Keywords
cervical neck dissection - postoperative complication - scar
Introduction
Since the original description of radical neck dissection proposed by Crile in 1906,[1] which included the resection of the sternocleidomastoid (SCM) muscle, the jugular
vein (YV), and the spinal nerve (SN), to the evolution of the technique to the functional
neck dissection following the fascial plane described by Suarez[2] and popularized by Gavilan[3] and Bocca,[4] passing through the classification of selective and modified radical neck dissection
proposed by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS),[5] multiple cervical incisions have been described with the purpose of carrying out
this type of surgical intervention.
Kocher, in 1880,[6] and Kuettner, in 1898,[7] would describe the first incisions for neck node dissection. In 1951, Martin would
report the incision in double Y,[8] and MacFee, in 1960, would describe the double transverse incision.[9] Meanwhile, in Europe, the bi-mastoid incision, related by Gluck-Sorensen and Tapia,
as well as the J incision, described by Paul-André, became more popular.[10] In 1957, Attie described the use of transverse cervical incision as the technique
of choice when performing radical neck dissection[11] and since 1979, thanks to the studies performed by Becker, this incision became
popular in the United States.[12]
Among all the incisions, it will be essential to follow some criteria that help us
choose the best one. These criteria can be grouped as follows: 1) Adequate exposure
of the surgical field, 2) Adequate blood flow to the apron flaps, 3) Adequate relationship
of the incision to the YV and the carotid artery (CA), 4) Easy conversion or adequate
to access to the resection of a primary tumor, 5) Useful to create the tracheal stoma
6) Compatible with any reconstructive effort and 7) Aesthetically acceptable.[6]
In our center, the extended cervical (horizontal) transverse incision was introduced
in 2012, and it began to be systematically performed in any cervical neck dissection
since 2014, modifying and expanding the incision when the primary tumor resection
was required. Once the procedure is standardized, we can present our results below.
Materials and Methods
A retrospective analysis was performed with the approval of the ethics committee of
our institution. Forty-seven patients diagnosed with malignant head & neck tumors
between June of 2016 and June of 2017 who required a primary surgical treatment or
rescue, accompanied by a selective, radical modified or radical neck dissection with
at least 6 months of postoperative follow-up in which an extended transverse incision
was used were included as a study group. All tumors were classified according to the
criteria of the Union Internationale Contre le Cancer (UICC) and the American Joint Committee on Cancer (AJCC—7th edition). All patients
requiring a surgical reintervention or cutaneous reconstruction were excluded. As
a control group, we included a historical retrospective cohort of those patients who
required surgical treatment for similar indications, between January of 2010 and January
of 2012, in which the incision used was in J (Paul-Andre) or classic U (Gluck-Sorensen-Tapia).
([Fig. 1]).
Fig. 1 A) Unilateral transverse - Horizontal incision B) Incision in J of Paul-Andre. C)
Bilateral transverse - Horizontal incision D) Bimastoid incision in U of Gluck-Sorensen-Tapia.
Patients previously treated by radiotherapy (RT) or chemotherapy/radiotherapy (CT/RT)
and who were considered candidates for salvage surgery due to tumor recurrence received
standard RT as organ preservation treatment at doses of 2 Gy daily, for a total dose
of between 64 and 70 Gy. The patients who required CT were given a regimen of cisplatin
(100 mg/m2) every 3 weeks. In the postoperative setting, some patients precise postoperative
radiation therapy treatment for a total dose of between 66 and 70 Gy for those with
high-risk factors, and 50 and 54 for those with low-risk factors.
Regarding the surgical technique, a transverse (horizontal) incision was performed
at the level of the midline of the thyroid cartilage when a selective supraomohyoid
or cervical jugular dissection was involved. When the neck dissection includes level
V, the incision will be drawn at the level of the cricothyroid membrane. The extension
of the incision will depend on the type of neck dissection to be performed. In case
of unilateral neck dissection, the incision will start from the posterior edge of
the SCM muscle and will exceed 2 cm of the midline in the contralateral direction.
