Head and Neck Dissection Lecture Presented by: Steven S. Chang MD Head and Neck Dissection Lecture November 13, 2018

Objectives/Disclaimers Review basic steps to procedures Avoid eponyms and esoteric anatomy Recognize that there are several ways to perform these operations, and this is just one way to do them Cadaver lab is the time to ask Why and How… Read before and after lab November 13, 2018

Thyroidectomy Skin Incision through platysma if visible Raise superior flaps to thyroid notch Raise inferior skin flaps to clavicle Divide straps in midline raphe, avoid anterior jugs

Thyroidectomy Dissect strap muscles off gland Identify trachea and lateral border of gland Isolate Superior Pole vessels Identify superior laryngeal nerve Superior Parathyroid

Thyroidectomy Identify middle thyroid vein Rotate Gland medially Dissect fascia off inferior pole Identify Inferior parathyroid gland

Thyroidectomy Identify Inferior Parathyroid Artery Identify Tracheo-esophageal groove Find RLN and trace superiorly without devascularizing parathyroid gland to insertion Dissect off trachea

Parotidectomy Blair/Facelift Incision Raise skin flap, think about SMAS Identify SCM muscle Identify Greater Auricular Nerve Dissect tragal cartilage free Anterior rotation of parotid gland

Parotidectomy Identify digastric muscle Palpate tympano-mastoid suture line Identify Facial Nerve Serially dissect each branch to masseter In-Lift-Spread Avoid the retromandibular vein

Neck Dissection and Submandibular Gland Excision Many ways to perform Tumor dictates how neck is performed Concept of lymphadenectomy and gland excision Know the levels of the neck and anatomic and radiographic borders November 13, 2018

Neck Dissection (Before)

Submandibular Gland Excision Skin incision in crease two finger breadths below mandible Raise skin flaps Identify inferior border of gland Identify/ligate facial vein and artery low Marginal Nerve

Submandibular Gland Excision Retract gland to find digastric Identify mylohyoid muscle and retract Identify lingual nerve and warthin’s duct Identify hypoglossal nerve Divide duct and ganglion

Submandibular Gland Excision Dissect facial vein superiorly, retract soft tissue with vein Identify and ligate facial artery superiorly Follow digastric anteriorly and posteriorly to SCM

General Concepts November 13, 2018

Neck Dissection Incise SCM fascia and unwrap from muscle until reach posterior border of SCM Identify CN XI and trace to IJ/digastric Circumferentially dissect CN XI Free apex from deep neck musculature Tuck apex under CN XI November 13, 2018

Neck Dissection Identify Omohyoid muscle and dissect free and retract inferiorly Identify transverse cervical vessels Identify IJ and vagus Identify and trace cervical rootlets Free corner from underneath clavicle Identify phrenic Continue lateral to medial dissection November 13, 2018

Neck Dissection Identify carotid sheath Transition to lateral IJ and dissect posterior to anterior Identify ansa hypolglossi and preserve Dissect off branches of IJ and strap muscles

Neck Dissection (AFTER)

Larnygectomy Raise Skin Flaps Identify SCM Trace SCM and create “outer tunnels” November 13, 2018

Laryngectomy Divide Strap muscles inferiorly and elevate off thyroid gland November 13, 2018

Laryngectomy Divide thyroid gland Dissect “inner tunnels” (carotid sheath away from larynx) Divide super laryngeal bundle Expose hyoid and free muscle from superior surface

Laryngectomy Free the greater cornu of the hyoid Rotate larynx and divide constrictors Free piriform mucosa Enter through vallecula and retract epiglottis Resect trachea

Laryngectomy Make tumor cuts under direct visualization November 13, 2018

Pectoralis Flap Plan your paddle size and pedicle length Now make them bigger and longer, respectively November 13, 2018

Pectoralis Flap Extend incisions away from paddle in a trapezoidal fashion to include perforators SKIN FAT MUSCLE November 13, 2018

Pectoralis Flap Incise lateral border of pectoralis major Bluntly dissect plane between pectoralis minor and major, keeping fat pad superficial with pectoralis major Should be on chest wall Thin pedicle while keeping fat packet around pedicle intact, and divide overlying muscle up to clavicle November 13, 2018

Pectoralis Flap November 13, 2018 Ramakrishnan, V. R. et al. Arch Facial Plast Surg 2009;11:306-310. November 13, 2018 Copyright restrictions may apply.

Pectoralis Flap November 13, 2018 Ramakrishnan, V. R. et al. Arch Facial Plast Surg 2009;11:306-310. November 13, 2018 Copyright restrictions may apply.

Pectoralis Flap November 13, 2018 Ramakrishnan, V. R. et al. Arch Facial Plast Surg 2009;11:306-310. November 13, 2018 Copyright restrictions may apply.

Pectoralis Flap November 13, 2018 Ramakrishnan, V. R. et al. Arch Facial Plast Surg 2009;11:306-310. November 13, 2018 Copyright restrictions may apply.

Pectoralis Flap November 13, 2018 Ramakrishnan, V. R. et al. Arch Facial Plast Surg 2009;11:306-310. November 13, 2018 Copyright restrictions may apply.