Modified Neck Dissection

Javier Gavila n, MD, and Jesu s Herranz, MD

he most important prognostic factor in cancer of the

head and neck is the status of the cervical lymph
nodes. For this reason, surgical therapy of the neck is an
essential part of the treatment and prognostic evaluation
of these malignancies.
The grandfather of neck dissection in North America is
George Crile of the Cleveland Clinic. By 1906, strongly
influenced by Halsted, Crile believed that if the neck
lymphatics could be removed in a radical manner and
en bloc, more cures could be accomplished.
Head and neck surgery made little progress in the
ensuing decades in North America. The various surgical groups interested in head and neck cancer acknowledged a need for a more focused effort. To this goal, a
head and neck service was established by Henry Janeway at the Memorial Hospital in New York City in
1914. Hayes Martin had a profound influence on the
direction and dogma of head and neck surgery. The
radical operation was standard. The radical operations
oncologic premise was the bigger the operation the
better the chance for cure.
It soon became evident to all those involved in the
management of patients with head and neck cancer that
the radical operation was reasonable for the treatment of
large palpable masses, but excessive for patients without
palpable nodes with a high risk of cervical metastasis and
for some patients with small palpable nodes. It was also
noteworthy that radical neck dissection was not practical
as a simultaneous bilateral procedure.
At the beginning of the second part of the century,
there were rumors about an operation called functional
neck dissection that was performed by an Argentinean
named Osvaldo Sua rez. He was on the staff of the
Depart- ment of Otolaryngology, and also worked at the
Depart- ment of Anatomy under the direction of Pedro
Ara. Pro- fessor Ara was known as the Spanish
anatomist, and he was very popular in Argentina for
having embalmed the

corpse of Eva Pero n. His dual projection as an

anatomist and otolaryngologist conferred Sua rez a
privileged posi- tion. As an otolaryngologist, he had a
thorough
knowl- edge of head and neck cancer,
especially cancer of the larynx. Functional
neck
dissection was designed to re- move the lymphatic
tissue of the neck and preserve the remaining neck
structures. However, the operation was not appealing for
the following two reasons: (1) It was less than the
accepted dogma of the time, ie, radical neck
dissection; and (2) the name suggested a dangerous approach to cancer. How can a terrible disease like cancer be
treated with a mild functional operation? (Remember
that Halstedian principles were still leading the world of
oncology at that time.) As an anatomist, he was very
familiar with all anatomic details concerning neck dissection. The operation, as performed by Sua rez, was
clean, systematic, comprehensive,
and easy to
understand and teach. The main goal of the functional
approach to neck dissection proposed by Sua rez was
removal of all lym- phatic tissue in the neck and
preservation of the remain- ing neck structures. This is
achieved by using the fascial planes of the neck that
surround most cervical structures and separate them
from adjacent lymphatic tissue. Apply- ing the technical
details
of functional
neck
dissection without
understanding the spirit of the procedure results in a
large number of different operations, be they selective
operations, modified procedures, or limited neck dissections (or any other name). This is in part what happens
with most neck dissection classifications currently used
in the literature. On the other hand, understanding the
spirit of the procedure but using the wrong techniques
produces a messy operation that is difficult to understand
and teach.
What is not clear, on a statistically supported basis, is
what dissection is appropriate for which clinical scenario.
The question of whether many of the modifications make
any clinical difference in terms of survival, morbidity, or
any other measure of value has not been answered. Only
empirical assumptions are offered as a basis for these

From the Department of Otolaryngology, La Paz University Hospital, Autonomous University of Madrid, Madrid; and the Department of Otolaryngology,
Juan Canalejo University Hospital, Corun a, Spain.
Address reprint requests to Jesu s Herranz, MD, Department of
Otolaryngology, Juan Canalejo University Hospital, Urbanizacio n Lamastelle,
Courel 39, Mon- trove, Corun a, 15179 Spain.
2004 Elsevier Inc. All rights reserved.
1524-153X/04/0602-0004$30.00/0
doi:10.1053/j.optechgensurg.2004.05.009

recommendations. It is unlikely that statistical data will

be forthcoming in the immediate future because the
whole issue of neck dissection type is being overshadowed by the issues surrounding neck treatment when
concomitant chemotherapyradiation programs are used
as initial treatment for both the primary site and neck
metastases.