If it is necessary to include the level V, the incision may extend up to 3 cm behind
the posterior edge of the ESCM. In the case of bilateral cervical neck dissection,
the incision would extend on both sides of the neck to the posterior border of the
SCM. The upper flap will be elevated until the lower border of the jaw is palpated,
and the lower flap is then raised to the level of the clavicle. If a first intraoral
approach is necessary, the incision will rise parallel to the tassel of the chin,
and we will have to incise the midline at the level of the lip. If it is necessary
to include the parotid in the neck dissection, we will start by making a modified
Blair incision and continue our incision at the level of a horizontal fold of the
neck. Once elevated, both flaps are fixed with Lone Star surgical elastic bands (Lone
Star Surgical, Laredo, TX, USA) ([Fig. 1]).
Due to the absence of specific scales validated regarding aesthetic results in cervical
incisions after oncological surgery, a visual analogue scale (VAS) was presented to
each patient 6 months after surgery questioning about the aesthetic results and life
quality, and the surgeons were consulted regarding the wound results. Great auricular
nerve damage was evaluated subjectively according to the patient's sensation the day
after surgery in the ward round.
The statistical analysis was performed using the JASP - Version 0.8.5.1 computer software
(University of Amsterdam, Amsterdam, Netherlands). The Kolmogorov-Smirnov was used
to assess the normal distribution. The quantitative variables within the study are
expressed as a mean ± standard deviation; the results are expressed as both total
and percentage. The Chi-squared test and the Fischer test were used in the univariate
analysis. The comparison concerning partial or total necrosis of the flap, aesthetic
results and quality of life between both groups was performed using the Student t-test for paired data and the p-value < 0.05 was considered significant.
Results
A total of 104 patients were included. Forty-seven patients in the study group, 38
men (80.9%) and 9 women (19.1%) with an average age of 62.79 years (±12.19; min: 35/max:
84). Fifty-seven patients were included in the control group, 35 men (61.4%) and 22
women (38.6%) with an average age of 62.02 years (±11.28; min: 30/max: 82). The clinical
and demographic data can be seen in [Table 1].
Table 1
Demographic data and statistical comparison of the variables associated with failure
during the post-surgical healing
|
Variable
|
Transverse incision - N (%)
|
J or U incision – N (%)
|
P (UA)
|
|
Sex
|
|
|
|
|
Men
|
38 (80.9)
|
35 (61.4)
|
|
|
Women
|
9 (19.1)
|
22 (38.6)
|
|
Age
|
62.79 ± 12.1 (Min: 25/Max: 84)
|
62.02 ± 11.28 (Min: 30/Max: 82)
|
0.984
|
|
ASA
|
|
|
|
|
1
|
0 (0)
|
1 (1.8)
|
0.830
|
|
2
|
24 (51.1)
|
25 (43.9)
|
|
3
|
22 (46.8)
|
31 (54.4)
|
|
4
|
1 (2.1)
|
0 (0)
|
|
COPD
|
|
|
|
|
Yes
|
8 (17)
|
10 (17.5)
|
0.736
|
|
No
|
39 (83)
|
47 (82.5)
|
|
Cardiopathy
|
|
|
|
|
Yes
|
14 (29.8)
|
17 (29.8)
|
0.602
|
|
No
|
33 (70.2)
|
