become increasingly nonsurgical. Currently, neck dissections are considered either therapeutic
(performed to treat palpable disease in the neck) or elective (per-

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6 NECK DISSECTION 3
Operative Planning
CHOICE OF PROCEDURE

Comprehensive Dissection: Radical and Modified Radical Neck

Dissection

II
I

III

VI

V
IV

Figure 1 Cervical lymph nodes are divided into six levels

on the basis of their location in the neck.

formed when the expected incidence of occult metastases from a

lesion exceeds 20%).Technically, neck dissections are classified as
comprehensive dissections, which incorporate five levels of the
neck, or selective dissections, in which only selected lymph node
levels are removed according to predicted drainage patterns from
specific primary sites.There is also a third technical classification,
extended neck dissections, which can be combined with selective
or comprehensive neck dissections for removal of additional
nodal basins [see Operative Planning, Choice of Procedure,
below]. Six lymph node drainage basins in the neck are recognized
[see Figure 1].
CONTRAINDICATIONS TO NECK DISSECTION

The only absolute contraindication to neck dissection is surgical unresectability. The determination of unresectability is made
by the operating surgeon either preoperatively, on the basis of
imaging studies, or in the operating room.Typically, the presence
of Horner syndrome, paralysis of the vagus nerve or the phrenic
nerve, or invasion of the brachial plexus or the prevertebral muscles indicates that the tumor is unresectable. The involvement of
the carotid artery may be predicted on the basis of imaging studies. Encasement of the carotid artery by tumor suggests direct
invasion of the vessel; however, studies correlating imaging characteristics and pathologic invasion of the carotid have shown that
tumors surrounding 180 or more of the carotids circumference
have a higher incidence of carotid invasion than tumors surrounding less than 180 (75% versus 50%). In the absence of
direct invasion of the vessel wall, tumor may be peeled off by
means of subadventitial surgical dissection. Tumors surrounding
270 of the vessel have an 83% incidence of carotid invasion,
necessitating sacrifice of the artery.15 However, sacrifice of the
carotid artery, with or without reconstruction with a vein graft,
has been associated with significant morbidity and confers no
survival benefit.16

The radical neck dissection was first described in 1906 by

George Crile, who based his approach on the Halstedian principle of en bloc resection. The procedure was subsequently standardized by Hayes Martin at Memorial Hospital in New York in
the 1930s and 1940s. In this latter version of the procedure, lymphatic structures from the strap muscles anteriorly, the trapezius
posteriorly, the mandible superiorly, and the clavicle inferiorly are
removed. Nonlymphatic structures in this space are also sacrificed, including the spinal accessory nerve, the sternocleidomastoid muscle, the internal and external jugular veins, the submandibular gland, and sensory nerve roots. The routine sacrifice
of the spinal accessory nerve, the internal jugular vein, and the
sternocleidomastoid muscle contributes to the significant morbidity associated with radical neck dissection.
Since the 1970s, the necessity of en bloc resection for oncologic cure has been reexamined. Structures once routinely sacrificed are now routinely preserved unless they are grossly involved
with cancer.The various functional, or modified, radical neck dissections are classified according to which structures are preserved. Type I dissections preserve the spinal accessory nerve;
type II, the spinal accessory nerve and the internal jugular vein;
type III, both of these structures along with the sternocleidomastoid muscle. Modified radical neck dissections have proved to be
as effective in controlling metastatic disease to the neck as the
classic radical neck dissection.17
Selective Neck Dissection
In a selective neck dissection, at-risk lymph node drainage
basins are selectively removed on the basis of the location of the
primary tumor in a patient with no clinical evidence of cervical
lymphadenopathy. Cancers in the oral cavity, for example, typically metastasize to levels I through III and, occasionally, IV; laryngeal cancers typically metastasize to levels II through IV.The rationale for selective neck dissection is based on retrospective pathologic reviews of radical neck dissection specimens from patients
without palpable lymphadenopathy. These reviews revealed that
lymph node micrometastases were confined to specific neck levels
for a given aerodigestive tract site.18
The advantages of selective neck dissection over radical and
modified radical neck dissection are both cosmetic and functional. A selective neck dissection involves less manipulation (and
thus less risk of devascularization) of the spinal accessory nerve,
thereby decreasing the incidence of postoperative shoulder dysfunction. Preservation of the sternocleidomastoid muscle alleviates the cosmetic deformity seen with a radical neck dissection
and provides some protection for the carotid artery.
Preservation of the internal jugular vein decreases venous congestion of the head and neck and is necessary if the contralateral
internal jugular vein is sacrificed.With primary lesions located in
the midline in the base of the tongue, the supraglottic larynx, or
the medial wall of the piriform sinus, bilateral regional metastases
are common, and bilateral neck dissections are therefore indicated. Sacrifice of both internal jugular veins is associated with significant morbidity, including increased intracranial pressure, syndrome of inappropriate antidiuretic hormone secretion, airway
edema, and death. Bilateral internal jugular sacrifice is managed
by staging the neck dissections or by carrying out vascular repair.

