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MODIFIED & RADICAL NECK DISSECTION

Johan Fagan

Neck dissection removes potential or and the anterior belly of the contra-
proven metastases to cervical lymph nodes. lateral digastric muscle anteriorly. The re-
It is a complex operation, and requires a vised classification (Figure 1) uses the pos-
sound knowledge of the 3-dimensional terior margin of the submandibular gland
anatomy of the neck. as the boundary between

Indications Levels I and II as it is clearly identified on

ultrasound, CT, or MRI. Level I is subdi-
Neck dissection may be elective (END) vided into Level Ia, (submental triangle)
when done for clinically occult metastases, which is bound by the anterior bellies of the
therapeutic (clinical metastases) or may be digastric muscles and the hyoid bone, and
a salvage procedure (previously treated Level Ib (submandibular triangle).
neck with surgery +/ radiation). END is in-
dicated when the risk of having occult cer- Level II extends between the skull base and
vical nodal metastases exceeds 15-20%. hyoid bone. The posterior border of the
sternocleidomastoid defines its posterior
Nodal Levels border. The stylohyoid muscle (alternately
the posterior edge of the submandibular
The neck is conventionally divided into 6 gland) defines its anterior border. The ac-
levels; Level VII is in the superior mediasti- cessory nerve (XIn) traverses Level II
num (Figure 1). obliquely and subdivides it into Level IIa
(anterior to XIn) and Level IIb (behind
XIn).

Level III is located between the hyoid bone

and the inferior border of the cricoid carti-
lage. The sternohyoid muscle marks its an-
terior limit and the posterior border of the
sternocleidomastoid its posterior border.

Level IV is located between the inferior bor-

der of the cricoid cartilage and the clavicle.
The anterior boundary is the sternohyoid
muscle, and the posterior border is the pos-
Figure 1: Classification of cervical nodal levels (Con-
terior border of sternocleidomastoid.
sensus statement on the classification and terminol-
ogy of neck dissection. Arch Otolaryngol Head Neck
Surg 2008; 134: 536–8). Level V is bound anteriorly by the posterior
border of the sternocleidomastoid, and pos-
Level I is bound by the body of the mandible teriorly by the trapezius muscle. It extends
above, the stylohyoid muscle posteriorly, from the mastoid tip to the clavicle, and is
subdivided by a horizontal line drawn from

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 Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery

the inferior border of the cricoid cartilage It has been proposed that neck dissections
into Level Va superiorly, and Level Vb infe- be more logically and precisely described
riorly. and classified by naming the structures and
the nodal levels that have been resected.
Level VI is the anterior, or central, compart- (Ferlito A, Robbins KT, Shah JP, et al. Pro-
ment of the neck. It is bound laterally by the posal for a rational classification of neck
carotid arteries, superiorly by the hyoid dissections. Head Neck. 2011;33(3):445-50)
bone, and inferiorly by the suprasternal
notch.

Neck Dissection Classification

Neck dissection operations are classified ac-

cording to the cervical lymphatic regions
that are resected (Figures 1, 2).

Selective neck dissection (SND) is done for

N0 necks (no clinical evidence of neck
nodes) or for very limited cervical metasta-
ses (Figure 2). Central neck dissection en-
compasses only Level VI (Figure 1). Figure 2: Common types of neck dissection

Comprehensive or therapeutic neck dissec- Modified neck dissection: Operative steps

tion involves surgical clearance of
Levels 1-V and may either be a radical The detailed step-by-step description of
(RND) or modified (MND) neck dissection. neck dissection that follows refers to a right-
RND includes resection of sternocleido- sided MND type I or II.
mastoid muscle (SCM) and accessory nerve
(XIn) and internal jugular vein (IJV). MND RND involved the same surgical steps, other
preserves SCM and/or XIn and/or IJV. than that the IJV is double-ligated superi-
MND type I entails preservation of 1/3, usu- orly and inferiorly with silk and with a silk
ally XIn; MND type II entails preservation transfixion suture passed through the vein,
of 2/3, usually XIn and IJV; with MND type taking care not to include the vagus nerve
III all 3 structures are preserved. MND type (Xn) in the ligature.
II is most commonly done, and is oncologi-
cally acceptable in the absence of adherence Anaesthesia, positioning and draping
of cervical nodal metastases to XIn or IJV.
The operation is done under general anaes-
Extended neck dissection includes addi- thesia without muscle relaxation as eliciting
tional lymphatic groups (parotid, occipital, movement on mechanical or electrical stim-
Level VI, mediastinal, retro-pharyngeal) or ulation of the marginal mandibular, hypo-
non-lymphatic structures (skin, muscle, glossal (XIIn) and accessory nerves assist
nerve, blood vessels etc.) not usually in- with locating and preserving these nerves. It
cluded in a comprehensive neck dissection. is a clean operation unless the upper aero-
digestive tract is entered, and antibiotics are