40 (70.2)
|
|
Smoker
|
|
|
|
|
Yes
|
33 (70.2)
|
19 (33.3)
|
0.249
|
|
No
|
8 (17)
|
8 (14)
|
|
Ex
|
6 (12.8)
|
30 (52.6)
|
|
Mean number of packages per year
|
38.5 ± 28.88 (Min 10/Max: 100)
|
26.58 ± 16.7 (Min: 12/Max: 60)
|
|
Alcohol
|
|
|
|
|
Yes (> 70 g/day)
|
36 (76.6)
|
44 (77.19)
|
0.605
|
|
No (< 70 g/day)
|
11 (23.4)
|
13 (22,8)
|
|
BMI < 18.5
|
|
|
|
|
Yes
|
8 (17)
|
4 (7)
|
0.001
|
|
No
|
39 (83)
|
53 (93)
|
|
Obesity
|
|
|
|
|
Yes
|
14 (29.8)
|
2 (3.5)
|
0.190
|
|
No
|
33 (70.2)
|
55 (96.5)
|
|
Hypertension (HTA)
|
|
|
|
|
Yes
|
20(42.6)
|
21 (36.8)
|
0.700
|
|
No
|
27 (57.4)
|
36 (63.2)
|
|
Diabetes Mellitus (DM)
|
|
|
|
|
Yes (non-insulin dependent)
|
11 (23.4)
|
11 (19.3)
|
0.100
|
|
No
|
36 (76.6)
|
46 (80.7)
|
|
Tx
|
0 (0)
|
7 (12.3)
|
0.018
|
|
T1
|
5 (10.6)
|
7 (12.3)
|
|
T2
|
17 (36.2)
|
24 (42.1)
|
|
T3
|
7 (14.9)
|
9 (15.8)
|
|
T4
|
18 (38.3)
|
10 (17.54)
|
|
N0
|
24 (51.1)
|
18 (31.6)
|
0.365
|
|
N1
|
11 (23.4)
|
13 (22.8)
|
|
N2a
|
3 (6.3)
|
14 (24.6)
|
|
N2b
|
8 (17)
|
7 (12.3)
|
|
N2c
|
1 (2.1)
|
3 (5.3)
|
|
N3
|
0 (0)
|
2 (3.5)
|
|
M0
|
47 (100)
|
57 (100)
|
|
|
M1
|
0 (0)
|
0
|
|
Histology
|
|
|
0.771
|
|
- Squamous cell carcinoma
|
44 (94.6)
|
51 (89.5)
|
|
|
- Adenocarcinoma
|
3 (5.4)
|
4 (7.1)
|
|
- Melanoma
|
0 (0)
|
1 (1.8)
|
|
- Undifferentiated nasopharyngeal carcinoma
|
0 (0)
|
1 (1.8)
|
|
RT or previous CT/RT
|
6 (12.7)
|
14 (24.6)
|
0.079
|
|
Parcial o total flap damage
|
4 (8.5)
|
7 (12.2)
|
0.078
|
Abbreviations: BMI, body mass index; COPD, chronic obstructive pulmonary disease;
CT, chemotherapy; DM, ; HTDA, ; RT, radiotherapy.
P (UA), univariate analysis.
The statistical result for partial or total damage of the flap corresponds to the
comparison between both groups.
Sixty-nine cervical neck dissections were performed in the study group, and 70 in
the control group. The type of surgery can be reviewed in [Table 2], the type of cervical neck dissection performed and the frequency of these can be
reviewed in [Table 3]. It was possible to isolate an average of 18 ± 7 (min: 11/max: 39) lymph nodes in
the study group, while in the historical control group an average of 16 ± 5 lymph
nodes were isolated (min: 6/max: 29). Regarding complications related to the incision
or the elevation of both flaps, we did not find significant differences regarding
complications between both (p = 0.078) ([Table 4]). In the univariate analysis, factors that could be associated with an alteration
in healing were included, with malnutrition being the only factor related to flap
damage (p = 0.001). Regarding the aesthetic result, the patients showed subjective compliance
according to VAS, with a mean of 7.25 in the study group and 6,20 in the historical
cohort (p = 0.002). According to their quality of life, the patients in the study group report
a mean of 6.91 versus a 7.71 in the historical cohort (p = 0.721). The aesthetic assessment of the surgeon regarding the wound results in
the follow-up was favorable in 65.7% of the cases in the study group and 60% of cases
in the historical cohort ([Table 5]).
