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12 Radical andModied Radical Neck Dissection

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suture on a tapered vascular needle. In the case of the IJV, a large vessel wall defect may allow entry of air and resultant embolism with cardiovascular collapse. To provide exposure for repair, nger tamponade of the vein above and below the laceration by the surgical assistant will allow for visualization without allowing inadvertent air entry. Late vascular complications may result in haematoma formation with compromise of the free ap vascular pedicle or airway, and must be carefully monitored in the medical-surgical unit.

12.5.3 Chyle Leak

The thoracic duct may be injured when dissecting deep in left level IV, though 8–25% of chyle injuries involve the accessory thoracic duct (right side). During surgery, clear or milky uid is seen at the junction of the thoracic duct and IJV, and is increased during a Valsalva manoeuvre (see Fig.12.4b).

The optimal time to manage a chyle leak is intraoperatively, immediately after it occurs, when the leak is oversewn using nonabsorbable suture and brin sealant. If a chyle leak is identied postoperatively, conservative management includes maintaining a closed suction drain with a supercial pressure dressing using foam tape, taking care to avoid compromise of a microvascular pedicle if present. The patient may also receive a medium-chain triglyceride diet to control the output. If the output is low (<1000mL/day), no surgical exploration is indicated.

Further Reading

Andersen PE, Warren F, Spiro J, Burningham A, Wong R, Wax

MK, et al. Results of selective neck dissection in management

of the node- positive neck. Arch Otolaryngol Head Neck Surg.

2002;128:1180–4. Byers RM, Weber RS, Andrews T, McGill D, Kare R, Wolf P.Frequency

and therapeutic implications of “skip metastases” in the neck from

squamous carcinoma of the oral tongue. Head Neck. 1997;19:14–9. Crile G.On the surgical treatment of cancer of the head and neck. Trans

South Surg Gynecol Assoc. 1905;18:109–27.

Davidson BJ, Kulkarny V, Delacure MD, Shah JP.Posterior triangle

metastases of squamous cell carcinoma of the upper aerodigestive tract. Am J Surg. 1993;166:395–8.

D’Cruz AK, Vaish R, Kapre N, Dandekar M, Gupta S, Hawaldar R,

et al.; Head and Neck Disease Management Group. Elective versus therapeutic neck dissection in node-negative oral cancer. N Engl J Med. 2015;373:521–529. doi: https://doi.org/10.1056/

NEJMoa1506007.

de Gier HH, Balm AJ, Bruning PF, Gregor RT, Hilgers FJ.Systematic

approach to the treatment of chylous leakage after neck dissection. Head Neck. 1996;18:347–51.

Fakih AR, Rao RS, Borges AM, Patel AR. Elective versus therapeutic

neck dissection in early carcinoma of the oral tongue. Am J Surg. 1989;158:309–13.

Ferlito A, Robbins KT, Shah JP, Medina JE, Silver CE, Al-Tamimi S,

etal. Proposal for a rational classication of neck dissections. Head Neck. 2011;33:445–50. https://doi.org/10.1002/hed.21614.

Fischel E. Surgical treatment of metastases to cervical lymph nodes

from intraoral cancer. Am J Roentgenol. 1933;29:237–40.

Lindberg R.Distribution of cervical lymph node metastases from squa-

mous cell carcinoma of the upper respiratory and digestive tracts. Cancer. 1972;29:1446–9.

Martin H, Del Valle B, Ehrlich H. Neck dissection. Cancer.

1951;4441–4499.

Medina JE.A rational classication of neck dissections. Otolaryngol

Head Neck Surg. 1989;100:169–76.

Morlandt AB, Holmes JD. Surgical management of the neck. In:

Haggerty CJ, Laughlin RM, editors. Atlas of operative oral and maxillofacial surgery. Oxford: Wiley; 2015. p.424–31.

Myers EN, Fagan JJ.Treatment of the N+ neck in squamous cell carci-

noma of the upper aerodigestive tract. Otolaryngol Clin North Am. 1998;31:671–86.

Robbins KT, Shaha AR, Medina JE, Califano JA, Wolf GT, Ferlito A,

etal.; Committee for Neck Dissection Classication, American Head and Neck Society. Consensus statement on the classication and terminology of neck dissection. Arch Otolaryngol Head Neck Surg. 2008;134:536–538. https://doi.org/10.1001/archotol.134.5.536.

Rouviere H.Anatomy of the human lymphatic system (Trans. Tobies

MJ). Ann Arbor: Edwards Brothers; 1938.