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 Johan Fagan

therefore not required. With an experi- vertical limb along the anterior border of
enced surgeon, blood transfusion is rarely the trapezius can be hidden by long hair.
required. Care has to be taken in patients who have
been previously irradiated as the postero-
The patient is placed in a supine position inferior corner has a tenuous blood supply
with the neck extended and turned to the and may slough, having to heal by second-
opposite side. Surgical draping must allow ary intention.
monitoring for movement of the lower lip
with irritation of the marginal mandibular
nerve, and must provide access to the clavi-
cle inferiorly, the trapezius muscle posteri-
orly, the tip of the earlobe superiorly and
the midline of the neck anteriorly. The
drapes are sutured to the skin.

Incisions and flaps

Incisions should take into consideration ac-

cess that may be required to resect the pri-
mary tumour, cosmetic factors, and the
blood supply to the flaps. Flaps are elevated
Figure 3: Incisions for neck dissection combined with
in a subplatysmal plane with a knife or with
oral cavity cancer resection
monopolar electrocautery. Making the flaps
too thin may compromise the blood supply
to the skin flaps.

Figure 3 demonstrates incisions commonly

used for MND done in association with
cancers of the oral cavity, oropharynx, nasal
cavity sinuses and skin cancers of the mid-
face. The transverse skin incision can be ex-
tended across to the opposite side with bi-
lateral neck dissections, or can be extended
superiorly to split the lower lip in the mid-
line to gain access to the oral cavity. Care
should be taken not to place the trifurcation
of the incision over the carotid artery, as Figure 4: Hockey-stick incision for neck dissection
combined with parotidectomy
skin loss at this point may expose the ca-
rotid artery with its attendant risks.
With laryngectomy patients, MND can be
done either via a wide apron flap, or by lat-
Figure 4 demonstrates the hockey stick inci-
eral extensions from the apron flap (Figures
sion. This can be extended into a preauric-
5, 6).
ular skin crease and is particularly useful for
combined parotidectomy and neck dissec-
tion. It has the advantage that the scar of the
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Figure 5: Wide apron flap

Figure 7: Completed right MND type II with sequence

of operative steps

Figure 6: Apron flap with lateral extensions

Neck dissection: Operative steps

Figure 7 shows a completed right-sided

MND type II. The superimposed numbers
indicate the sequence of the main operative
steps that will be referred to in the descrip-
Figure 8: Note platysma muscle (transected), and the
tion of the surgery that follows. external jugular vein and greater auricular nerve
overlying the SCM
Step 1 (Figure 7)
Next the superior flap is elevated with cau-
The neck is opened via a horizontal incision tery until the submandibular salivary gland
placed in a skin crease at about the level of is identified. The submandibular gland fas-
the hyoid bone. The incision is made cia is then incised inferiorly over the gland
through skin, subcutaneous fat, and plat- so as to avoid injury to the marginal man-
ysma muscle. Identify the external jugular dibular nerve (Figure 9).
vein and greater auricular nerve overlying
the sternocleidomastoid muscle (SCM)
(Figure 8).