Table 2
Type of surgery performed
|
Type of surgery
|
Transverse incision – N (%)
|
J or U incision – N (%)
|
|
TL + CND
|
12 (26.5)
|
12 (21.1)
|
|
TLM + CND
|
5 (10.6)
|
7 (12.28)
|
|
THPLM + CND
|
5 (10.6)
|
3 (5.26)
|
|
Glossectomy + CND
|
5 (10.6)
|
5 (8.8)
|
|
Transoral oropharyngectomy + CND
|
9 (19.1)
|
2 (3.5)
|
|
FM + CND
|
1 (2.1)
|
0 (0)
|
|
RND
|
4 (8.5)
|
5 (8.8)
|
|
MND
|
0 (0)
|
10 (17.5)
|
|
Parotidectomy + CND
|
3 (6.4)
|
4 (7.32)
|
|
Submaxilectomy + CND
|
1 (2.1)
|
1 (1.8)
|
|
Maxilectomy + CND
|
1 (2.1)
|
0 (0)
|
|
Cheek Mucosa + CND
|
1 (2.1)
|
0 (0)
|
|
Regional flap
|
|
|
|
- Pec major flap
|
4 (8.5)
|
3 (5.3)
|
|
- Supraclavicular island flap
|
2 (4.25)
|
0 (0)
|
|
- FAMM
|
2 (4.25)
|
0 (0)
|
|
Free Flap
|
|
|
|
- Radial forearm flap
|
1 (2.1)
|
2 (3.5)
|
|
- Fibula
|
1 (2.1)
|
0 (0)
|
Abbreviations: CND, cervical neck dissection; FAMM, facial artery musculo-mucosal
flap; FM, floor of the mouth; MND, modified neck dissection; RND, radical neck dissection;
THP, transoral hypopharyngeal Co2 laser microsurgery; TL, total laryngectomy; TLM,
transoral Co2 laser microsurgery - glottis and supraglottis are included.
Table 3
Type of cervical neck dissection performed and mean of isolated lymph nodes
|
Type (Levels)
|
Transverse incision (%)
|
Mean of node isolated
|
J or U Incision (%)
|
Mean of node isolated
|
|
JND (II-IV)
|
49 (71.3)
|
18 ± 7 (Min: 11/Max: 39)
|
55 (78.57)
|
16 ± 5 (Min: 6/Max: 29)
|
|
SOHND (I-III)
|
14 (20.3)
|
18 ± 8 (Min: 13/Max: 33)
|
6 (8.57)
|
14 ± 7 (Min: 8/Max: 21)
|
|
RMND (I-V)
|
3 (4.34)
|
21 ± 7 (Min: 18/Max: 26)
|
5 (7.14)
|
19 ± 4 (Min: 17/Max: 24)
|
|
Parotidectomy + ND (II, III y V)
|
3 (4.34)
|
17 ± 3 (Min: 16/Max: 22)
|
4 (5.71)
|
15 ± 5 (Min: 13/Max: 19)
|
|
Total
|
69 (100)
|
18 ± 7 (Min:11/Max: 39)
|
70 (100)
|
16 ± 5 (Min: 6/Max 29)
|
Abbreviations: JND, jugular neck dissection; RMND, radical modified neck dissection;
SOHND, supraomohyoid neck dissection.
Table 4
Postsurgical complications
|
Type
|
Transverse incision number (%)
|
J or U incision number (%)
|
|
Bleeding
|
7 (14.9)
|
2 (3.6)
|
|
Marginal paresis
|
4 (8.51)
|
2 (3.6)
|
|
Surgical flap dehiscence
|
3 (6.38)
|
5 (8.77)
|
|
Tracheal stoma suture dehiscence
|
1 (2.1)
|
1 (1.8)
|
|
Lymphatic leak
|
2 (4.2)
|
2 (3.6)
|
|
Seroma
|
1 (2.1)
|
1 (1.8)
|
|
Partial flap necrosis
|
0 (0)
|
1 (1.8)
|
|
Superior flap lymphedema
|
6 (12.7)
|
No data available
|
|
GAN lesion
|
5 (10.6)
|
No data available
|
Abbreviation: GAN, great auricular nerve.