Operative Techniques in General Surgery, Vol 6, No 2 (June), 2004: pp 83-94

83

INDICATIONS FOR FUNCTIONAL NECK

DISSECTION
The decision whether to remove the whole lymphatic
system of the neck or just a portion will depend on the
following factors: location of the primary tumor, N stage,
and the experience and preferences of the surgeon. Currently, we have a fairly consistent description of the most
frequent metastatic areas for most primary sites in the
head and neck. This situation allows the surgeon to preserve some nodal groups, according to the location of the
primary tumor, without a significant risk of undertreatment. This is especially true in pathologic N0 patients in
whom the lymph flow should not have been disturbed by
metastatic disease. However, in pN necks, the situation
may be different. The following problems must be considered:
1. The theoretic predictability of the lymph node metastatic pattern may have been modified by changes produced by the tumor cells contained within the lymphatic
system. This may result in positive nodes outside the
normal route.
2. The presence of metastasis in the usual nodal areas
significantly increase the chance of positive nodes in
other less common regions of the primary site. In the
preoperative clinical N neck with small palpable nodes,
this is the strongest argument against selective neck dissections.
To be safe, functional neck surgery requires all metastatic disease to be confined within the lymphatic tissue.
This approach is ideal for N0 patients with a high risk of
occult metastasis. An additional advantage of functional
neck dissection is that it may be performed simultaneously on both sides of the neck without increasing
morbidity.
The nodes should not be greater than 2.5 to 3 cm in
diameter. This is justified by the need to have all metastatic disease confined within the lymph node capsule.
Although extracapsular spread is possible for lymph
nodes of all sizes, it is well known that extracapsular
spread increases with increasing lymph node size. Gross
extracapsular extension results in lymph node fixation to
contiguous structures. In no instance should functional
neck dissection be attempted in patients with fixed nodes.
If at operation there is any doubt about the feasibility of
the functional operation, the suspicious structure must be
removed with the specimen.
The number of palpable nodes is not a contraindication
for functional neck dissection as long as all nodes fulfill
the previously mentioned criteria. The same can be said
with respect to the location of the primary tumor. The fact
that patients with cancer of the hypopharynx do less well
than those with laryngeal tumors cannot be changed by
performing more aggressive operations than those required for the N-stage patient.
By definition, functional neck dissection is not possible

in patients previously treated with radiotherapy or other

types of neck surgery. In these patients, the fascial planes
have disappeared as a consequence of the previous treatment; thus, fascial dissection is not possible.

SURGICAL TECHNIQUE
Incision
The exact location and type of skin incision will depend
on the site of the primary tumor and whether a unilateral
or bilateral neck dissection is planned. The following are
the main goals to be achieved by the skin incision:
allow adequate exposure of the surgical field
assure adequate vascularization of the skin flaps
protect the carotid artery if the sternocleidomastoid
muscle has to be sacrificed
include scars from previous procedures, eg, surgery,
biopsy
consider the location of the primary tumor
facilitate the use of reconstructive techniques
contemplate the potential need for postoperative radiotherapy
produce acceptable cosmetic results
After the incision is completed, the skin flaps are elevated to the platysma muscle, preserving the superficial
layer of the cervical fascia. The limits for a complete
functional neck dissection are similar to those of the classical radical neck dissection. The surgical field should
expose the inferior border of the mandible and the tail of
the parotid gland superiorly and, inferiorly, the clavicle
and the sternal notch (Fig 1). The midline of the neck will
be the anterior boundary, whereas the anterior border of
the trapezius muscle in the lower half of the neck constitutes the posterior boundary of the dissection.