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2 HEAD AND NECK
In the presence of multiple pathologically positive lymph nodes
or evidence of ECS, adjuvant therapy is indicated.19 Accordingly,
selective neck dissection may be viewed as a diagnostic as well as
a therapeutic procedure. To date, however, no randomized clinical trials have demonstrated that selective neck dissection with
adjuvant treatment as needed is better than so-called watchful
waiting with regard to prolonging survival in patients who present
without evidence of cervical metastatic disease. Therefore, it
is not yet possible to justify the added cost and morbidity of elective neck dissection in patients without evidence of metastatic disease. SLN mapping may facilitate pathologic staging in this setting and spare low-risk patients from unnecessary interventions;
however, its sensitivity and specificity for this purpose are still
under investigation.
The growing focus on preservation of function and limitation
of morbidity has led some surgeons to promote the use of selective neck dissection to treat node-positive neck tumors.
Although retrospective studies have suggested that a selective
neck dissection may be adequate in carefully selected node-positive patients,20 the effectiveness of this approach is still
unproven, and its application remains subject to individual surgical judgment.
Extended Neck Dissection
Extended neck dissections can be combined with selective
or comprehensive neck dissections to remove additional nodal
basins, such as the suboccipital and retroauricular nodes. These
groups of nodes, which are located in the upper posterior neck,
are the first-echelon nodal basins for posterior scalp skin cancers. The retroauricular nodes lie just posterior to the mastoid
process, and the suboccipital nodes lie near the insertion of the
trapezius muscle into the inferior nuchal line. Cancers of the
anterior scalp, the temple, and the preauricular skin drain to periparotid lymph nodes; these lymph nodes are removed in conjunction with a parotidectomy [see 2:5 Parotidectomy]. Retropharyngeal nodes may be removed in the treatment of selected
cancers originating in the posterior pharynx, the soft palate, or
the nasopharynx. A mediastinal lymph node dissection may be
combined with a neck dissection in the treatment of metastatic
thyroid carcinomas.
NECK DISSECTION AFTER CHEMORADIATION

The indications for neck dissection have been significantly

affected by the increasing use of organ preservation protocols for
the treatment of head and neck cancer. Nasopharyngeal carcinomas, which are uniquely radiosensitive, are generally treated with
irradiation, with or without chemotherapy; neck dissection is
reserved for patients who experience an incomplete response and
for patients with bulky cervical lesions. Similarly, patients with
early nodal disease (N0 or N1) treated according to organ preservation protocols may undergo nonsurgical therapy. For patients
who have advanced neck disease (N2 or N3) or who respond
incompletely to therapy, a planned posttreatment neck dissection
is recommended because surgical salvage of so-called neck failures is rarely successful.21 As a rule, the planned neck dissection
should be done within 6 weeks of the completion of chemoradiation therapy: if it is delayed past the 6-week point, progressive
soft tissue fibrosis may develop, resulting in difficult surgical dissection, increased postoperative morbidity, and, potentially,
tumor progression.
A 2003 study highlighted the need for planned neck dissection
after definitive chemoradiation for N2 or N3 nodal disease.22 In
this study, 76 patients presenting with N2 or N3 disease under-