Skolnik EM, Yee KF, Friedman M, Golden TA.The posterior triangle in

radical neck surgery. Arch Otolaryngol. 1976;102:1–4.

Suen JY, Goepfert H.Standardization of neck dissection nomenclature.

Head Neck Surg. 1987;10:75–7.

Ward GE, Robben JO.A composite operation for radical neck dissec-

tion and removal of cancer of the mouth. Cancer. 1951;4:98–109.

Tsang RK, Chung JC, To VS, Chan JY, Ho WK, Wei WI.Efcacy of

salvage neck dissection for isolated nodal recurrences in early carcinoma of oral tongue with watchful waiting management of initial N0 neck. Head Neck. 2011;33:1482–5. https://doi.org/10.1002/

hed.21643.

Functional Neck Dissection

https://t.me/med1917

LauraRodrigáñez, AlejandroCastro, andJavierGavilán

13.1 Introduction

Functional Neck Dissection (FND) was rst described in 1960 by Osvaldo Suárez, from Argentina. Although it is generally considered in the English literature as one more “modied radical neck dissection,” FND is not a modication of the radical neck dissection described by George Crile in 1906, but a new technique with entirely different surgical principles. FND is a respectful anatomical technique that takes the cervical fascial planes as the motorways of the neck, to remove the brofatty tissue that contains the lymphatics, whilst preserving every single functioning structure. This chapter includes a brief description of the surgical technique. A complete explanation of the history, principles, and steps of FND can be found in other works of the authors (see Further Reading).

13.2 Anatomical Basis

There are several anatomical descriptions of the fascial layers of the neck. However, for practical reasons, we will consider two layers: the supercial cervical fascia and the deep cervical fascia. The former corresponds to the subcutaneous tissue, and embodies the platysma muscle. The deep cervical fascia is the crucial element for functional neck dissection and for teaching purposes, it could be divided into three different layers: a supercial layer, a middle (or visceral) layer, and a deep (or prevertebral) layer (Fig.13.1).

The supercial layer of the deep cervical fascia surrounds all the neck structures under the platysma muscle and supercial fascia. It encases the trapezius muscle, the sternocleido-

L. Rodrigáñez · A. Castro · J. Gavilán (*) Department of Otorhinolaryngology—Head and Neck Surgery, La Paz University Hospital, Madrid, Spain

https://doi.org/10.1007/978-3-031-36593-5_13

Fig. 13.1 Schematic cross sections of the neck showing the layers of the cervical fascia: supercial fascia in light grey; supercial layer of the deep cervical fascia in black; visceral fascia (middle layer of the deep cervical fascia) in purple; and prevertebral fascia (deep layer of the deep cervical fascia) in green

mastoid muscle, and the posterior belly of the omohyoid muscle. The middle or visceral layer envelops the upper aerodigestive tract, as well as the thyroid gland and central compartment. The deep or prevertebral layer encircles the vertebral column and the paraspinal and prevertebral muscles.

By the contribution of those three layers, emerge the

carotid or vascular sheath, a cylinder-like structure that has

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independent compartments for the internal jugular vein, carotid artery, vagus nerve, and ansa cervicalis.

This fascial compartmentalisation enables the removal of the brofatty and lymphatic tissues following the fascial walls of the mentioned containers, respecting the remaining structures that stay in place undamaged.

13.3 Indications andLimitations

FND was designed as a unilateral or bilateral approach to the neck when all the metastatic disease is conned within the lymphatic tissue, either in the elective or therapeutic scenarios. Palpable mobile nodes are not a contraindication, regardless of the number or size. However, node xation is a reex of macroscopic extracapsular spread, and trespassing through the fascia should be suspected. The modied radical concept is more appropriate for these situations. If during FND there is suspicion of invasion of any structure, this should be removed and FND converted into a real modied radical neck dissection.

FND is not meant to treat necks that have been treated previously, either with surgery or radiation therapy, as the fascial planes were already damaged and fascial dissection is not possible. Again, the modied radical concept is the appropriate procedure for these cases.

The location of the primary or the extent of surgery (i.e. the number of neck levels included in the dissection) is not a concern for the functional concept. Selective neck dissections of a number of neck levels can be accomplished according to the functional principles as long as the fascial barriers had not been violated by the disease or prior treatments.

13.4 Surgical Technique

The extension of the surgery depends on the location of the malignant tumour and the clinical scenario. Therefore, not every step of the technique has to be performed in each dissection, as not every nodal group should be removed in all patients.

We recommend using a number 10 scalpel for as many parts of the surgery as possible because of the avascular condition of the majority of fascial planes. The assistant should maintain the dissected tissue under appropriate tension, which facilitates the knife dissection.