Unwrapping the Sternocleidomastoid Muscle

Usually, the first step of the operation is the dissection of
the fascia that covers the sternocleidomastoid muscle
(SCM) to completely unwrap the muscle from its surrounding fascia (Fig 2). The dissection of the SCM begins
with a longitudinal incision over the fascia along the entire length of the muscle near the posterior border. The
external jugular vein should be transected as close to the
posterior border of the SCM as possible.
When the deep medial aspect of the muscle is approached (Fig 3), small perforating vessels are found entering the muscle through the fascia; these need to be
cauterized. The surgeon must be extremely careful in the
upper half of this region, where the spinal accessory nerve
enters the muscle. One or more small vessels usually
accompany the spinal accessory nerve, which often divides before entering the muscle. The vessels should be
cauterized without injuring the nerve, and all branches of
the nerve must be preserved to maintain the best shoulder
function.

Modified Neck Dissection

85

Right side of the neck after elevation of the cutaneous flap that includes the platysma muscle. The superficial layer of the
cervical fascia is present overlaying the SCM and strap muscles. The anterior, posterior, medial and inferior limits of the surgical
field are indicated.

Unwrapping the SCM. Forceps pull the fascial covering of the lateral aspect of the SCM so that the surgeon is able to dissect
the fascia sharply.

Dissection over the medial surface of the SCM. Dissection continues over the medial aspect of the SCM by retracting the
muscle posteriorly. The internal jugular vein is visible covered by the fascia of the vascular sheath.

Modified Neck Dissection

87

Identification of the spinal accessory nerve in the upper corner of the neck. The SCM is retracted posteriorly, and the inferior
pole of the parotid gland is retracted superiorly. The internal jugular vein is identified, and the spinal accessory nerve is located
entering in the upper third of the medial surface of the SCM.

Identification of the Spinal Accessory Nerve

The main goal of this step of the operation is to locate the
nerve at its entrance to the SCM (Fig 4). The dissection of
the entire course of the nerve between the SCM and the
internal jugular vein will be performed at a later stage of
the procedure. The spinal accessory nerve enters the SCM
at approximately the junction of the upper and middle
third of the muscle. The transverse process of the atlas
serves as a useful anatomic landmark. Adequate exposure
of the area requires posterior retraction of the SCM.

Dissection of the Submandibular Fossa

Removal of the submental and submandibular lymph
nodes (area 1) comes next. The surgical treatment of most
primary tumors that require the inclusion of area I as part

of the dissection also requires the removal of the submandibular gland. On the other hand, those tumors in which
the submandibular gland may be preserved without compromising the onocologic safety of the operation, such as
cancer of the larynx, hypopharynx, or thyroid gland, usually do not require dissection of area I.
Dissection starts with a fascial incision from the midline
to the tail of the parotid gland. The anterior jugular vein
must be ligated and divided. The fascia is then incised in
the submental area and the tissue in the submental region
is dissected inferiorly. The incision is continued posteriorly
1 cm below and parallel to the lower border of the mandible
to avoid injuring the marginal mandibular branch of the
facial nerve. Most often, identification of the marginal
nerve is tedious and unnecessary. Safe preservation may
be accom-

Spinal accessory nerve maneuver. The lymph nodes and fatty tissues located above the spinal accessory nerve are dissected
from the internal jugular vein and underlying musclessplenius capitis and levator scapulaand pulled down by passing
underneath the spinal accessory nerve.

plished by the identification of the facial vein at the

lower border of the submandibular gland. The vein is
ligated and divided so that it can be reflected superiorly
over the body of the mandible, taking the marginal
mandibular branch of the facial nerve out of the dissection
field.
The dissection is continued over the anterior border of
the submandibular gland. The posterior border of the
mylohyoid muscle is dissected free from the submandibular gland and retracted anteriorly. The dissection continues along the superior border of the submandibular
gland, if this is to be removed, or along its inferior border,
if it is to be preserved.
The submandibular gland is reflected and the fascia
over the digastric and stylohyoid muscle is incised from
the midline to the tail of the parotid gland. After the
posterior belly of the digastric muscle is cleared, the stylomandibular ligament is transected. At this level, the retromandibular vein, the posterior auricular vein, and the
external jugular vein are identified and ligated.
The digastric and stylohyoid muscles are retracted superiorly, exposing the hypoglossal nerve as well as the
lingual veins that follow and cross the nerve in this area.