ACS Surgery: Principles and Practice

6 NECK DISSECTION 4
went a planned neck dissection. Tumor cells were present in the
neck specimens of 25% of patients with complete and 39% of
patients with incomplete clinical responses. No patients with
complete pathologic responses experienced regional recurrence,
whereas 20% of patients with pathologically positive neck dissection specimens experienced nonsalvageable regional recurrences. In addition, planned neck dissection led to reduced rates
of regional recurrence in patients treated with chemoradiation.
The authors suggested that all patients presenting with N2 or
N3 cervical lymphadenopathy should undergo planned neck
dissection, regardless of clinical response to chemoradiation
therapy.
The required extent of planned neck dissection after chemoradiation is still under investigation. Neck dissection after chemoradiation carries significant morbidity in the form of severe soft tissue fibrosis and increased spinal accessory nerve injury. Pathologic
review of comprehensive neck specimens after chemoradiation
reveals that in patients with oropharyngeal cancer, levels I and V
are rarely involved in the absence of radiographic abnormalities,23
which suggests that a planned selective dissection involving levels
II through IV may be sufficient for cases of oropharyngeal cancer
treated with chemoradiation. This more limited approach undoubtedly causes less morbidity, but additional data are required
to assess its oncologic efficacy.
Typically, management of the neck is determined in part by
management of the primary tumor. Early neck dissection for
bulky nodal disease before nonsurgical treatment of the primary
lesion is a controversial practice. Bulky cervical adenopathy is
unlikely to exhibit a complete pathologic response to nonsurgical
treatment. A patient who requires dental extractions before radiation therapy may undergo a neck dissection at the same time,
proceeding to radiation therapy 7 to 10 days after operation.
Early neck dissection decreases the tumor burden, thereby allowing lower adjunctive doses of radiation to be delivered to the neck.
Thus, it is possible that early neck dissection for bulky resectable
cervical adenopathy can reduce the expected morbidity of
planned postchemoradiation neck dissection.There is limited evidence in the literature that such an approach is feasible in certain
circumstances24; however, it is recommended that significant
delays in initiating treatment to the primary site be avoided
because such delays may ultimately have a negative impact on
survival.
RECONSTRUCTION AND RECURRENCE AFTER NECK
DISSECTION

The use of microvascular free tissue transfer to reconstruct

surgical defects in the head has allowed surgeons to resect large
tumors with large margins while simultaneously achieving
improved functional results. Preservation of vascularand,
occasionally, neuralstructures during neck dissection may
facilitate the reconstructive process. Typically, several vessels,
including an artery and one or two veins, are required for inflow
and outflow into a free flap. The facial artery, the retromandibular vein, and the external jugular vein, which are preserved during level I and level II dissection, are the vessels that
are most frequently used for flap revascularization. If these vessels are unavailable as a consequence of high-volume neck disease, the superior thyroid artery and the transverse artery, with
companion veins, are suitable substitutes. To date, there is no
evidence in the literature that preservation of vascular structures
in the neck predisposes patients to regional recurrence. Caution must, however, be exercised in the setting of pathologic
lymphadenopathy.

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6 NECK DISSECTION 5

Figure 2 Illustrated are incisions used for neck dissections. Incision design is a critical element of operative planning. Incisions are chosen with the aims of optimizing exposure of relevant neck levels and minimizing morbidity. The
incisions depicted in (a) and (b) are useful for selective neck dissections. For the more extensive exposure required in
a radical or modified radical neck dissection, a deeper half-apron style incision (c) may be used, or a vertical limb
may be dropped from a mastoid-submental incision (d); the latter incision is less reliable and may break down, exposing vital structures such as the carotid. The incision depicted in (e) is also useful for selective neck dissections. The
Macfee incision (f) provides limited exposure and results in persisent lymphedema in the bipedicled skin flap.

