CC-BY-NC 3.

NECK DISSECTION USING THE FASCIAL PLANE TECHNIQUE

Patrick J Bradley & Javier Gavilán

The importance of identifying the presence an Argentinean professor of anatomy and

of metastatic neck disease with head and otolaryngologist, in the early 1960s; he pro-
neck cancer is recognised as a prominent posed the term “vaciamento ganglionar
factor determining patients’ prognosis. The functional” or “functional neck dissection”
current available techniques to identify dis- 2, 3
. While he himself only published his
ease in the neck all have limitations in terms work in Spanish, this procedure was popu-
of accuracy; thus elective neck dissection is larised in the English world in the mid-20th
the usual choice for management of the century by Etore Bocca, an Italian otolaryn-
clinically N0 neck (cN0) when the risk of gologist, and his colleagues 5.
harbouring occult regional metastasis is sig-
nificant (≥20%) 1. Methods available to Fascial compartments allow the removal of
identify the N+ (cN+) neck include imaging cervical lymphatic tissue by separating and
(CT, MRI, PET), ultrasound-guided fine removing the fascial walls of these “con-
needle aspiration cytology (USGFNAC), tainers” along with their contents from the
and sentinel node biopsy, and are used de- underlying vascular, glandular, neural,
pending on resource availability, for the pa- and muscular structures.
tient as well as the local health service. In
many countries, certainly in Africa and Anatomical basis
Asia, these facilities are not available or af-
fordable. In such circumstances patients The basic understanding of fascial planes in
with head and neck cancer whose primary the neck is that there are two distinct fascial
disease is being treated surgically should layers, the superficial cervical fascia, and
also have the neck treated surgically. the deep cervical fascia (Figures 1A-C).

Employing fascial planes as a concept to Superficial cervical fascia

perform excision of neck nodal areas is
based on specific anatomic concepts re- The superficial cervical fascia is a connec-
garding the relationship between the lym- tive tissue layer lying just below the dermis.
phatic structures and their distribution Surgically it is indistinct from the fatty tis-
within the tissues of the neck 2-4. It is crucial sue that surrounds it. The neck is one of the
that the anatomical description of the fas- few places where it splits to surround the
cial layers is reviewed as its understanding muscles of facial expression. The space deep
is essential to understand the rationale and to this layer contains fat, neurovascular
surgical technique of the procedure. bundles and lymphatics. It does not consti-
tute part of the deep neck space system.
This technique for performing a neck dis-
section was proposed by Osvaldo Suárez, Deep cervical fascia (Figures 1A-C)

The deep cervical fascia encloses the deep

neck spaces and is further divided into 3

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 Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery

layers, the superficial, middle and deep lay- the vertebral column. This fascia also arises
ers of the deep cervical fascia. posteriorly from the transverse and spinous
processes of the cervical vertebrae and the
Superficial layer of deep cervical fascia ligamentum nuchae. It passes laterally
(Figure 1A) around the prevertebral and postvertebral
muscles and covers the scalene muscles an-
The superficial layer of the deep cervical fas- teriorly, then passes in front of the vertebral
cia arises posteriorly from the vertebral spi- body and forms a thick layer from which it
nous processes and ligamentum nuchae. It receives its name. This thick fascial layer
surrounds the entire neck, splitting to en- forms the floor of the posterior triangle of
close the trapezius muscle, the omohyoid the neck, and anterior to the vertebral bod-
muscle, parotid gland, sternocleidomastoid ies, it provides a base on which the pharynx,
muscle and the strap muscles. Anteriorly oesophagus, and other cervical structures
this fascia is attached to the hyoid bone. The glide during swallowing and neck move-
inferior attachments of the fascia are the ments.
acromion of the scapula, the clavicle and the
sternum. The fascia remains split in two lay- The cervical plexus emerges from between
ers until it attaches to the sternum; thus, the the scalene muscle bundles. The phrenic
superficial layer attaches to the anterior sur- nerve crosses obliquely on the anterior sur-
face of the sternum and posterior layer to face of the anterior scalene muscle from lat-
the posterior surface of the sternum. eral to medial and lies deep to the preverte-
bral fascia. The cervical and brachial nerve
1A plexuses and the sympathetic trunk are in-
vested by the prevertebral fascia, which
forms the floor of the lateral triangle of the
neck. The consequences of elevating the
prevertebral fascia during neck dissecttion,
beyond merely increasing the devastation
wrought by the surgical exercise, can be se-
vere. If this fascia is raised, there is risk of
injuring what lies deep in the fascia, nota-
bly the cervical and brachial plexus, the
sympathetic trunk, and the phrenic nerve.