The lingual veins should be carefully ligated because they

may be a source of troublesome bleeding. When bleeding
occurs in this area, bipolar coagulation may be used instead of clamps and ligatures to avoid injury to the hypoglossal nerve.

Dissection of the Spinal Accessory Nerve

To approach this area, the SCM is retracted posteriorly
and the posterior belly of the digastric muscle is pulled
superiorly with a smooth blade retractor (Fig 5). At this
level, the nerve runs within the lymphatic container of
the neck, forcing the surgeon to cut across the fibrofatty
tissue overlying the nerve from the SCM to the internal
jugular vein. Usually, the internal jugular vein lies immediately behind the proximal portion of the nerve, but the
nerve may go behind or even cross the vein.
Once the spinal accessory nerve has been completely
exposed, the tissue lying superior and posterior to the
nerve must be dissected from the splenius capitis and
levator scapulae muscles (Fig 6). The tissue is pulled in an
anteroinferior direction toward the spinal accessory

Posterior triangle approach. The superficial layer of the cervical fascia is dissected along the posterior border of the SCM, and
the anterior border of the trapezius muscle is identified. The SCM is retracted medially, and dissection is directed toward the level
of the scalene muscles. The tendon of the omohyoid muscle and transverse cervical vessels is identified.

nerve. The occipital and sternocleidomastoid arteries are

often found during this step of the operation. Once the
dissected tissue reaches the level of the spinal accessory
nerve, it must pass underneath the nerve to be removed in
continuity with the main part of the specimen. Osvaldo
Sua rez called this step of the operation the spinal
acces- sory maneuver.
Keeping the SCM retracted posteriorly, an incision is
made into the tissue located between the entrance of the
spinal accessory nerve and Erbs point. The underlying
levator scapulae muscle is identified and the tissue is
dissected slightly forward and medially over its fascia.
The rest of the dissection in this area will be completed
later.

Dissection of the Posterior Triangle

of the Neck
To facilitate the exposure of the supraclavicular area, this
region is approached posterior to the SCM. The dissection
begins with the removal of the fascia, which still covers
the posterior border of the SCM. It must be remembered
that the fascia was dissected off the muscle up to its
posterior border in a previous step of the operation. Wet

surgical sponges left between the anteromedial aspect of

the muscle and the dissected fascia are used as a reference
to complete the fascial isolation of the SCM. Once completed, this maneuver results in a total release of the
muscle from its surrounding fascia.
Some anatomic landmarks define the boundaries of the
surgical field in the posterior triangle. The inferior limit is
located at the level of the clavicle. The posterior margin is
clearly marked by the anterior edge of the trapezius muscle, and the upper boundary is defined by the exit of the
spinal accessory nerve toward the trapezius muscle. The
transverse cervical vessels and the omohyoid muscle constitute important anatomic landmarks within this area.
The SCM is retracted anteriorly, and the external jugular
vein is divided and ligated low in the neck if this was not
performed at a previous stage of the operation. The dissection then proceeds from the anterior border of the
trapezius muscle in a medial direction, including the lymphatic contents of the supraclavicular fossa. It is the
upper margin of this area where there is the greatest
risk for damage to the spinal accessory nerve. The spinal
acces- sory nerve leaves the SCM deep to Erbs point
and de- scends obliquely downward and backward
toward the

Management of the cervical plexus branches. After dissection from the posterior triangle to the scalene muscles is completed,
the fibrofatty tissues are passed underneath the SCM, pulling it medially, and the SCM is retracted posteriorly.