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 Johan Fagan

Figure 9: Incision of submandibular salivary gland Figure 11: Resection of submental triangle onto mylo-
capsule hyoid muscles

The surgeon then resects the fat and lymph Step 2 (Figure 7)
nodes from the submental triangle (Level
Ia). A subplatysmal dissection of the overly- The surgeon next addresses Level Ib of the
ing skin is extended to the opposite anterior neck. Because the marginal mandibular
belly of digastric muscle, taking care not to nerve runs in an extracapsular plane, the
injure the anterior jugular veins. The sub- submandibular gland capsule is dissected
mental triangle is resected inferiorly to the from the gland in a superior direction in a
hyoid bone with electro-cautery. The deep subcapsular plane (Figure 9). The marginal
plane of dissection is the mylohyoid mus- mandibular nerve does not need to be rou-
cles (Figures 10 & 11). tinely identified. The assistant however
watches for twitching of the lower lip, as this
indicates proximity of the nerve. The facial
artery and vein are identified by blunt dis-
section with a fine haemostat (Figure 12).
The marginal mandibular nerve crosses the
facial artery and vein (Figure 12).

Next attention is directed at the fat and

lymph nodes tucked anteriorly and deeply
between the anterior belly of digastric and
mylohyoid muscle. These nodes are espe-
cially important to resect with malignancies
of the anterior floor of mouth. To resect
these nodes one retracts the anterior belly of
Figure 10: Resection of submental triangle
digastric anteriorly and delivers the tissue
using electrocautery dissection with the
deep dissection plane being the mylohyoid
muscle (Figures 12, 13).

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then divided and tied close to the subman-

dibular gland so as not to injure the mar-
ginal mandibular nerve (Figure 13).

This frees up the gland superiorly, which

can then be reflected away from the mandi-
ble (Figure 14).

Figure 12: The submandibular gland has been dis-

sected in a subcapsular plane; the marginal mandib-
ular nerve is seen crossing the facial artery and vein
(at tip of haemostat); fat and nodes are delivered from
the anterior pocket deep to the digastric

Figure 14: Marginal mandibular nerve visible over di-

vided facial vessels; gland reflected inferiorly; mylohy-
oid muscle widely exposed

Next the surgeon addresses the lingual

nerve, submandibular duct, and XIIn. The
Figure 13: Dividing the facial vessels below the mar-
ginal mandibular nerve mylohyoid muscle is retracted anteriorly,
and the clearly defined dissection plane be-
Other than the nerve to mylohyoid and ves- tween the deep aspect of the submandibular
sels that pierce the muscle that are cauter- gland and the fascia covering the XIIn is
ized or ligated, there are no significant opened. This is done with finger dissection
structures until the dissection reaches the taking care not to tear the thin-walled veins
posterior free margin of the mylohyoid accompanying XIIn.
muscle. Next attention is directed at the re-
gion of the facial artery and vein. The sur- The XIIn is now visible in the floor of the
geon palpates around the facial vessels for submandibular triangle (Figure 15).
facial lymph nodes; if present, they are dis-
sected free using fine haemostats, taking
care not to traumatise the marginal man-
dibular nerve. The facial artery and vein are

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 Johan Fagan

Figure 17: Separating the submandibular ganglion

from the lingual nerve

Figure 15: Finger dissection delivers the submandibu- The facial artery is divided and ligated just
lar gland and duct, and brings the lingual nerve into above the posterior belly of digastric (Figure
view. The proximal stump of the facial artery is visible 18).
at the tip of the thumb, and the XIIn behind the nail
of the index finger

Inferior traction on the gland brings the lin-

gual nerve and the submandibular duct into
view (Figure 15). The submandibular duct is
separated from the lingual nerve, divided
and ligated (Figures 16, 17).

Figure 18: Clamping and dividing the facial artery

just above the posterior belly of digastric

Note: A surgical variation of the above tech-

nique is to preserve the facial artery by di-
viding and ligating the 1-5 small branches
that enter the submandibular gland. This is
usually simple to do, it reduces the risk of
Figure 16: Submandibular duct injury to the marginal mandibular nerve,
and permits the use of a buccinator flap
The submandibular ganglion, suspended
based on the facial artery (Figure 19).
from the lingual nerve, is clamped, divided
and ligated, taking care not to cross-clamp
the lingual nerve (Figure 17).