As every major operation, FND is accomplished under general endotracheal anaesthesia, with the patient in the supine position and neck hyperextension. A 30° antiTrendelenburg position helps to reduce bleeding during surgery.

13.4.1 Incision andFlaps

Several skin incisions could be utilised. The election should take into account many factors, such as the site of the primary tumour, the association of further procedures, whether a unilateral or a bilateral neck dissection is intended, the type of reconstruction planned, and the presence of previous scars.

Nevertheless, in our daily practice, we usually perform the classic Gluck-Sorenson incision (Fig.13.2), which is an apron ap incision extending from one mastoid tip to the other, running through the sternocleidomastoid muscle and

Fig. 13.2 Skin incision and elevation of the aps. The Gluck-Sorenson incision

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crossing the midline a few centimetres above the sternal notch. The boundaries of a comprehensive FND can be exposed using this incision: superiorly, the inferior border of the mandible; inferiorly, the clavicle and the sternal notch; and posteriorly, the trapezius muscle.

Many other skin incisions have been described, the single- Y incision, the double-Y incision of Martin, the Schobinger ap and its Conley modication, and the Mac Fee parallel transverse incision or the H incision. Those and many others could be used depending on the patient factors mentioned above, and on the preferences and experience of the surgeon.

The skin ap should be raised in the subplatysmal plane. The vascularisation of the skin depends on descending and ascending branches that run between the skin and the platysma muscle. Preserving the platysma will keep these branches undisturbed.

13.4.2 Dissection oftheSternocleidomastoid

Muscle

The rst step of this technique consists of completely divesting the sternocleidomastoid muscle from its fascia. A longitudinal incision along the posterior border of the muscle is made with a number 10-knife blade, and the external jugular vein is ligated and transected at this level. The incision is carried out anterior to the great auricular nerve to preserve it. Conversely, the transverse cervical nerve is cut. Several haemostats are used to medially retract the jugular vein and the dissected fascia (Fig.13.3a). The assistant should maintain the specimen with adequate careful tension as the surgeon continues the dissection towards the anterior margin of the muscle. Once reached, the muscle is retracted laterally and posteriorly, and the deep medial face of the sternocleidomastoid muscle is approached. Coagulation of the small perforating vessels that enter the muscle is recommended (Fig. 13.3b). The spinal accessory nerve penetrates the medial face of the sternocleidomastoid muscle at the union of the upper and medial thirds. The surgeon must be cautious so as not to injure it (Fig.13.3c). The dissection continues along the entire length of the muscle.

13.4.3 Dissection oftheSubmandibular Fossa

The dissection of the submental and submandibular nodes (area I) is not necessary for every head and neck tumour. The surgeon should decide whether to accomplish this step or not. Removing the submandibular gland is the easier and safer way to include all the nodes in this level. For teaching purposes, the following description will present the surgical details of the entire technique.

Fig. 13.3 Dissection of the sternocleidomastoid muscle fascia. (a) The external face of the muscle has been dissected. (b) The internal face is approached. (c) The spinal accessory nerve has been located. (1) sternocleidomastoid muscle; (2) sternocleidomastoid muscle fascia; (3) great auricular nerve; (4) external jugular vein (transected); (5) internal jugular vein; (6) perforating vessels to be coagulated; (7) spinal accessory nerve

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The fascia is incised along the inferior border of the submandibular gland, from the midline to the tail of the parotid gland. The marginal branch of the facial nerve runs within the fascia of the anterior face of the submandibular gland. To preserve the nerve, the facial vein is identied, ligated, and transected, and the fascia of the external surface of the gland is elevated along with the vein, thus protecting the nerve. The distal ligature of the facial vein is left long and reected superiorly with a haemostat to keep the nerve protected during the rest of the procedure.

The removal of the submandibular gland comes next. To free the upper edge of the gland, the facial artery must be ligated and divided (Fig.13.4a). The gland is then retracted inferiorly, exposing the anterior belly of the digastric muscle and the mylohyoid muscle. Medial retraction of the mylohyoid muscle exposes the lingual nerve, the deep lobe of the submandibular gland, and Wharton’s duct. The lingual nerve is xed to the gland through the submandibular ganglion, and forms a “V” due to the inferior retraction of the gland (Fig. 13.4b). After coagulating the accompanying vessels,

Fig. 13.4

been incised in the inferior border of the gland and the external surface is reected superiorly along with the facial vein. The superior border of the gland has been dissected and the facial artery is being ligated for the rst time. (b) The gland is reected inferiorly and the mylohyoid muscle is reected anteriorly. Wharton’s duct has been ligated and the lingual nerve is still attached to the gland through the submandibular