trapezius muscle. The position of the patients head along

with the traction exerted by the surgeon during the dissection may displace the nerve from its original course,
creating a slight anterior curvature where the nerve may
be inadvertently damaged. Displacement of the nerve is
caused by its connections with the second, third, and
fourth cervical nerves. During dissection of this region,
several supraclavicular branches of the cervical plexus
may be found. They follow a similar course but are located superficial to the spinal accessory nerve (Fig 7).
Although the difference between the eleventh nerve and
the supraclavicular branches is easily noticed, the novice
surgeon may sometimes find this difficult.
The omohyoid muscle is then identified and its fascia is
dissected off the muscle to be removed with the contents
of the posterior triangle. The muscle may be transected at
this time if this will be required for removal of the
primary tumor; otherwise, it is preserved and retracted
inferiorly with a smooth
blade retractor.
The
transverse cervical vessels are identified deep to the
omohyoid muscle. The deep layer of the cervical fossa
over the levator scapulae and scalene muscles is now
visible. The brachial plexus is

easily identified because it appears between the anterior

and middle scalene muscles. Staying superficial to the
scalene fascia prevents injury to the brachial plexus and
the phrenic nerve (Fig 8). The dissection is continued
medially until it reaches the level of the anterior border of
the SCM. The muscle is then pulled laterally with retractors, and the contents of the supraclavicular fossa are
passed underneath to meet the tissue previously dissected
from the upper half of the neck. The SCM is then
retracted posteriorly and the dissection continues
anterior to the muscle toward the carotid sheath.

Dissection of the Deep Cervical Muscles

If the previous steps have been properly performed, there
will now be two main blocks of the dissection (Fig 9). The
upper part includes the submandibular and submental
triangles (area I), as well as the upper jugular and spinal
accessory regions (upper part of areas II and V). The
lower block includes the supraclavicular fossa (remaining
part of area V). A small bridge of tissue still separates
these two blocks and connects the specimen to the deep

Dissection of the vascular sheath. Once the phrenic nerve has been identified on the anteromedial aspect of the anterior
scalene muscle, the branches of the cervical plexus are divided and the dissection continues over the fascia covering the vagus nerve,
common carotid artery, and internal jugular vein in the vascular sheath.

cervical muscles. This bridge usually goes from just below

the entrance of the spinal accessory nerve into the SCM to
a level just below Erbs point. With a scalpel, this bridge
is transected and the fascia of the levator scapulae muscle
is identified. This maneuver creates a single block that
must be dissected free from the deep muscles toward the
ca- rotid sheath. The dissection that follows will be
per- formed with sharp dissection. Thus, the specimen is
grasped with forceps and adequate traction is applied.
As the dissection proceeds medially, several branches
of the cervical plexus are found. To achieve optimal
shoulder function, the deep branches from the second,
third, and fourth cervical nerves that may anastomose
with the spinal accessory nerve should be preserved. Similarly, the contribution to the phrenic nerve from the
third, fourth, and fifth cervical nerves should also be
preserved. This is best achieved by keeping the dissection
superficial to the scalene fascia, where the branches of the
cervical plexus usually lie. On the other hand, the superficial or cutaneous branches of the cervical plexus will be
transected as the dissection approaches the carotid
sheath.
Dissection of the deep cervical muscles must be

stopped as soon as the carotid sheath is exposed. Continuing the dissection posterior to the carotid sheath carries a high risk of damage to the sympathetic trunk.