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Figure 21: Divide the external jugular vein

Figure 19: Facial artery has been kept intact; a branch
is being divided
Continue to expose the posterior belly of di-
gastric along its entire length, taking care
Step 3 (Figure 7)
not to wander above the muscle as this
This step entails identifying the XIIn in would jeopardise the facial nerve (Figure
Level IIa, and freeing and tracing the XIIn 22). This step is the key to facilitating sub-
posteriorly where it leads the surgeon di- sequent exposure of the IJV and XIn.
rectly to the internal jugular vein (IJV). First
divide the fascia along the lateral aspect of
the digastric (Figure 20).

Figure 22: Dissect the entire length of the digastric

Figure 20: Divide the fascia overlying the posterior

Next identify the XIIn below the greater
belly of the digastric muscle
cornu of the hyoid bone before it crosses the
Then divide the external jugular vein (Fig- external carotid artery. It is generally more
ure 21). superficial than expected, and is located just
deep to the veins that cross the nerve. Care-
fully dissect in a posterior direction and di-
vide the veins to expose the XIIn (Figure
23).

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 Johan Fagan

Figure 23: Dividing the veins that cross the XIIn

Figure 25: Dividing the sternomastoid branch of the

After the nerve has crossed the external ca-
occipital artery frees the XIIn that then leads directly
rotid artery, identify the sternomastoid to IJV. Note the XIn and the tunnel created behind
branch of the occipital artery that tethers IJV
the XIIn (Figure 24).
Step 4 (Figure 7)

Using dissecting scissors or a haemostat to

part the fatty tissue in Level II, the surgeon
next identifies the XIn which may course
lateral, medial or very rarely through the
IJV (Figure 26).

Figure 24: Sternomastoid branch of occipital artery

tethering the XIIn

Dividing this artery releases the XIIn (Fig-

ure 25). The nerve then courses vertically
and leads the surgeon directly to the ante-
rior border of the IJV (Figure 25).
Figure 26: XIn passing through the IJV

Create a tunnel immediately posterior to

the IJV (Figure 25). This maneuver speeds
up the subsequent dissection of Level 2
(Steps 4 & 7). The transverse process of the
C1 vertebra can be palpated immediately
posterior to the XIn and IJV, and serves as

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an additional landmark for these structures

in difficult surgical cases. Note that the oc-
cipital artery crosses the IJV at the top of
Level II, branches of which may need to be
cauterized should they be severed while dis-
secting in Level II.

Step 5 (Figure 7)

Surgery now is directed at the anterior neck.

The surgeon raises an anteriorly based sub-
platysmal flap and exposes the omohyoid
Figure 28: Dividing the omohyoid and clearing Lev-
muscle and the SCM muscle inferiorly els II and III
down the clavicle, leaving the anterior jug-
ular vein in the elevated flap (Figure 27). Step 6 (Figure 7)
The anterior margin of the omohyoid cor-
responds with the anterior margin of the The surgeon elevates a posteriorly-based
neck dissection. flap using electrocautery or a knife, with
good counter traction provided by an assis-
tant. The platysma is often absent posteri-
orly and the flap may be very thin. Placing
the index finger behind the flap permits the
surgeon to gauge the thickness of the flap,
and avoid “buttonholing” the skin (Figure
29).

Figure 27: Anteriorly based flap elevated to expose the

omohyoid and SCM

The omohyoid is divided with cautery, and

freed up posteriorly with the surrounding
fatty tissue of Levels II and III (Figure 28).
Finger dissection deep to the omohyoid af-
ter it disappears behind the SCM exposes Figure 29: Technique of elevating the posterior skin
flap
the carotid sheath.
Take care not to elevate the external jugular
vein or the greater auricular nerve with the
flap, but to leave them lying on the SCM
muscle. Movement of the shoulder is noted
as one approaches the XIn or the trapezius

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 Johan Fagan

muscle. The dissection continues until the

anterior border of trapezius is reached (Fig-
ure 30). In a thin patient the XIn may be ex-
tremely close to skin. Note that the XIn, un-
like branches of the cervical plexus, passes
deep to the trapezius muscle.

