Incisions for Neck Dissection

General Principles of Neck Incision Design

• Adequate exposure of all lymph node levels to be dissected
• Protection and coverage of the carotid artery
• Preservation of the blood supply to the neck skin (branches of the facial and occipital arteries superiorly; transverse cervical and suprascapular arteries inferiorly)
• Flaps that are broadly based (superiorly or inferiorly)
• Avoidance of trifurcations overlying the carotid sheath
• Allowance for excision of previously violated or irradiated skin when needed
• Subplatysmal flap elevation to preserve skin vascularity

Diagram 1 - Incisions for Radical and Modified Radical Neck Dissection (Fig. 118.4, Cummings)

Diagram 2 - Incisions for Selective Neck Dissection (SND Levels I-III) (Fig. 118.10, Cummings)

Individual Incisions: Description, Advantages, and Disadvantages

1. Hockey Stick Incision

• Excellent exposure of all 5 lymph node levels (I-V)
• No trifurcation over the carotid artery - the junction is placed posteriorly
• Broadly based superior flap with good blood supply
• Can be extended across the midline as a bilateral (apron) incision
• Excellent for radical and modified radical neck dissection
• Can be extended for mandibulotomy or lip-split approaches

• Long scar that is visible along the SCM
• Less cosmetically acceptable than a transverse skin crease incision
• Not ideal in previously irradiated patients (risk of flap necrosis at angulation point)

2. Boomerang Incision

• Excellent exposure for all five lymph node levels
• No trifurcation over the carotid sheath
• Preferred companion to oral cavity and oropharyngeal tumor resections, especially when a mandibulotomy (lip-split) approach is required - the incision extends seamlessly through the lower lip
• Can be extended bilaterally for bilateral neck dissections (bilateral boomerang replaces the bilateral apron when lip-splitting is needed)
• Better cosmesis than hockey stick along the visible SCM region

• Somewhat less aesthetically pleasing compared to a purely transverse skin crease incision
• Not as cosmetically superior as the MacFee double-transverse incision
• Wider dissection required for adequate flap elevation

3. McFee (MacFee) Incision - Two Parallel Transverse Incisions

• Excellent cosmesis - incisions fall in natural Langer's lines, scars are well concealed
• The bipedicled central skin bridge is surprisingly resistant to ischemia despite appearing to transect the dominant blood supply - studies confirm it is safe
• Preferred incision in previously irradiated patients - the bipedicled flap tolerates radiation-induced vascular compromise better than a raised single flap
• No trifurcation over the carotid
• Good carotid coverage

• Limited direct access to the midneck - the skin bridge between the two incisions limits lateral retraction and exposure in the central zone
• Technical difficulty - requires working through the tunnel created by the two incisions
• Extension of the incision to include the primary site is more difficult
• Not suitable when combined resection of the primary tumor (oral cavity, larynx) requires additional exposure - the limited access between incisions is a problem
• Wound dehiscence rate of 8% (vs. 0% for apron and 11% for triradiate incisions per one comparative study)

4. Schobinger Incision (Modified Schobinger / Conley-Modified)

• Excellent wide exposure for comprehensive neck dissection
• Creates a large, robust anterior flap
• The modification places the trifurcation posterior to the carotid artery - reducing risk of carotid blowout if wound breaks down
• Good for bilateral neck dissections

• The original Crile single-Y and Martin double-Y designs placed the trifurcation directly over the carotid artery - a serious liability if wound breakdown occurs
• Tri-radiate incisions have the highest wound dehiscence rate (11%) in comparative studies, especially in irradiated necks
• Tenuous blood supply to posterior skin flaps
• Falls out of favor in previously irradiated patients due to highest rate of wound complications

5. Apron Incision (Bilateral Hockey Stick)

• Lowest wound dehiscence rate (0%) in comparative studies - the widely based superior flap has excellent blood supply
• Ideal for bilateral neck dissection
• Well-suited when combined with laryngectomy (the apron flap is the standard companion incision for total laryngectomy + neck dissection)
• Excellent exposure of levels I-V bilaterally
• No trifurcation over the carotid
• Recommended for neck dissection in previously irradiated patients (superior flap vascularity)
• Good carotid protection

• Large incision - wider and more conspicuous than a unilateral approach
• The entire anterior neck skin is elevated as one flap - if devascularized, consequences are extensive
• Not needed for unilateral neck dissection where a single hockey stick suffices

6. Modified Apron Incision

• Adequate exposure for supraomohyoid selective neck dissection (levels I-III)
• Better cosmesis than full apron for unilateral procedures
• Can be extended across midline for bilateral dissection

• More limited exposure than a full apron - not suitable for level IV-V dissection

7. Attie Incision

• Single incision serves both the thyroid exposure and neck dissection
• Good cosmesis - follows a skin crease line
• Eliminates need for a separate neck dissection incision

• Limited exposure compared to hockey stick or boomerang
• Use restricted to selected cases where neck dissection accompanies thyroid surgery

8. Early Historical Designs (Crile Single-Y and Martin Double-Y)

• Provided excellent exposure (the reason they were used historically)

• Trifurcation placed directly over the carotid artery - catastrophic if wound breakdown leads to carotid blowout
• Created tenuous posterior skin flaps
• Anterior flaps partially dependent on contralateral external carotid artery blood supply
• Now largely abandoned in favor of safer designs

Summary Comparison Table