Dissection of the Carotid Sheath

The carotid sheath is a fascial envelope surrounding the
internal jugular vein, common carotid artery, and vagus
nerve. This part of the dissection needs a new no. 10 knife
blade and adequate tension. The surgical specimen is
grasped with hemostats and retracted medially by the
assistant, while the surgeon uses one hand with a gauze
pad to pull laterally over the deep cervical muscles. This
allows complete exposure of the carotid sheath along the
entire length of the surgical field.
An incision is made with the scalpel over the vagus
nerve along the entire length of the carotid sheath. The
nerve can easily be identified between the internal jugular
vein and the carotid artery. The dissection then continues
removing the fascia from the internal jugular vein. This is
achieved by continuously passing the knife blade along
the wall of the internal jugular vein up and down along its
entire length. The scalpel must be moved obliquely with

Dissection of the superficial fascia covering the strap muscles. The anterior jugular vein must be ligated in the upper and
lower limits of the surgical field. The superficial layer of the cervical fascia is incised in the midline and dissected over the strap
muscles (omohyoid and sternohyoid), toward the vascular sheath, until the internal jugular vein is reached. At this point, the
contents of the neck dissection are free from the neck structures.

respect to the vein, with the blade pointing away from the
vein wall. When it is properly performed and the traction
exerted on the tissue is adequate, this maneuver is extremely safe and effective.
The facial, lingual, and thyroid veins appear as the
dissection approaches the medial wall of the internal jugular vein. They should be clearly identified, ligated, and
divided to complete the isolation of the internal jugular
vein.
The dissection of the carotid sheath has two danger
points, one at each end (upper and lower) of the dissection. At these two points, the traction exerted to facilitate
the dissection of the fascial envelop produces a folding of

the wall of the internal jugular vein that can be easily

damaged with the touch of the scalpel blade. We refer to
these two points as the initial folds, and they should be
freed before further dissection of the internal jugular vein
is attempted. The surgeon must be extremely cautious to
avoid injuring the vein at these points.
Lower in the neck, the terminal portion of the thoracic
duct on the left side and the right lymphatic duct (when
present) are also within the boundaries of the dissection
and must be preserved.
Once the internal jugular vein is released from its covering fascia, the dissection continues medially over the
carotid artery. The specimen is now completely separated

from the great vessels and remains attached only to the

strap muscles. The dissection of the strap muscles will
complete the release of the neck dissection specimen.

Dissection of the Strap Muscles

The sternohyoid and omohyoid muscles are completely
freed from their fascial covering. As the dissection proceeds laterally, the superior thyroid artery can be identified coursing in an inferomedial direction toward the thyroid gland. Depending on the resection of the primary
tumor, the superior thyroid artery can be preserved or
should be ligated and divided. The common facial vein
and a variable vein connecting the superficial and deep
venous systems of the neckKochers veinare usually
ligated and divided before the specimen is completely
released from the strap muscles.

Dissection of the Central Compartment

During dissection of the central compartment, the recurrent laryngeal nerve must be identified and followed upward to the larynx and downward to the upper mediastinum. The inferior thyroid artery is ligated and divided
when total lobectomy is planned, and the lymphatic tissue is removed from the central compartment of the neck.
Adequate management of the parathyroid glands is also
extremely important in all cases. Once the specimen is
removed, the neck is carefully inspected for bleeding
points and surgical sponges. Careful hemostasis is time
consuming but rewarding. The entire field is thoroughly
irrigated with normal saline. Finally, the skin is closed in
two layers over a large suction catheter. The platysma is
sutured with absorbable buried sutures and the skin with
skin clips. A moderately tight dressing is applied, with
special attention given to the supraclavicular fossa, because this is the area where most sero-hematomas develop.

SOME TECHNICAL ADVICE FOR THE

FUNCTIONAL APPROACH
The principle of fascial dissection is more easily achieved
when the surgeon uses the knife through fascial planes.
For some steps of the operation, the scalpel is the best
surgical tool, whereas for others, scissors are preferred.
Elevation of the skin flaps and dissection of the SCM,
submandibular fossa, deep cervical muscles, carotid
sheath, and strap muscles are best performed with knife
dissection. On the other hand, dissection of the area
around the spinal accessory nerve, posterior triangle, and
paratracheal space is more easily accomplished with scissors. The main difference between these two groups is the
type of tissue being dissected. Knife dissection requires
firm tissue such as muscle or vessels, whereas fibrofatty
tissue is more easily dissected with scissors. Knife dissection requires precise handling of the scalpel, careful sur-