Operative Technique
RADICAL NECK DISSECTION

Step 1: Incision and Flap Elevation

When a radical or modified radical neck dissection is indicated,
appropriate neck incisions must be designed so as to facilitate exposure while preserving blood flow to the skin flaps [see Figure 2]. The
incision provides access to the relevant levels of the neck, affects
cosmesis, and determines the extent of lymphedema and postoperative fibrosis (woody neck), especially in previously irradiated
areas. If a biopsy was previously performed, the tract should be
excised and incorporated into the new incision.When a total laryngectomy is done, the stoma is fashioned separately from the neck
incision; in the event of a pharyngocutaneous fistula, the salivary
flow will be diverted away from the stoma.
Once the incision is made, subplatysmal flaps are raised. If
there is extensive lymphadenopathy or extension of tumor into
the soft tissues of the neck, skin flaps may be raised in a
supraplatysmal plane to ensure negative surgical margins. Such
flaps, however, are not as reliably vascularized as subplatysmal
flaps. Clinical judgment must be exercised in these situations.The
flaps are raised to the mandible superiorly, the clavicle inferiorly,
the omohyoid muscle and the submental region anteriorly, and
the trapezius posteriorly. Typically, radical neck dissections are
performed in patients with clinically positive lymphadenopathy,
and adequate exposure of levels I through V is required. If a vertical limb is used, it must not be centered over the carotid artery,
because of the risk of potentially catastrophic dehiscence. Deep
utility-type incisions yield more limited exposure of level I but
provide reliable vascular inflow to skin flaps.

Step 2: Dissection of Anterior Compartment

Embedded within the fascia overlying the submandibular
gland is the marginal mandibular branch of the facial nerve,
which must be elevated and retracted to prevent lower-lip weakness. The submental fat pad is then grasped, retracted posteriorly and laterally, and mobilized away from the floor of the submental triangle.The omohyoid muscle is identified inferior to the
digastric tendon and skeletonized to its intersection with the sternocleidomastoid muscle posteriorly.The omohyoid muscle forms
the anteroinferior limit of the dissection.
Fat and lymphatic structures are dissected away from the
digastric muscle and the mylohyoid muscle. The hypoglossal and
lingual nerves lie just deep to the mylohyoid muscle and are protected by it [see Figure 3]. In this region, the distal end of the facial
artery can be identified and preserved as needed for reconstructive purposes. Once the posterior edge of the mylohyoid muscle
is visualized, an Army-Navy retractor is inserted beneath the
muscle to expose the submandibular duct, the lingual nerve with
its attachment to the submandibular gland, and the hypoglossal
nerve.The submandibular duct and the submandibular ganglion,
with its contributions to the gland, are ligated, and the submandibular gland is retracted out of the submandibular triangle.
The posterior belly of the digastric muscle is then identified
inferior to the submandibular gland and skeletonized to the sternocleidomastoid muscle posteriorly, where it inserts on the mastoid tip.The specimen must be mobilized off structures just inferior to the digastric muscle. To prevent inadvertent injury, it is
essential to understand the relationships among these structures
[see Figure 3]. The hypoglossal nerve emerges from beneath the
mylohyoid muscle and passes into the neck under the digastric

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6 NECK DISSECTION 6

Internal Carotid
Artery

External
Carotid
Artery
Facial
Artery
Digastric
Muscle
Spinal
Accessory
Nerve

Lingual
Artery
Hypoglossal
Nerve

Occipital Artery
Mylohyoid
Muscle

Internal Jugular
Vein

Hyoid Bone

Ansa Hypoglossi
Superior
Thyroid
Artery
Carotid Sheath

Hyoglossal
Muscle

Common Carotid
Artery

Vagus Nerve

Figure 3 Depicted are the key anatomic relationships in levels I and II that must be kept in
mind in performing a neck dissection. View is of the right neck.