Table 5
Quality of life of patients and subjective perception of the surgical wound
|
Variable
|
Transverse incision
|
J or U incision
|
p
|
|
Aesthetic perception of the patient (VAS 0–10)
|
7.25
|
6.20
|
0.002
|
|
Quality of life (VAS 0–10)
|
6.91
|
6.71
|
0.721
|
|
Surgeon's assessment
|
|
|
|
|
- Wound with correct healing
|
65.7%
|
60%
|
|
|
- Wound with a flat adherent scar
|
20%
|
25%
|
|
- Cutaneous retraction without functional affectation.
|
8.6%
|
7%
|
|
- Cutaneous retraction with functional affectation
|
5.7%
|
8%
|
Abbreviation: VAS, visual analogue scale.
Discussion
Before performing a cervical neck dissection, it is essential to know the vascularization
patterns of the skin in the neck. Kambic and Sirca, in 1967, showed that the lateral
cervical cutaneous vascularization was directed vertically, receiving blood supply
from the descending perforating branches of the facial, submental, occipital, posterior
auricular and external carotid arteries, as well as from the ascending branches of
the transverse cervical and suprascapular artery. Also, the platismocutaneous branches
of the superior thyroid artery irrigate the skin of the anterior region in the neck.[13] In 1985, Rabson et al, in a study performed on cadavers, describe the presence of
arterial perforators of the platysma muscle to the skin of the neck as well as the
anastomosis between them, which will guarantee arterial blood supply at this level
during the elevation of the apron flap.[14]
Despite the different incisions described in the literature, it is evident that most
of them do not respect the natural skin tension lines originally described by Langer,[15] with the increased risk of contractures at the level of the scar or the appearance
of keloids or hypertrophic scars. The alteration of these tension lines secondary
to cicatricial retraction will condition the range of cervical mobility,[16] causing pain, in some cases, which may be disabling, directly affecting the physical
activity and quality of life of the patient.
Since the inclusion of RT in the treatment schemes of head and neck tumors, there
has been an increased risk of healing failure. From the initial works presented by
Ellis[17] and Stell,[18] who described failures in the wound primary closure of 79% and 55% of the cases,
respectively, several series report similar results, with the posterior flap and the
trifurcation area being the most frequent sites of necrosis and dehiscence, leading
to an increased risk of carotid exposure and blowout.[19] Acar et al,[20] in a series in which included 320 patients who had undergone a J incision, described
a dehiscence rate of 12.6%, a rate of apron flap necrosis of 3.3%, and contracture
at the cervical level in up to 3% of cases. A recent study published by Guillier et
al compares the use of the Paul-André, or J incision, with the transverse incision,
with the perception regarding the aesthetic result by the surgeon and patient satisfaction
between both groups being the only statistically significant parameters, in both cases
in favors of the transverse incision group.[21] In our study, we found significant results regarding aesthetic perception, but we
could not find any difference according to the quality of life in patients. According
to the surgeon's perception of the scar during the follow-up, correct healing was
found in 65.7% of the patients in the study group and 60% of patients in the historical
cohort.