Figure 1a: Horizontal cross-section of neck at level of

6th cervical vertebra showing superficial layer of deep
cervical fascia

Deep layer of deep cervical fascia (Figure

1B)

The deep layer of the deep cervical fascia is

also called “prevertebral fascia” because it
constitutes a prominent layer just in front of

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 Patrick J Bradley & Javier Gavilán

1B 1C

Figure 1b: Horizontal cross-section of neck at level of Figure 1c: Horizontal cross-section of neck at level of
6th cervical vertebra showing deep layer of deep cervi- 6th cervical vertebra showing carotid sheaths
cal fascia
Indications for fascial plane technique
Middle layer of deep cervical fascia (Figure
1C) To ensure oncologic safety, fascial plane
surgery requires that all nodal disease be
The middle layer of the deep cervical fascia confined within lymphatic tissues.
or “pretracheal fascia” has two divisions,
muscular and visceral. The muscular divi- • Ideally suited to N0 necks at high risk of
sion surrounds the strap muscles (sternohy- harbouring occult metastases e.g. oral
cavity, oropharynx, and supraglottis
oid, sternothyroid, thyrohyoid, omohyoid)
and the adventitia of the great vessels. The • Can be performed simultaneously on
both sides of the neck without increas-
visceral division surround the constrictor
ing morbidity
muscles of the pharynx and oesophagus to
• May be considered when nodes meas-
create the buccopharyngeal fascia and the
ure < 2.5-3.0cms in greatest diameter,
anterior wall of the retropharyngeal space.
and are discrete and mobile (with cau-
Both the muscular and visceral divisions
tion)
contribute to the carotid sheath. The middle
layer also envelopes the larynx, trachea, and • Small aggregated or matted nodes that
thyroid gland. It attaches to the base of the are mobile (with caution)
skull superiorly and extends inferiorly as
Contraindications
low as the pericardium via the carotid
sheath.
• Large nodes > 3.0cms (usually fixed)
• Previously treated neck, either surgi-
cally or non-surgically

Should a surgeon be concerned that nodal

disease is exhibiting aggressive features e.g.

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 Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery

soft tissue invasion or fixity, then the proce- After the skin incision, subplatysmal skin
dure should be converted to a “modified flaps are elevated, preserving the superfi-
radical neck dissection”. cial layer of the cervical fascia. The limits
of tissue elevation are similar to those of the
Surgical technique classic radical neck dissection (Figures 2A,
B).
The technique described below encom-
passes all of the cervical levels and aims to
2A
preserve major non-lymphatic structures.
To facilitate teaching, the surgical steps are
sequentially detailed. However depending
on the clinical situation, the operation may
be modified so that only the cervical levels
most at risk of harbouring metastases are
included in the dissection.
Figure 2a: Surgical view of right neck after skin flaps
The operation is performed under general
have been elevated
anaesthesia, with the patient in the supine
position and the neck fully extended. Ele-
2B
vating the upper half of the operating table
to 30º reduces bleeding.