muscle. It then loops around the external carotid artery at the origin of the occipital artery and ascends to the skull base between
the external carotid artery and the internal jugular vein. Often,
the hypoglossal nerve is surrounded by a plexus of small veins,
branching off the common facial vein. Bleeding in this region
places the hypoglossal nerve at risk.The jugular vein, located just
posterior to the external carotid artery and the hypoglossal nerve,
may be isolated and doubly suture-ligated at this point.
Frequently, the spinal accessory nerve is identified just lateral and
posterior to the internal jugular vein, proceeding posteriorly into
the sternocleidomastoid muscle.
In a radical neck dissection, the sternocleidomastoid muscle
and the spinal accessory nerve are transected at this point and elevated off the splenius capitis and the levator scapulae to the
trapezius posteriorly. The anterior edge of the trapezius is skeletonized from the occiput to the clavicle. The accessory nerve is
again transected where it penetrates the trapezius.
Step 3: Control of Internal Jugular Vein Inferiorly; Ligation of
Lymphatic Pedicle
The sternal and clavicular heads of the sternocleidomastoid
muscle are transected and elevated to expose the anterior belly of
the omohyoid muscle.The soft tissue overlying the posterior belly
of the omohyoid muscle is dissected, clamped, and ligated as necessary. The omohyoid muscle is then transected, and the jugular
vein, the carotid artery, and the vagus nerve are exposed. The
jugular vein is isolated and doubly suture-ligated. Care is taken
not to transect the adjacent vagus nerve and carotid artery. The
lymphatic tissues in the base of the neck adjacent to the internal
jugular vein are clamped and suture-ligated 1 cm superior to the
clavicle. If a chyle leak is encountered, a figure-eight stitch is

placed along the lymphatic pedicle until there is no evidence of

clear or turbid fluid on the Valsalva maneuver. Care is taken to
avoid inadvertent injury to the vagus nerve or the phrenic nerve,
which course through this region.
Step 4: Mobilization of Supraclavicular Fat Pad (Bloody
Gulch)
The fascia overlying the supraclavicular fat pad is incised, and
the supraclavicular fat pad is bluntly retracted superiorly so as to
free the tissues from the supraclavicular fossa. If transverse cervical vessels are encountered, they are clamped and ligated as necessary. Fascia is left on the deep muscles of the neck, which also
envelop the brachial plexus and the phrenic nerve.
Step 5: Dissection and Removal of Specimen
Attention is then turned to the posterior aspect of the neck. Fat
and lymphatic tissues are retracted anteriorly with Allis clamps,
and the specimen is dissected off the deep muscles of the neck
with a blade. Again, a layer of fascia is left on the deep cervical
musculature: stripping fascia off the deep cervical musculature
results in denervation of these muscles, which adds to the morbidity associated with accessory nerve sacrifice. Once the specimen is mobilized beyond the phrenic nerve, the cervical nerves
(C1C4) may be divided. The specimen is peeled off the carotid
artery and removed.
Step 6: Closure
The neck incision is closed in layers over suction drains.
MODIFIED RADICAL NECK DISSECTION

The incision is made and flaps elevated as in a radical neck dis-

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ACS Surgery: Principles and Practice

