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

2. 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

3. 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

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

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

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

7. 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

8. 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

9. 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

10. Neck Dissection (Before)

11. 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

12. 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

13. 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

14. General Concepts
November 13, 2018

15. 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

16. 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

17. 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

18. Neck Dissection (AFTER)

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

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

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

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

23. Laryngectomy Make tumor cuts under direct visualization
November 13, 2018

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

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

26. 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

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

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

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

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

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