Cervical Fascia Anatomy for Lateral Neck Dissection

Objective: Fascial organization of the neck is quite sophisticated. Fascial layers separate fundamental structures in the neck, and in this way, they build anatomical walls against the spread of malignant lesions. However, metastatic lymph node around the margin of cervical fasciae has a relatively higher incidence of residual disease and local recurrence after surgery. The video aims to demonstrate the strategy of cervical fascia anatomy for lateral neck dissection. Methods: The cervical fascia anatomy is to perform the operation regarding the anatomy of the fascia and biological behavior of tumors. The concept of this procedure is to dissect along the plane of the cervical fasciae in a particular order, which will preserve the functional structures maximally as well as minimize the recurrence of the diseases.1–4 In this video, the concept of cervical fascia anatomy is illustrated through the procedure of lateral neck dissection. Results: There are three typical cervical fasciae in the lateral neck: the investing fascia, the visceral fascia, and the prevertebral fascia. These three hotspots are described as follows: (1) the intermuscular hotspot area located between the sternocleidomastoid and the strap muscles, and here is the attachment of the investing fascia and the visceral fascia. (2) The level II hotspot is in the cross of the internal jugular vein and the accessory nerve, and this is the cross point of all three fasciae. (3) The vertebral artery triangle hotspot is in the crossing of visceral fascia and the pervertible fascia. The procedure of cervical fascia anatomy in lateral neck dissection was as follows: (1) preprocessing the external jugular vein and nerves at level V, (2) separate two layers of investing fasciae enveloped in the sternocleidomastoid muscle, (3) dissect the intermuscular lymph node between the sternocleidomastoid and strap muscles, (4) isolate the vessels in the carotid triangle on the surface of visceral fascia, (5) anatomize the accessory nerve to resect lymph nodes around the nerve, (6) expose the cervical plexus and continue the lateral dissection along the plane of the prevertebral fascia, (7) separate venous corner and anatomize the vertebral triangle, and (8) transfer the specimen to level V and completed the lateral compartment with an entire resection. Conclusion: The concept of cervical fascia anatomy provided an ideal strategy for lateral neck dissection, which will make better protection of the cervical nerve in the lateral compartment. This strategy focuses on dealing of the margin area of cervical fasciae, which will further reduce the residual disease and local recurrence. Authors' Contributions: B.W. (Bo Wang) is the chief surgeon of this operation and provides the original idea of this article, B.W. (Bo Wang), YJ.W., J.Z., YF.Z., and S.L. prepared the article of narration. WX.Z. made a critical revision of this video, SY.Y. was the assistant of this surgery, and B.W. (Brandon Wang) is the English name of Bo Wang. Acknowledgments: Many thanks for the friendship of Professor Gregory Randolph, Dipti Kamani, Ayaka Iwata, and Okenwa Okose in Massachusetts Eye and Ear Infirmary. No competing financial interests exist. Funding Information: This research was supported by the joint funds for the innovation of science and technology, Fujian province (Grant Nos.: 2018Y9093, 2018Y0915, and 2018Y9018); The Health Research Talents Training Project of Fujian Provincial (Grant Nos.: 2019-CX-16 and 2018-CX-17); and the Guiding Social Development Project of Fujian Province (Grant No. 2018Y0035). Additional supporting information may be found in the online version of this article. Runtime of video: 9 mins 32 secs