The surgery is best performed by dissecting

along the fascial planes with a scalpel; the
fascial planes of the neck are mainly avascu-
lar and can be easily followed with the scal-
pel. It is essential that an assistant apply
firm countertraction on the tissues to per-
mit easy, speedy and effective surgical for- Figure 2b: Boundaries and anatomic landmarks of a
ward progressive progress to be achieved. complete right sided neck dissection (ml: Midline; bm:
Inferior border of mandible; c: Clavicle; tm: Trapezius
muscle; ga: Greater a auricular nerve; sc: Ster-
Incisions and flaps
nocleidomastoid muscle; sm: Strap muscles; pm: Plat-
ysma muscle; ej: External jugular vein; aj: Anterior
The placement and type of skin incision(s) jugular vein; sg: Sub-mandibular gland
depend on the site of the primary tumour
and whether the primary tumour and the Dissecting the sternocleidomastoid
neck are to be addressed synchronously, or (SCM) muscle
whether the neck dissection is being per-
formed alone, and whether the neck dissec- This step completely unwraps the SCM
tion is to be unilateral or bilateral. Naturally from its surrounding superficial layer of
the personal bias of the surgeon should also deep cervical fascia. Before approaching
be considered. the fascia of the SCM muscle, the external
jugular vein is ligated and divided. Dissec-

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 Patrick J Bradley & Javier Gavilán

tion of the SCM commences with a longitu- 5A

dinal incision in the fascia along the entire
length of the muscle (Figure 3).

Figure 5a: Dissection of SCM muscle continues over

its medial surface.

5B
Figure 3: Longitudinal incision over the entire length
of the posterior border of the SCM muscle. The fascia
is being retracted anteriorly with haemostats

This incision is placed near the posterior

border of the muscle. With the application
of several haemostats the fascia is retracted
anteriorly while the surgeon carries out the
subfascial dissection toward the anterior
margin of the muscle. Fascial retraction Figure 5b: The contents of the carotid sheath can be
seen shining through the fascia
should be performed with extreme care
since the thin superficial layer of the cervical
As the deep medial surface of the muscle is
fascia is the only tissue now included in the
approached, small perforating vessels are
specimen (Figure 4).
identified entering the muscle through the
fascia. These are cauterised sequentially, al-
lowing the surgeon to continue mobilising
the entire medial surface of the SCM mus-
cle. Attention and care needs to be in-
creased when dissecting the upper half of
the SCM muscle where the spinal accessory
nerve (SAN) enters the muscle, approxi-
mately at the junction of the upper and mid-
dle thirds of the muscle. The transverse pro-
Figure 4: The fascia dissected from the SCM muscle cess of the atlas serves as a useful anatomic
landmark to locate the SAN (Figure 6).
When the dissection reaches the anterior
border of the SCM, the muscle is retracted
posteriorly to continue the dissection over
its medial surface (Figures 5 A, B).

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Figure 6: Anatomic landmarks to locate the spinal ac-

cessory nerve in its course between the internal jugu-
lar vein and the SCM muscle on the right side. (*: Figure 7: Schematic view of the approach to the neck
Transverse process of atlas; sa: Spinal accessory nerve; for a complete neck dissection. Above Erb’s point the
IJ: Internal jugular vein; dg: Digastric muscle; sl: Sple- operation is performed anterior to the SCM muscle.
nius capitis and levator scapulae muscles; SC: SCM The lower part of the posterior triangle is approached
muscle) posterior to the SCM muscle. (SC: Sternocleidomas-
toid muscle; TM: Trapezius muscle; *: Erb’s point)
As the dissection progresses posteriorly
along the entire length of the SCM muscle, In the upper half of the neck (above Erb’s
the internal jugular vein is seen through the point) the dissection is performed anterior
fascia of the carotid sheath (Figure 5). The to the SCM muscle, whereas in the lower
use of wet sponges aid to identify the fascia half of the neck (below Erb’s point) the dis-
that still covers the posterior border of the section is performed posterior to SCM mus-
SCM muscle. This fascia must be dissected cle. The tissue dissected from the lower half
posteriorly and slightly medially under- of the neck (supraclavicular fossa) is then be
neath the muscle, to meet the anterior dis- passed beneath the SCM muscle to join the
section. This manoeuvre completely re- main part of the specimen. When the poste-
leases the muscle from its surrounding fas- rior triangle is not included in the resection,
cia. the whole dissection can be performed from
anterior to the SCM muscle.
Including the posterior triangle of the neck
in the dissection requires a combined ap- Dissecting the submandibular triangle
proach, both posterior and anterior to the
SCM muscle (Figure 7). The next step is to resect the submental and
submandibular lymph nodes (Levels 1a, b).
This level is at risk in patients with cancers
of the oral cavity and oropharynx, but is un-
likely to be involved in patients with larynx,
hypopharynx and thyroid cancers. The sub-
mandibular gland does not need to be re-
sected as, unlike the parotid gland, there are
no lymph nodes within the substance of the
gland 6.
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 Patrick J Bradley & Javier Gavilán

