Presented by Steven S Chang MD ObjectivesDisclaimers 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 ID: 745986
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Slide1
October 10, 2011
1
Head and Neck Dissection Lecture
Presented by: Steven S. Chang MDSlide2
Objectives/Disclaimers
Review basic steps to proceduresAvoid eponyms and esoteric anatomyRecognize that there are several ways to perform these operations, and this is just one way to do themCadaver lab is the time to ask Why and How…
Read before and after lab
October 10, 2011
2Slide3
Thyroidectomy
Skin Incision through platysma if visibleRaise superior flaps to thyroid notchRaise inferior skin flaps to clavicleDivide straps in midline raphe, avoid anterior jugs
3Slide4
Thyroidectomy
Dissect strap muscles off glandIdentify trachea and lateral border of glandIsolate Superior Pole vesselsIdentify superior laryngeal nerveSuperior Parathyroid
4Slide5
Thyroidectomy
Identify middle thyroid veinRotate Gland mediallyDissect fascia off inferior poleIdentify Inferior parathyroid gland
5Slide6
Thyroidectomy
Identify Inferior Parathyroid ArteryIdentify Tracheo-esophageal grooveFind RLN and trace superiorly without devascularizing parathyroid gland to insertionDissect off trachea
6Slide7
Parotidectomy
Blair/Facelift IncisionRaise skin flap, think about SMASIdentify SCM muscleIdentify Greater Auricular NerveDissect tragal cartilage free
Anterior rotation of parotid gland
7Slide8
Parotidectomy
Identify digastric musclePalpate tympano-mastoid suture lineIdentify Facial NerveSerially dissect each branch to masseterIn-Lift-Spread
Avoid the retromandibular vein
8Slide9
Neck Dissection and Submandibular Gland Excision
Many ways to performTumor dictates how neck is performedConcept of
lymphadenectomy and gland excisionKnow the levels of the neck and anatomic and radiographic borders
October 10, 2011
9Slide10
Neck Dissection (Before)Slide11
Submandibular Gland Excision
Skin incision in crease two finger breadths below mandibleRaise skin flapsIdentify inferior border of glandIdentify/
ligate facial vein and artery lowMarginal Nerve
11Slide12
Submandibular Gland Excision
Retract gland to find digastricIdentify mylohyoid muscle and retract
Identify lingual nerve and warthin’s duct
Identify hypoglossal nerve
Divide duct and ganglion
12Slide13
Submandibular Gland Excision
Dissect facial vein superiorly, retract soft tissue with veinIdentify and ligate facial artery superiorlyFollow
digastric anteriorly and
posteriorly
to SCM
13Slide14
General Concepts
October 10, 2011
14Slide15
Neck Dissection
Incise SCM fascia and unwrap from muscle until reach posterior border of SCMIdentify CN XI and trace to IJ/digastric
Circumferentially dissect CN XIFree apex from deep neck musculatureTuck apex under CN XI
October 10, 2011
15Slide16
Neck Dissection
Identify Omohyoid muscle and dissect free and retract inferiorlyIdentify transverse cervical vessels
Identify IJ and vagusIdentify and trace cervical rootlets
Free corner from underneath clavicle
Identify
phrenic
Continue lateral to medial dissection
October 10, 2011
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Neck Dissection
Identify carotid sheathTransition to lateral IJ and dissect posterior to anteriorIdentify ansa
hypolglossi and preserveDissect off branches of IJ and strap muscles
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Neck Dissection (AFTER)Slide19
Larnygectomy
Raise Skin FlapsIdentify SCMTrace SCM and create “outer tunnels”
October 10, 2011
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Laryngectomy
Divide Strap muscles inferiorly and elevate off thyroid gland
October 10, 2011
20Slide21
Laryngectomy
Divide thyroid glandDissect “inner tunnels” (carotid sheath away from larynx)Divide super laryngeal bundleExpose hyoid and free muscle from superior surface
21Slide22
Laryngectomy
Free the greater cornu of the hyoidRotate larynx and divide constrictors
Free piriform mucosaEnter through
vallecula
and retract epiglottis
Resect
trachea
22Slide23
Laryngectomy
Make tumor cuts under direct visualization
October 10, 2011
23Slide24
October 10, 2011
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Pectoralis
Flap
Plan your paddle size and pedicle length
Now make them bigger and longer, respectivelySlide25
Pectoralis Flap
Extend incisions away from paddle in a trapezoidal fashion to include perforators
October 10, 2011
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SKIN
FAT
MUSCLESlide26
October 10, 2011
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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 clavicleSlide27
October 10, 2011
27
Copyright restrictions may apply.
Ramakrishnan, V. R. et al. Arch Facial Plast Surg 2009;11:306-310.
Pectoralis
FlapSlide28
October 10, 2011
28
Copyright restrictions may apply.
Ramakrishnan, V. R. et al. Arch Facial Plast Surg 2009;11:306-310.
Pectoralis
FlapSlide29
October 10, 2011
29
Copyright restrictions may apply.
Ramakrishnan, V. R. et al. Arch Facial Plast Surg 2009;11:306-310.
Pectoralis
FlapSlide30
October 10, 2011
30
Copyright restrictions may apply.
Ramakrishnan, V. R. et al. Arch Facial Plast Surg 2009;11:306-310.
Pectoralis
FlapSlide31
October 10, 2011
31
Copyright restrictions may apply.
Ramakrishnan, V. R. et al. Arch Facial Plast Surg 2009;11:306-310.
Pectoralis
Flap