Figure 31: The XIn is located 1-2cm behind the greater

auricular nerve

Figure 30: Posterior flap fully elevated to the trapezius

muscle

Step 7 (Figure 7)

This step involves dissecting out the XIn

Figure 32: XIn is dissected upward through the SCM
and mobilizing Level IIb. The XIn is iden-
muscle
tified by dissecting with a haemostat at the
posterior border of the SCM muscle, ap-
proximately 1-2cm posterior to the point
where the greater auricular nerve curves
around the muscle (Figure 31). The nerve is
often located by seeing movement of the
shoulder due to mechanical stimulation of XIn

the nerve. The XIn passes through the SCM, Lesser occipi-
unlike the cervical plexus that passes deep tal n

to the muscle. It is dissected upward

through the SCM muscle by tunneling Trapezius
muscle
though the muscle over the nerve with a
haemostat, and the cutting the muscle with
diathermy (Figure 32). The lesser occipital
nerve (C2) crosses the XIn at the inferior
margin of the SCM (Figure 33). Take care Figure 33: The lesser occipital nerve (C2) can be con-
not mistake it for the XIn when dissecting fused with the XIn
superiorly through the SCM muscle.
Once the XIn has been exposed up to and
freed from the IJV, expose the nerve distally
to where it disappears behind the trapezius
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 Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery

muscle, and then free the nerve completely

and section the branches to SCM (Figure 34,
35).

Figure 35: Operative field at end of Step7; note divided

SCM along course of XIn

Figure 34: Free the XIn and divide its branches to

SCM

Step 8: (Figure 7)

This step involves dissection of Level IIb

and transposition of the XIn. The SCM is
divided below the mastoid. This exposes fat
at the top of Level IIb. The dissection is car-
ried deeper until the deep muscles of the
neck that run in a postero-inferior direction
appear. The only structure that can be in-
jured here is the occipital artery, and this is
Figure 36: Division of SCM and identification and di-
simply ligated or cauterized. The dissection
vision of greater occipital nerve and deep muscles of
is then directed postero-inferiorly, where the neck
the greater occipital nerve (C1) is divided
(Figure 36). The contents of Level IIb and IIa are then
dissected off the deep muscles of the neck
deep to the epimysium until the upper
branches of the cervical plexus come into
view (Figure 37). The XIn is now trans-lo-
cated posteriorly (Figure 38).

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 Johan Fagan

Figure 39 illustrates the status of the neck

dissection at this point.

Figure 39: Status of neck dissection before proceeding

to Step 9. Note the transected SCM superiorly

Step 9: (Figure 7)

The clavicular and sternal heads of the SCM

Figure 37: Dissecting Level II
are next divided with cautery just above the
clavicle (Figure 40).

Figure 40: Transecting the sternal head of the SCM

The surgeon applies continuous traction to

the muscle during the dissection so as to
part the muscle fibres as they are transected
and to visualise the IJV immediately deep to
the muscle (Figure 41). A scalpel is used to
Figure 38: The XIn has been translocated posteriorly cut through the carotid sheath onto the IJV
(Figure 41).

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Figure 41: Exposing the IJV by incising the carotid Figure 43: The haemostat is under the omohyoid; the
sheath external jugular vein is more posteriorly

Take care not to dissect immediately lateral

to the IJV, as the right lymphatic duct (right
neck) or thoracic duct (left neck) may be in-
jured leading to a troublesome chyle leak
(Figure 42).

Figure 44: External jugular vein is divided

Figure 42: A distended thoracic duct immediately lat-

eral to the carotid artery and IJV in the (L) neck

Next identify the external jugular vein and

the omohyoid muscle (Figure 43).
Figure 45: Division of the omohyoid with cautery
The external jugular vein is divided and li-
gated, followed by division of the omohyoid The surgeon then incises the fascia overly-
with cautery (Figures 44, 45). ing the supraclavicular fat just above the
clavicle, once again steering clear of the
right lymphatic duct or thoracic duct (Fig-
ure 46).

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 Johan Fagan

Figure 48: The supraclavicular nerves

Figure 46: Exposing the supraclavicular fat Next incise the fatty vascular pedicle con-
taining the transverse cervical artery and
Once the fat has been exposed, a finger can vein (Figure 49).
be used to expose the fascia covering the
brachial plexus (Figure 47). The finger is
then swept medially to expose the phrenic
nerve, laterally towards the axilla and supe-
riorly along the carotid sheath. Take care
not to tear the transverse cervical vessels
with the medial sweep.