After the flaps have been raised the sub-

mandibular gland is visible through the su-
perficial layer of cervical fascia in the upper
part of the surgical field. The fascia is in-
cised at the level of the lower border of the
submandibular gland from the midline to
the tail of the parotid gland as for a gland
removing procedure. Then the facial vein is
ligated and divided, and is reflected up-
wards by the superior ligature to displace
and preserve the marginal mandibular
branch of the facial nerve (Figure 8).
Figure 9: Anatomic relations of the lingual nerve in
the submandibular triangle. (ln: Lingual nerve; SG:
Submandibular gland; wd: Wharton’s duct)

The fibro-fatty tissue containing the sub-

mandibular nodes is grasped and dissected
off the submandibular triangle preserving
the gland. The dissection may be continued
medially to include the submental nodes
but this is seldom required in tumours that
allow preservation of the submandibular
gland.

Figure 8: Protecting the marginal mandibular branch

The dissection is continued over the digas-
of the facial nerve by elevating the distal stump of the
ligated facial vein over the mandible
tric and stylohyoid muscles. These muscles
are retracted superiorly and the fascial
The retromandibular vein and the external sheath is easily dissected from the subdigas-
jugular vein are ligated and divided. Now, tric and upper jugular spaces.
instead of including the submandibular
gland within the specimen, its fascia is re- The hypoglossal nerve is identified (Figure
flected inferiorly while the gland is retracted 10) and the dissection is continued along
superiorly (Figure 9). the nerve, carefully dividing and ligating the
lingual veins as they may be a troublesome
source of bleeding.

The specimen is reflected inferiorly and the

fascia over the digastric and stylohyoid
muscles is incised from the midline to the
tail of the parotid gland. Following the pos-
terior belly of the digastric muscle the stylo-
mandibular ligament is transsected (Figure
11a).

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 Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery

and the posterior belly of the digastric mus-

cle is retracted superiorly with a retractor. It
is important to identify the entire SAN be-
tween the SCM muscle and the internal jug-
ular vein (IJV). Usually the IJV lies immedi-
ately behind the proximal portion of the
nerve. Occasionally the nerve may go be-
hind the vein or even cross it (Figures 11 a –
Figure 10: The hypoglossal nerve is identified under- c).
neath the intermediate tendon of the digastric muscle.
A lingual vein can be seen crossing superficial to the Once the SAN has been exposed, the tissue
nerve (hn: Hypoglossal nerve; it: Inter-mediate tendon lying superior and posterior to the nerve is
of the digastric muscle; lv: Lingual vein crossing hypo-
dissected free from the splenius capitis and
glossal nerve)
levator scapulae muscles. When the dis-
At this level, the retromandibular vein, the sected tissue (Level IIb) reaches the level of
posterior auricular vein and the external the SAN it is passed beneath the nerve to be
jugular vein are identified, ligated and di- removed in continuity with the main part of
vided according to their anatomical distri- the specimen (Figure 11 b).
butions. Depending on the lower extension
of the tail of the parotid gland, part of the 11A
gland may also be included in the resection.
This facilitates visualisation of the upper
jugular nodes as well as includes in the spec-
imen the infraparotid lymph nodes.