gical technique, and good help from assistants. The blade

of the scalpel must be directed obliquely to the tissue that
is being dissected and away from the muscle or vessel
whose fascia is being removed. This protects the structures, and especially the veins, from being injured by the
knife blade. To be appropriate, knife dissection must be
carried all the way up and down the surgical field, avoiding the creation of holes along the dissected structure.
The knife blade is much more efficient when cutting over
tense tissue. Thus, assistants must apply good tension to
the surgical field to increase the effectiveness of knife
dissection. Clear visualization of the different structures
in the surgical field is of paramount importance. Blood
obscures the field and makes identification of structures
more difficult. A bloodless field must be maintained
throughout the operation. Washing the field regularly
with warm saline greatly contributes to cleaning the
working area.
The superficial layer of the cervical fascia must remain
intact after the flaps have been raised. This may pose a
problem to the novice surgeon, who usually finds it difficult to preserve the integrity of the fascial layer. The best
way to achieve this goal is by cutting with the scalpel
over the deep aspect of the platysma muscle. As with any
other type of neck dissection, the platysma muscle is
included with the skin flaps because it provides
additional blood supply that protects the skin and
assists in the healing process. The proper sequence for
an adequate incision will be to mark the skin incision,
incise the skin, cut the platysma muscle, and start raising
the flap, keeping the deep aspect of the platysma under
vision. If the muscular fibers of the platysma are seen
throughout the elevation of skin flaps, preservation of the
superficial layer of the cer- vical fossa is assured.

REFERENCES
1. Bocca E, Pignataro O, Sasaki C: Functional neck dissection. A
description of operative technique. Arch Otolaryngol Head Neck
Surg 106:524-527, 1980
2. Caalearo CV, Teatini G: Functional neck dissection. Anatomical
grounds, surgical technique, clinical observations. Ann Oto Rhinol Larynol 92:215-222, 1983
3. DeSanto LW, Holt JJ, Beahrs OH: Neck dissection: is it worthwhile? Laryngoscope 92:502-509, 1982
4. Gavila n Alonso C, Blanco Galdin A, Sua rez Nieto C: El
vacia- miento functional-radical ce rvico ganglionar. Anatomia
quiru r- gica, te cnica y resultados. Acta Oto-Rino-Laringol
Ibero-Ameri- cana 23:703-817, 1972
5. Gavila n J, Gavila n C, Herranz J: Functional neck dissection:
three decades of controversy. Ann Otol Rhinol Laryngol
101:339-341,
1992
6. Gavila n J, Herranz J, Desanto L, et al: Functional and
selective neck dissection. New York, Thieme Medical Publishers,
2002
7. Lindberg R: Distribution of cervical lymph node metastases from
squamous cell carcinoma of the upper respiratory and digestive
tracts. Cancer 29:1446-1448, 1972
8. Medina JE: A rational classification of neck dissection. Otolaryngol Head Neck Surg 100:169-176, 1989
9. Olsen KD, Caruso M, Foote RL, et al: Primary head and neck

cancer: histopathologic predictors of recurrence after neck dissection in patients with lymph node involvement. Arch Otolaryngol
Head Neck Surg 120:1370-1374, 1994
10. Robbins KT, Medina JE, Wolfe GT, et al: Standardizing neck
dissection terminology. Official report of the Academys Committee for Head and Neck Surgery and Oncology. Arch Otolaryngol
Head Neck Surg 117:601-605, 1991
11. Shah JP, Andersen PE: The impact of patterns of neck metastasis

on modifications of neck dissection. Ann Surg Oncol 1:521-532,

1994
12. Shah JP: Patterns of cervical lymph node metastases from squamous carcinomas of the upper aerodigestive tract. Am J Surg
160:405-409, 1990
13. Sua rez O: El problema de las meta stasis linfa ticas y alejadas
del ca ncer de laringe e hipofaringe.
Revista de
Otorinolaryngologia (Santiago de Chile) 23:83-99, 1963