Dissection of the submandibular fossa. (a) The fascia has

ganglion. (c) The gland is liberated from the fossa and reected inferiorly with the rest of the specimen. (1) submandibular gland; (2) proximal stump of facial vein; (3) distal stump of facial vein, reected along with the external fascia of the submandibular gland; (4) facial artery; (5) anterior belly of the digastric muscle; (6) retractor for the mylohyoid muscle; (7) lingual nerve; (8) Wharton’s duct (ligated and transected); (9) hypoglossal nerve; (10) mylohyoid muscle (not retracted)

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the ganglion is divided at the tip of the “V,” and the lingual nerve retracts superiorly out of the surgical eld. The submandibular duct is then identied inferior to the lingual nerve and should be ligated and transected. This releases the gland, which is now only attached to the submandibular fossa by the facial artery. The proximal end of the facial artery is located as it appears under the posterior belly of the digastric muscle, and is ligated and transected a second time. The hypoglossal nerve can be identied entering the fossa in its inferior border, crossing the deep surface of the posterior belly of the digastric muscle. The gland is now reected inferiorly with the brofatty tissue of area I (Fig.13.4c).

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13.4.4 Dissection oftheUpper Jugular Nodes andtheSpinal Accessory Nerve

The fascia over the posterior belly of the digastric muscle is incised, and the stylomandibular ligament is transected. In this area, the retromandibular vein, the posterior auricular vein, and the external jugular vein shall be ligated and divided according to their anatomical distribution. Part of the tail of the parotid gland might be included in the resection depending on its lower extension. The posterior belly of the digastric muscle and the stylohyoid muscle are retracted superiorly, along with the body of the mandible. At the same time, the upper third of the sternocleidomastoid muscle is retracted laterally. This manoeuvre enables the exposure of the upper jugular nodes (area II) and the spinal accessory nerve (Fig.13.5a).

The dissection of the spinal accessory nerve and upper jugular nodes is usually made with scissors instead of the scalpel, as there is no fascial plane to follow. At this level the nerve runs within the “lymphatic container” of the neck, thus forcing the surgeon to cut across the brofatty tissue. To adequately expose the nerve, a fascial tunnel is created (Fig. 13.5a). The brofatty tissue covering the nerve is divided and the nerve entirely exposed from the internal jugular vein to the sternocleidomastoid muscle (Fig.13.5b). The proximal end of the spinal accessory nerve crosses the internal jugular vein usually passing anterior to the vein. However, sometimes, it runs deep or even across the vein, a fact that should be kept in mind to avoid unintentional damage. Whilst dissecting through the brofatty tissue, the transverse process of the atlas serves as a palpable landmark to localise the point where the nerve crosses the vein.

Once the nerve is completely exposed, the brofatty tissue superior and posterior to the nerve is dissected until the prevertebral fascia covering the splenius capitis and the levator scapula muscles is reached. The occipital artery and its sternocleidomastoid branch may be coagulated and divided if needed. The specimen is nally freed from the lat-

Fig. 13.5 Dissection of the spinal accessory nerve. (a) The nerve is followed from the sternocleidomastoid muscle to its proximal end using a fascial tunnel that envelopes it. (b) The brofatty tissue anterior to the nerve has been cut and the nerve is completely exposed. (1) spinal accessory nerve; (2) internal jugular vein; (3) Langenbeck retractor for the posterior belly of the digastric muscle and stylohyoid muscle; (4) Farabeuf retractor for the sternocleidomastoid muscle; (5) hypoglossal nerve

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eral wall of the internal jugular vein (Fig.13.6a). Then, the brofatty tissue is passed beneath the nerve in the step called by Osvaldo Suárez “the spinal accessory nerve manoeuvre” (Fig.13.6b). The specimen, including the submandibular and submental lymph nodes (area I), the submandibular gland, and the uppermost jugular nodes (area II), is nally pulled inferiorly and dissected from the subdigastric and upper jugular spaces (Fig.13.6c).