2 HEAD AND NECK

section. Care must be exercised in elevating the posterior skin
flap.Typically, the platysma is deficient in this area, and often, no
natural plane exists. Dissection deep in the posterior triangle may
result in inadvertent injury to the spinal accessory nerve, which
travels inferiorly and posteriorly across the posterior triangle in a
relatively superficial plane to innervate the trapezius.
A type I modified radical neck dissection begins with dissections of levels I and II, as described for a radical neck dissection
(see above). The spinal accessory nerve is identified just superficial or posterior to the internal jugular vein and preserved; the
distal spinal accessory nerve is then identified in the posterior triangle.Typically, the spinal accessory nerve can be identified 1 cm
superior to the cervical plexus along the posterior border of the
sternocleidomastoid muscle. Provided that the patient is not fully
paralyzed, the surgeon can distinguish this nerve from adjacent
sensory branches by using a nerve stimulator.
Once the spinal accessory nerve is identified, it is dissected and
mobilized distally to the point at which it penetrates the trapezius. Proximally, the nerve is dissected through the sternocleidomastoid muscle, which is transected over the nerve. The branch
to the sternocleidomastoid muscle is divided with Metz scissors,
and the nerve is fully mobilized from the trapezius posteroinferiorly to the posterior belly of the digastric muscle anterosuperiorly, then gently retracted out of the way.
The rest of the neck dissection proceeds as described for a radical neck dissection. If the tumor does not involve the internal
jugular vein, it may also be preserved; this constitutes a type II
modified radical neck dissection. If the spinal accessory nerve, the
internal jugular vein, and the sternocleidomastoid muscle are all
preserved, the procedure is a type III modified radical neck dissection. In a type III dissection, the sternocleidomastoid muscle
is fully mobilized and retracted with two broad Penrose drains,
and the contents of the neck are exposed. The spinal accessory
nerve is preserved thoughout its entire course, including the
branch to the sternocleidomastoid muscle. The remainder of the
neck dissection proceeds as previously described (see above).
SELECTIVE NECK DISSECTION

Levels I to IV
In a selective neck dissection, the posterior triangle is not
removed; thus, there is no need to elevate skin flaps posterior to
the sternocleidomastoid muscle. Limited elevation of skin flaps is
beneficial, particularly for patients who have previously undergone chemoradiation therapy, in whom extensive flap elevation
may contribute to significant persistent lymphedema after operation. Subplatysmal skin flaps are raised sufficiently to expose the
neck levels to be dissected, with the central compartment left
undisturbed. If level I dissection is planned, the fascia overlying
the submandibular gland is raised and retracted so as to preserve
the marginal nerve. The submental fat pad is grasped and mobilized away from the floor of the submental triangle (composed of
the anterior belly of the digastric muscle and the mylohyoid muscle). Inferiorly, the lymphatic tissues are mobilized off the posterior aspect of the omohyoid muscle, which forms the anteroinferior limit of the neck dissection.
Once the digastric tendon and the posterior edge of the mylohyoid muscle are visualized, the mylohyoid is retracted with an
Army-Navy retractor so that the submandibular duct, the lingual
nerve with its attachment to the submandibular gland, and the
hypoglossal nerve are visualized. The submandibular duct and
ganglion are ligated, and the submandibular gland is retracted out
of the submandibular triangle.
At this point, the facial artery is encountered and suture-ligat-

6 NECK DISSECTION 7

Digastric Muscle
(Posterior Belly)

Omohyoid
Muscle

Mylohyoid
12th Nerve
Muscle

Common
Carotid
Artery

Internal
Jugular
Vein

External
Carotid
Artery

Sternocleidomastoid
Muscle

Occipital
Artery

11th Nerve

Figure 4 Selective neck dissection. The posterior belly of the

digastric muscle is identified inferior to the submandibular gland.
This muscle protects several critical structures just deep to it (the
hypoglossal nerve, the carotid artery, the internal jugular vein,
and the spinal accessory nerve). View is of a left neck dissection.