The dissected tissue is finally retracted infe-

riorly and dissected free from the subdigas-
tric and upper jugular spaces. The speci-
Figure 11a: The “spinal accessory manoeuvre” allows
men at this stage includes the submental
removal of the tissue lying posterior and superior to
and submandibular lymph nodes (Level I), the nerve in continuity with the rest of the specimen.
and the uppermost jugular nodes (Level The nerve is exposed between the SCM muscle and the
IIa). internal jugular vein

Dissecting spinal accessory nerve (SAN)

The SAN runs within the “soft tissue” of the

neck, so that one has to divide the tissue
overlying the nerve, rather than to follow a
fascial plane. Dissecting the SAN is usually
performed with scissors rather than a scal-
pel because of the loose consistency of the
tissue in this area and the restricted access.
The SCM muscle is retracted posteriorly

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 Patrick J Bradley & Javier Gavilán

12). The loose fibro-fatty tissue of the supra-

11B
clavicular fossa and absence of well-defined
dissection planes within this area make
knife dissection ineffective, and it is best
performed with scissors and blunt dissec-
tion.

scm

Figure 11b: The “spinal accessory manoeuvre” allows

removal of the tissue lying posterior and superior to
scm
the nerve in continuity with the rest of the specimen.
The fibrofatty tissue lying posterior and superior to
the nerve is passed beneath the nerve
11C
Figure 12: Dissection of the supraclavicular fossa. The
SCM muscle (scm) is retracted anteriorly and the dis-
section proceeds posterior to the muscle until the sca-
lene muscles are identified

The SCM muscle is retracted anteriorly and

the external jugular vein is divided and li-
gated inferiorly in the neck if this had not be
done previously. The dissection proceeds
from the anterior border of the trapezius
muscle in a medial direction including the
Figure 11c: The “spinal accessory manoeuvre” allows lymphatic contents of the supraclavicular
removal of the tissue lying posterior and superior to fossa. At the upper margin of this area is
the nerve in continuity with the rest of the specimen. where damage to the SAN is most likely to
Artist’s view of the “spinal accessory manoeuvre” on occur.
the right side of the neck. (sa: Spinal accessory nerve;
ij: Internal jugular vein; s: Specimen; sc: SCM muscle;
The omohyoid muscle is next identified; its
sp: Splenius capitis muscle)
fascia is dissected off the muscle so that is
Then the specimen is further freed by mak- may be removed with the contents of the
ing an incision into the tissues located be- posterior triangle. The muscle may be
low the entrance of the SAN into the SCM transsected if necessary, but may be re-
muscle, down as far as the level of Erb’s tracted inferiorly to identify the transverse
point. cervical vessels deep to the omohyoid mus-
cle.
Dissecting posterior triangle of neck
The deep layer of the cervical fascia overly-
To facilitate exposure of supraclavicular ing the levator scapulae and scalene muscles
area (Level Vb), this region is approached now comes into view. The brachial plexus is
from posterior to the SCM muscle (Figure easily identified because it appears between

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 Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery

the anterior and middle scalene muscles – these should also be preserved. Preserva-
(Figure 13). tion of these nerves is best achieved by keep-
ing the dissection superficial to the scalene
Remaining superficial to the scalene fascia fascia.
(deep layer of the cervical fascia) prevents
injuring the brachial plexus and the phrenic Continuing the dissection posterior to the
nerve. Dissection proceeds medially until carotid sheath carries a high risk of damage
the anterior border of the SCM muscle is to the sympathetic chain.
reached. The muscle is retracted posteriorly
and the dissection is continued anterior to
the muscle towards the carotid sheath.

Figure 14: Lateral view of the deep branches of the cer-

vical plexus that have been preserved on the right side
(SC: SCM muscle; IJ: Internal jugular vein; *: Deep
branches of cervical plexus)

15A

Figure 13: Anterior view of the anatomic landmarks

of the right supraclavicular fossa. (BP: Brachial
plexus; pn: Phrenic nerve; tc: Transverse cervical ar-
tery; sn: Supraclavicular branch of cervical plexus; oh:
Omohyoid muscle retracted inferomedially)

Dissecting the deep cervical muscles

As the dissection proceeds medially to- Figure 15a: Dissecting carotid sheath
wards the carotid sheath, several branches
of the cervical plexus are found over the 15B
deep muscles of the neck (Figures 14 and
15A).

