Neck Dissection - Level 1

Considerations

• • Anatomy 

    • marginal mandibular nerve

    • digastic muscle 

    • mylohyoid muscle

    • submandibular ganglion

    • lingual nerve

    • submandibular gland and submandibular duct

    • hypoglossal nerve

  • Indications 

Preparation

Procedure

• Identify the marginal mandibular nerve and elevate it, along with the surrounding tissue, in its own plane

• Remove the submental fatty tissue and identify the anterior belly of the digastric muscle

• Follow the anterior belly of the digastric muscle and identify the mylohyoid muscle

• Retract anteriorly the mylohyoid and expose the submandibular ganglion, lingual nerve, and submandibular duct

• Divide and ligate the submandibular duct

• Clamp, divide, and ligate the facial artery's feeding vessels into the submandibular gland (SMG) as well as the veins draining the SMG 

• Remove the SMG and the submandibular lymph nodes

• Identify the hypoglossal nerve deep into the fascia of the submandibular triangle

• Identify and expose completely the posterior belly of the digastric muscle up to the mastoid tip

• Optional: If the facial artery is reencountered at this point, tie it and ligate it

• After completion of all of the above, dissect and displace inferiorly the submental fatty tissue, submandibular nodes, and submandibular gland

Sample operative report

The skin was  incised through skin and subcutaneous tissue and platysma muscle. A subplatysmal flap was  raised a short distance superiorly. The inferior edge of the submandibular gland was identified and the fascia overlying the gland was then elevated off of the gland. The flap was elevated to the inferior aspect of the mandible. The soft tissue of the submandibular gland and its soft tissue contents were elevated away from the mandible. The soft tissue between the anterior bellies of the digastric was dissected out with a Bovie electrocautery and reflected toward the lateral aspect of the neck. The specimen was  rolled onto the mylohyoid muscle and then onto the digastric musculature. The digastric muscle was retracted and the hypoglossal nerve was identified and preserved. The lingual nerve was identified and preserved. The submandibular duct was clamped, divided and ligated. The submandibular ganglion was clamped, divided and ligated. The facial artery and facial vein were identified and traced out and preserved. The attachments of the submandibular gland were divided as well as the small feeding branches of the vein and artery into the gland. The gland along with its accompanying fibrofatty/nodal issue were reflected further onto the lateral aspect of the neck. The posterior belly of digastric was followed and traced superiorly to complete the level 1 dissection.

Post-op

• • Complications 

Pearls & Pitfalls

High-Yield

Links

• YouTube (15:39): Surgical Pearls for Neck Dissection – Management of the N0 Neck

• eMedicine article: Neck Dissection Classification

• eMedicine artticle: Management of the N0 Neck

• eMedicine - Supraomohyoid Neck Dissection

• 2010: Neck dissection: past and present (Ducic)

• OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY - MODIFIED & RADICAL NECK DISSECTION

• UTMB - Neck Dissections: Classifications, Indications, and Techniques