ed. Because the artery curves around the submandibular gland,

the facial artery, if not preserved, must be ligated twice (proximally and distally). If the neck dissection is part of a large extirpative procedure involving free-flap reconstruction, the facial
artery is preserved for use in microvascular anastomosis.
The posterior belly of the digastric muscle is then identified
inferior to the submandibular gland. This muscle has been
referred to as one of several residents friends in the neck
because it serves to protect several critical structures that lie just
deep to it, including the hypoglossal nerve, the external carotid
artery, the internal jugular vein, and the spinal accessory nerve
[see Figure 4]. The posterior belly of the digastric muscle is skeletonized to the sternocleidomastoid muscle, where it inserts on the
mastoid tip.The specimen is then mobilized away from structures
just inferior to the digastric muscle. The hypoglossal nerve
emerges from beneath the mylohyoid muscle and passes into the
neck just below the digastric muscle, looping around the external
carotid artery at the origin of the occipital artery and ascending
to the skull base between the external carotid artery and the internal jugular vein. Bleeding from small branches of the common
facial vein that envelop the hypoglossal nerve place this structure
at risk for injury. The spinal accessory nerve is often visualized
just superficial or posterior to the internal jugular vein, extending
posteriorly to innervate the sternocleidomastoid muscle.
Next, the fascia overlying the sternocleidomastoid muscle is
grasped and unrolled medially throughout its length, starting at
the anterior edge of the muscle. The fascia is removed until the
spinal accessory nerve is identified at the point where it penetrates the muscle.This nerve is dissected and mobilized superiorly through fat and lymphatic tissues to the digastric muscle. Care
must be taken not to inadvertently injure the internal jugular

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ACS Surgery: Principles and Practice

2 HEAD AND NECK

vein, which lies in close proximity to the nerve superiorly. Tissue
posterior to the accessory nerve is grasped and freed from the
deep muscles of the neck, the digastric muscle superiorly, and the
sternocleidomastoid muscle posteriorly.The tissue included in socalled level IIb is passed beneath the spinal accessory nerve and
incorporated into the main specimen.
The sternocleidomastoid muscle is retracted, and the fascia
posterior to the internal jugular vein is incised. Dissection is carried down to the deep cervical musculature and cervical nerves,
which form the floor of the dissection. The specimen is retracted
anteriorly. A layer of fascia is left on the deep cervical musculature
and the cervical nerves to preserve innervation of the deep muscles of the neck and protect the phrenic nerve as it courses over
the anterior scalene muscle.
The specimen is peeled off the internal jugular vein and
removed. Dissection too far posteriorly behind the vein may result
in injury to the vagus nerve or the sympathetic trunk and predisposes to postoperative thrombosis of the vein. Ligation of internal
jugular vein branches should be done without affecting the caliber
of the vein or giving the vessel a sausage link appearance, which
would create turbulent flow patterns predisposing to thrombosis.
Overall, gentle dissection around all vessels, with care taken to
avoid pulling-related trauma, minimizes the risk of endothelial
injury. Dissection behind the internal jugular vein may result in
injury to the vagus nerve or the sympathetic trunk.
A level IV dissection may be facilitated by retracting the omohyoid muscle inferiorly or by dividing it for additional exposure.
The tissue inferior to the omohyoid is mobilized and delivered
with the main specimen. The lymphatic pedicle is clamped and
ligated. Care is taken to look for leakage of chyle, particularly
when a level IV dissection is performed on the left.
Levels II to IV
When level I is spared, a smaller incision suffices for exposure.
Subplatysmal flaps are raised superiorly to the level of the submandibular gland. The inferior flap is raised, exposing the anterior edge of the sternocleidomastoid muscle. Dissection proceeds
just inferior to the submandibular gland until the posterior belly of
the digastric muscle is identified. The digastric muscle is skeletonized posteriorly to the sternocleidomastoid muscle and anteriorly to the omohyoid muscle, which forms the anterior limit of the
dissection. The rest of the neck dissection proceeds as described
for a selective neck dissection involving levels I through IV.
Complications
INTRAOPERATIVE