Optimal shoulder function may be pre-

served if the deep branches of the 2nd, 3rd,
and 4th cervical nerves are preserved, as they
may communicate with the SAN. There are
also similar anastomoses from the 3rd, 4th
and 5th cervical nerves to the phrenic nerve Figure 15b: Dissecting carotid sheath

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 Patrick J Bradley & Javier Gavilán

Dissecting the carotid sheath Following release of the internal jugular

vein from its fascia, the dissection proceeds
This part of the dissection is best executed medially over the carotid artery. The speci-
with a knife while applying adequate coun- men is now completely separated from the
tertension to the tissues. The surgical speci- great vessels, remaining attached only to the
men is grasped with haemostats and re- strap muscles.
tracted medially, while the surgeon uses a
gauze pad in the non-dominant hand to pull Dissecting the strap muscles
laterally over the deep cervical muscles.
This may be the last step or may already
An incision is made with the scalpel along have been performed at an earlier stage of
the entire length of the carotid sheath over the operation, depending on the preference
the vagus nerve. The fascia is then dissected surgeon or the location of the primary tu-
from the internal jugular vein. This is mour. The midline of the neck constitutes
achieved by continuously passing the knife the medial margin of the neck dissection.
blade up and down along the wall of the in-
ternal jugular vein along its entire length. This the superficial layer of the deep cervi-
The fascia can be seen parting from the vein cal fascia is incised in the midline from the
after each pass of the blade, until the inter- upper border of the surgical field to the ster-
nal jugular vein is completely released from nal notch. The anterior jugular vein is iden-
its fascial covering (Figure 15B). tified, ligated, and divided at both ends of
the surgical field. The fascia is now dissected
The facial, lingual, and thyroid veins should from the underlying strap muscles. The dis-
next be clearly identified, ligated, and di- section starts at the upper part of the surgi-
vided to complete the isolation of the inter- cal field and continues in a lateral and infe-
nal jugular vein. rior direction. The sternohyoid and omohy-
oid muscles are completely freed from their
Dissection of the carotid sheath has two fascial coverings (Figures 16 A, B).
danger points for surgeons – at the top and
the bottom of the dissection. The surgeon 16A
must be extremely cautious to avoid injur-
ing the vein at these two points as traction
exerted at these two points to facilitate dis-
section of the fascial envelope produces a
folding of the wall of the internal jugular
vein that is easily cut at the touch of the scal-
pel blade.
Figure 16a: Dissection of strap muscles
Low in the neck, the terminal portion of the
thoracic duct on the left, and the right lym-
phatic duct – when present – also are within
the boundaries of the dissection and must
be preserved.

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 Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery

Figure 16b: Artist’s view of dissection of the fascia cov-

ering the strap muscles

At this point the specimen is almost free

and any remaining vessels - arteries or veins
- should be ligated and divided unless re-
quired for some other procedure such as
anastomosis of a free flap!
Figure 17: Image of the right neck after a neck dissec-
Dissecting the central compartment
tion. Note the preserved sub-mandibular gland

During dissection of the central compart- The skin is closed in two layers over a large
ment (Level VI), the recurrent laryngeal suction drain. The platysma is sutured with
nerves must be identified and followed up- absorbable buried sutures, and the skin clo-
wards to the larynx and downwards to the sure with skin clips.
upper mediastinum. The lobe of the thy-
roid, if being preserved, makes such surgery Comment
difficult, as preservation of the parathyroid
glands is extremely important with its func- While the term functional neck dissection
tioning blood supply. has not been included in more recent clas-
sifications of neck dissection, the procedure
Closure of wound as described is eminently suited to elective
selective neck dissections (Level I, II, III and
The neck is carefully inspected for bleeding IV) and for therapeutic selective neck dis-
points and retention of sponges etc. The en- sections for N1 necks.
tire wound is irrigated with saline (Figure
17). Video

• Download: Functional neck dissection

technique
• YouTube:
https://www.youtube.com/watch?v=sd
qQxbZMLlA

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 Patrick J Bradley & Javier Gavilán

Other Open Access Atlas neck dissection Copyright

chapters:
Figures reproduced with permission of
• Modified and radical neck dissection THIEME
technique
• Selective neck dissection operative Authors
technique
Patrick J Bradley, MBA FRCS
References Emeritus Honorary Professor of Head and
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