Concerning the extended transverse incision, since its original description, one of
the main drawbacks has been the lack of exposure. However, in [Figs. 2], [3] and [4], we can see how with this incision we can correctly expose the totality of the cervical
areas and even when we need to combine the cervical incision with other approaches
for the primary lesion. In our series, although we found more N2-N3 patients in the
control group, no statistical difference was found between both groups (p = 0.365); moreover, there was no need for the surgeon to limit lymph node resection
due to inadequate field exposure in any of the cases. Additionally, the mean number
of isolated lymph nodes per neck dissection, which was 18 ± 7 (min: 11/max: 39), is
in relation to the oncological parameters previously described.[22] On the other hand, we must emphasize the importance of avoiding angles and their
propensity to necrosis during flap elevation as well as a horizontal direction opposite
to the large vessels,
Fig. 2 Horizontal incision and exposure of all cervical levels. With preservation of the
great auricular nerve.
Fig. 3 Mandibular swing to approach a parapharyngeal space tumor.
Fig. 4 Left superficial parotidectomy + carnival neck dissection.
In this way, this cervical incision guarantees a safe approach when the surgeon performs
an oncological cervical procedure and, due that the direction of the incision is related
to the natural lines of skin tension in the neck, the suture will have an adequate
relaxation that will decrease the appearance of cicatricial retraction, guaranteeing
an aesthetic benefit in patients subjected to a mutilating surgical procedure. ([Figs. 5] and [6])
Fig. 5 Patient on his 6th postoperative day of left radical neck dissection (left). Patient
after 1 month postoperatively due to selective jugular neck dissection – levels II-IV
(right).
Fig. 6 Left supraomohyoid cervical neck dissection 6 months after surgery
According to the complications rates associated with healing in this group of patients,
only 4 (8.5%) patients in the transverse incision group presented dehiscence of the
operative wound, while 7 (12.2%) in the historical group showed a dehiscence of the
wound without finding differences between both groups (p = 0.078). The only factor related to the appearance of these complications in those
patients was a body mass index lower than 18.5. Theoretically, the transverse incision
could create scarring interfering with the lymphatic draining of the flap, especially
compared with a J or hockey-stick incision, in our cohort 6 (12.7%) patients developed
superior flap lymphedema related to this problem, all of them resolved during the
follow-up.
Furthermore, during the elevation of the flap using a transverse incision, the great
auricular nerve (GAN) can be at risk, affecting the sensation at the level of the
ear lobule. Careful dissection is needed to avoid this kind of complication and even
doing this, the risk still exists. In our cohort, 5 (10.6%) patients suffered alteration
of sensibility at the level of the auricle after the transverse incision, secondary
to an injury during the flap elevation. However, due to the retrospective nature of
data obtained from the historical cohort, we cannot evaluate the rate of lymphedema
or GAN damage to compare and extract any conclusion. None of the patients presented
hypertrophy scarring or keloid onset during follow-up.
Another important consideration is the use of regional free flaps during head & neck
surgery. In both cohorts, patients who precise the use of myomucosal pectoralis major
flap for pharyngeal reinforcement after salvage total laryngectomy were included,
in this patient, the bulky effect of the pedicle can be considered an aesthetic problem.
However, no difference was found between the groups. Also, the use of fascio-cutaneous
flaps like the supraclavicular artery island flap or radial forearm free flap for
tongue reconstruction or pharyngeal wall reconstruction after total laryngectomy as
well as one patient who precise a fibula free flap after a segmental mandibulectomy
were included in the final analysis without any significant difference when compared
with other patients. However, all those patients who needed a skin flap reconstruction
after an ablative procedure of the head and neck were excluded.
Finally, we must highlight the limitations of the present study, which include the
retrospective nature of the study, the absence of albumin level in both groups, the
lack of a specific test to assess the quality of life of patients, the rate of patients
affected by shoulder pain after neck dissection, and the difference in the proportion
of patients having radiation prior to the neck surgery; with radiation being less
frequent in the transverse incision group (13%) when compared with the other incisions
(25%).
Conclusion
The transverse incision represents a safe, aesthetic and oncological adequate option,
associated with a lower cicatricial retraction rate, a lower rate of complications
and allowing adequate exposure of the surgical field similar in comparison with the
classic J or U incision.