Figure 49: Note the proximity of the XIn (below the

diathermy) when dividing the vascular pedicle.

Figures 50 and 51 demonstrate the isolation

and division of the transverse cervical artery
and its proximity to the XIn.

Figure 47: Exposing the brachial plexus

Step 10: Supraclavicular vascular pedicle

(Figure 7)

This step involves freeing the inferolateral

part of Level V. First identify and divide the
supraclavicular nerves, which are branches Figure 50: Transverse cervical vessels
of the cervical plexus (Figure 48).

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Figure 51: Division of transverse cervical vessels

Step 11: (Figure 7)

Figure 53: Dissection up to the cervical plexus; note

This part of the neck dissection involves
the phrenic nerve running parallel to the IJV.
anterograde dissection of Levels II – V and
is done with a scalpel. The assistant The cervical plexus nerves are each divided,
maintains firm anterior traction on the neck taking care not to injure the phrenic nerve
dissection specimen, and the surgeon esta- (Figure 54).
blishes a subepimysial dissection plane on
the deep muscles of the neck, except over
the brachial plexus where the overlying
fascia is retained to protect the nerves
(Figure 52).

Figure 54: Division of nerves of cervical plexus, stay-

ing well clear of the phrenic nerve

This brings the carotid sheath containing

common and internal carotid arteries, the
vagus nerve and the IJV into view (Figure
55).
Figure 52: Anterograde dissection of Levels II – V

The dissection proceeds over a broad front

until the entire cervical plexus has been
exposed.The phrenic nerve is identified as it
descends obliquely across the scalenius an-
terior muscle, deep to the prevertebral layer
of deep cervical fascia (Figure 53).

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 Johan Fagan

Figure 55: The common carotid artery, the vagus Figure 57: Inferiorly the pedicle adjacent to the IJV is
nerve and IJV divided; note the proximity of the phrenic nerve

The carotid sheath is incised along the full Step 12: (Figure 7)
course of the vagus nerve, and the neck dis-
section specimen is stripped off the IJV The final step is to strip the neck dissection
while remaining inside the carotid sheath. specimen off the infrahyoid strap muscles,
The ansa cervicalis, which courses either to identify and preserve the superior
deep or superficial to the IJV may be pre- thyroid vascular pedicle, and to deliver the
served (Figure 56). Inferiorly the pedicle ad- neck dissection specimen (Figure 58)
jacent to the IJV containing fat, thoracic or
right lymphatic duct, and transverse cervi- Closure
cal artery and vein is divided, taking care
not to include the vagus or phrenic nerves The neck is irrigated with water, the anaes-
in the pedicle (Figure 57). thetist is asked to do a valsalva maneuver to
elicit unsecured bleeding vessels and chyle
leakage, and a 5mm suction drain is in-
serted. The neck is closed in layers with con-
tinuous vicryl to platysma and sutures/sta-
ples to skin.

Postoperative care

The drain is maintained on continuous suc-

tion e.g. low pressure wall suction, until the
drainage volume is <50ml /24hrs.

Figure 56: The neck dissection specimen has been

stripped off the carotid, vagus and IJV in a plane
deep to the carotid sheath; the ansa cervicalis has
been preserved

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Figure 58: Completed MND type 2; note the superior thyroid pedicle and ansa cervicalis

Useful References Author & Editor

Robbins KT, Shaha AR, Medina JE, et al. Johan Fagan MBChB, FCORL, MMed
Consensus statement on the classification Professor and Chairman
and terminology of neck dissection. Arch Division of Otolaryngology
Otolaryngol Head Neck Surg 2008;134: University of Cape Town
536–8 Cape Town
South Africa
Ferlito A, Robbins KT, Shah JP, et al Pro- johannes.fagan@uct.ac.za
posal for a rational classification of neck
dissections. Head Neck. 2011
Mar;33(3):445-50

Harris T, Doolarkhan Z, Fagan JJ. Timing

of removal of neck drains following head
and neck surgery. Ear Nose Throat J. 2011
Apr;90(4):186-9

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