Most intraoperative complications may be prevented by means

of careful surgical technique, coupled with a thorough understanding of head and neck anatomy. Injury to the internal jugular
vein may occur either proximally or distally. Uncontrolled proximal bleeding endangers adjacent critical structures, such as the
carotid artery and the hypoglossal nerve.The bleeding may be initially controlled with pressure, followed by a methodical search for
the bleeding source. Internal jugular vein lacerations can often be
repaired with 5-0 nylon sutures; if a laceration cannot be repaired,
the vein must be ligated. Occasionally, a laceration extends up to
the skull base, and the vessel cannot be controlled with clamping
and ligation. In these cases, it is acceptable to pack the jugular
foramen for hemostasis.
It is important to gain distal control of the internal jugular vein
before repair to prevent air embolism. Harbingers of air embolism

6 NECK DISSECTION 8
include the presence of a sucking sound in the neck, a mill-wheel
murmur over the precordium, ECG changes, and hypotension.
Predisposing factors include elevation of the head of the bed and
spontaneous breathing, which increase negative intrathoracic
pressure and thus promote entry of air into the venous system.
Injury to the internal jugular vein is more difficult to control when
it occurs distally in the neck or chest at the junction with the subclavian vein. For this reason, ligation of the internal jugular vein in
radical and modified radical neck dissections is typically performed 1 cm superior to the clavicle.
Opalescent or clear fluid in the inferior neck suggests the presence of a chyle fistula. Chyle fistulas generally can be prevented
by clamping and ligating the lymphatic pedicle at the base of the
neck.Those fistulas that occur are repaired at the time of the neck
dissection.There is no benefit in isolating individual lymphatic vessels, because these structures are fragile, do not hold stitches, and
are prone to tearing. A figure-eight stitch is placed along the lymphatic pedicle until there is no evidence of clear or turbid fluid
on the Valsalva maneuver. Care must be taken not to inadvertently
injure the vagus nerve or the phrenic nerve during repair of a chyle
leak.
POSTOPERATIVE

The best treatment of postoperative complications such as

hematoma and chyle leak is prevention. Hematomas, once present, are best managed by promptly returning the patient to the
OR for evacuation. Management of postoperative leakage of chyle
depends on the volume of the leak. Low-volume leaks may be
managed with packing, wound care, and nutritional supplementation with medium-chain triglycerides.
Wound complications (e.g., infection, flap necrosis, and carotid
artery exposure or rupture) share certain interrelated causative
factors. Poor nutritional status, advanced tumor stage at presentation, hypothyroidism, and preoperative radiation therapy have
all been associated with wound complications. After chemoradiation therapy, the use of smaller incisions and more limited dissection of soft tissues may lower the incidence of postoperative
wound problems, including persistent lymphedema and soft tissue fibrosis. Conversely, poor planning of skin incisions may
increase the likelihood of wound complications such as wound
breakdown, skin flap loss, and exposure of vital structures.Wound
complications predispose to carotid artery rupture, the most catastrophic complication of neck dissection.
In some case, severe edema after planned neck dissections in
patients previously treated with chemoradiation may cause respiratory decompensation that necessitates tracheotomy. Postoperative internal jugular vein thrombosis is not uncommon despite
preservation at the time of surgery,25 and it may exacerbate
edema. Impaired venous outflow predisposes to increased
intracranial pressure.26 This may be a greater concern in patients
who require bilateral neck dissections. If a radical neck dissection
is performed on one side, the internal jugular vein must be preserved on the other, or else the neck dissections must be staged.
These problems are further exacerbated when the patient has
undergone chemoradiation therapy before operation.
Most neck dissections result in some degree of temporary
shoulder dysfunction. Patients in whom nerve-sparing procedures
are performed can expect function to return within 3 weeks to 1
year, depending on the procedure performed. Shoulder dysfunction and pain are exacerbated when nerves supplying the deep
muscles of the neck are also sacrificed. All patients benefit from
physical therapy, which preserves full range of motion in the
shoulder while function returns.

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ACS Surgery: Principles and Practice

2 HEAD AND NECK

6 NECK DISSECTION 9

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Acknowledgment
Figures 1 through 3

Tom Moore.