----------------------------------------------------------------------------- TITLE: DESIGN OF NECK INCISIONS SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: January 12, 1994 RESIDENT PHYSICIAN: John Kinsella, M.D. FACULTY: Christopher. H. Rassekh, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. ------------------------------------------------------------------------------ "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. Preoperative Considerations A. Age and Sex of the patient B. Characteristics of the skin C. Location of the Primary D. Unilateral vs. Bilateral Neck Dissection E. Location of Adenopathy/ Type of Neck Dissection F. Likelihood of Postoperative Radiation G. Patterns of Skin Necrosis in different Skin flap designs H. Potential for Wound healing problems (preoperative radiation, diabetes, vascular disease, previous surgery) I. Need for reconstructive flaps J. Tracheotomy may affect blood supply of some flap designs II. Neck Incisions for Neck Dissection - General Rules A. General Rule of Placing the Incisions in Lines of Relaxed Skin Tension Lines (RSTL) 1. Horizontal Curving Incisions placed at a level in the neck depending on the site of the tumor 2. Facial incisions for parotid tumors can be combined with various neck incisions depending on preoperative considerations as listed in I. 3. High submandibular incisions should be placed at least 2cm below body of mandible B. General Rule of placing vertical incisions so that weakest blood supply areas and trifurcations are away from (usually posterior to) carotid artery and at right angles for at least 2cm then with a "lazy" S-shape to minimize potential for scar contracture C. General Rule of Excising scars 1. Potentially seeded with tumor 2. Scar area has poor blood supply 3. Cosmetically more desirable D. General Rule of Excising areas of skin compromised by underlying tumor or poor blood supply (may need flap reconstruction) III. Blood Supply Patterns to Cervical Skin (generally vertical arterial branches) A. Facial artery-submental branch supplies most of upper anterior neck skin B. Thyrocervical trunk branches come upward from lower neck C. Superior thyroid and sternocleidomastoid arteries lesser contributors superiorly D. Superficial clavicular vessels inferiorly E. Watershed areas in the mid-neck and in the midline F. Safest to include platysma with the flap unless need to resect for oncologic reasons IV. Specific Incisions- Uses, advantages and disadvantages A. Utility Flap (fig.1) - Mastoid tip curving to midline at level of superior border of thyroid cartilage 1. Useful flap with most of visible scar in RSTL 2. Convenient for Laryngeal tumors, Bilateral neck dissection, thyroid surgery and easily combined with parotid incisions 3. Disadvantage of poorer exposure posteriorly with large inferior flap B. Modifications of Utility Flap 1. Lahey 1940 (fig 2) 2. Schobinger 1957-(fig 3a and 3b) Higher horizontal incision allows easier access to oral cavity and various modifications for posterior vertical limb. Shorter superior flap allows midline lip splitting extension with less likelihood of loss of tip (Becker 1984, fig 3c) 3. Grandon 1960 (fig 3d) Curtain Flap. a. Tip of mastoid down anterior border of trapezius then turns medially in 3cm above sternum b. Safer blood supply c. Better exposure 4. Fraser, Schweitzer 1965, Conley 1952 incisions are also modifications of Schobinger/Utility(fig 3e-3f). Crile 1905, Armknecht, 1906 are the earliest of these reported (fig 3g, 3h) 5. Apron Flap and "U" Flap modifications of Utility flap (Edgerton 1957, Farr 1969, Latyshevsky 1960, Lore 1970-fig 3i-3l) C. McFee Incisions(fig 4a) 1. Two parallel incisions in RSTL's-very cosmetic, and very safe but bipedicle flap limits exposure - Laterally based flap 2. Shaw Modification has better blood supply and exposure (fig 4b) - Adopted from Grillo and Edmunds, 1965 D. Martin incision and variations 1. Classic Martin is a "double Y" (fig 5a) a. excellent exposure b. sharp angles less cosmetic and at risk c. contains two trifurcations-dangerous for carotid, especially for radiated patients 2. Slaughter 1955 eliminates sharp angles, improves vascularity (fig 5b) E. H-Flaps, T-Flaps and modifications (Kambic 1967, fig 6a-6f) 1. Excellent for bilateral dissection but usually not needed 2. Preserves superior and inferior vascular supply F. Parotid and Neck combined 1. Blair (fig 7) 2. Martin (fig 8)-can be used for posterior neck dissection 3. Cervicofacial(Rhytidectomy-like) Incision-Appiani 1984 (fig 9)-also useful for posterior dissection - cosmetically excellent G. Straight Single Incision Vertically (fig 10) 1. Used historically in heavily irradiated patients 2. Now replaced by other incision designs H. S-shaped Flaps (fig 11) 1. Rarely used 2. Probably an improvement over straight line due to better exposure and less chance for scar contracture, webbing VI. Summary In general, the utility flap and modifications of the Schobinger flaps are preferred for most procedures involving neck dissection alone or with upper aerodigestive tract tumor resections. MacFee type flaps, longer apron flaps and cervicofacial flaps are sometimes preferred for cosmetic reasons if the disease process allows their use without compromising the resection. ----------------------------------------------------------------------------- BIBLIOGRAPHY 1. Appiani E, Delfino MC: Plastic incisions for facial and neck tumors. Ann Plast Surg 13(4):335-352, 1984. 2. Babcock WW, Conley J: Neck incision in block dissection (experiences with the long anterior cervical flap incision). Arch Otolaryngol 84:554-557, 1966. 3. DeVito RV: Horizontal "T" incision for neck dissection. Plas Recon Surg 43(5):538-540, 1969. 4. Kambic V, Sirca A: H incision-method of choice for radical neck dissection. J Laryngol Otol 91(5):383-390, 1977. 5. Lore J: An Atlas of Head and Neck Surgery. pp. 662-673, W.B. Saunders Co., 1988. 6. Maran AGD, Amin M, Wilson JA: Radical neck dissection: a 19-year experience. J Laryngol Otol 103:760-764, 1989. 7. Martin H: Radical neck dissection. Clinical Symposia 13:103-120, 1961. 8. Nickell WB, Jurkiewicz MJ, Furlow LT: Multipurpose incision for neck dissection after irradiation. Am J Surg 119(3):354-355, 1970 9. Shaw HJ: A modification of the MacFee incisions for neck dissection. J Laryngol Otol 102:1124-1126, 1988. 10. Suen JY: Cancer of the Neck. In: Suen JY, Myers EN (eds.). Cancer of the Head and Neck. Churchill and Livingstone, New York, 1990, p 221-254. 11. Woods JE: Use of the bipedicle flap in radical neck dissection for head and neck cancer. Am J Surg 131:641-642, 1975. -------------------------------END-------------------------------------------