Fig. 13.6 (continued)

13.4.5 Dissection ofthePosterior Triangle oftheNeck

Fig. 13.6 Dissection of the uppermost jugular nodes (area IIB). (a) The brofatty tissue has been dissected from the sternocleidomastoid muscle, the prevertebral fascia, and the lateral wall of the internal jugular vein. (b) The “spinal accessory nerve manoeuvre”. (c) The upper limit of FND is completed: the submental, submandibular, and upper jugular nodes (areas I–II) are already dissected and included in the specimen. (1) spinal accessory nerve; (2) internal jugular vein; (3) Langenbeck retractor for the posterior belly of the digastric muscle and stylohyoid muscle; (4) Farabeuf retractor for the sternocleidomastoid muscle; (5) brofatty tissue in the uppermost jugular region (area IIB); (6) prevertebral fascia

The attention comes now to the inferior limit of the FND.The supraclavicular fossa (area VB) has been usually approached from posterior to the sternocleidomastoid muscle, by the anterior retraction of it. The tissue dissected from this area was then passed beneath the muscle to join the main part of the specimen. However, in our current daily practice, this area is generally approached anteriorly to the muscle, retracting it posteriorly. If a comprehensive dissection of the area VB is required, the posterior approach is recommended.

The omohyoid muscle is identied and retracted inferiorly to expose the internal jugular vein (Fig 13.7a). The absence of fascia that denes a plane to follow forces the surgeon again to use scissors instead of the knife across the brofatty tissue of this area. The brofatty tissue is pulled upwards and it is dissected away from the sternocleidomastoid and trapezius muscle laterally, and the lateral wall of the internal jugular vein medially. The tissue is horizontally cut at the approximate level of the clavicle to create the inferior limit of the dissection (Fig.13.7b). Deep to the original position of the posterior belly of the omohyoid muscle (which is now retracted inferiorly), the transverse cervical vessels are located and preserved. Deeper to them, the prevertebral fascia covering the scalene muscles and the brachial plexus is reached. Staying always supercial to the prevertebral fascia

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will prevent damage to the brachial plexus and phrenic nerve (Fig.13.7c).

13.4.6 Dissection oftheDeep Cervical Muscles

At this time, the superior and inferior limits of the dissection

are already completed, but a strip of tissue between them anchors the specimen in the middle part of the posterior limit (Fig. 13.8a). Retracting once again the sternocleidomastoid muscle in a lateral direction, this strip of tissue is dissected. Different branches of the cervical plexus are found in this area. Whilst the anterior sensorial branches must be severed to advance in the dissection, the deep branches of the second, third, and fourth cervical nerves should be preserved when possible, as they anastomose with the spinal accessory nerve

Fig. 13.7 Dissection of the posterior triangle of the neck. (a) The ster- nocleidomastoid muscle is retracted laterally and the omohyoid muscle inferiorly to expose this area. (b) The specimen has been freed from the lateral aspects of the supraclavicular triangle (sternocleidomastoid and trapezius muscles) and the inferior limit of the dissection is being created through the brofatty tissue. (c) The inferior limit of FND is completed and released from the internal jugular vein, the prevertebral fascia, and the sternocleidomastoid and trapezius muscles. (1) omohyoid muscle (retracted); (2) sternocleidomastoid muscle (retracted); (3) internal jugular vein; (4) brofatty tissue in the supraclavicular fossa; (5) transverse cervical artery; (6) anterior scalene muscle; (7) phrenic nerve

Fig. 13.8 Dissection of the deep cervical muscles. (a) After complet- ing the superior and inferior limits, a strip of tissue anchors the specimen to the middle part of the posterior limit. (b) The posterior limit has been completed and the prevertebral structures are visible. (1) sternocleidomastoid muscle (retracted); (2) internal jugular vein; (3) spinal accessory nerve; (4) phrenic nerve; (5) posterior branches of the cervical plexus; (6) brachial plexus; (7) levator scapulae muscle; (8) anterior scalene muscle; (9) middle and posterior scalene muscles; (10) transverse cervical artery

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and contribute to shoulder function. Besides, the third, fourth, and fth cervical branches are the origin of the phrenic nerve. Between the anterior and middle scalene muscles, the brachial plexus is seen. The dissection should be discontinued when reaching the carotid sheath as continuing medially has a high risk of injuring the sympathetic trunk (Fig.13.8b). As stated before, staying supercial to the deep cervical fascia is crucial to prevent damage to important structures, such as the brachial plexus, the phrenic nerve, or the sympathetic trunk.

13.4.7 Dissection oftheCarotid Sheath

Once the dissection reaches the carotid sheath, the assistant retracts the specimen medially maintaining adequate tension. Using a new number 10-knife blade, the surgeon incises the fascia over the vagus nerve along its entire length (Fig.13.9a).

The dissection continues repeatedly passing the knife blade over the wall of the internal jugular vein throughout its extension. Lateral retraction with gauze pad over the deep cervical muscles rst, and over the internal jugular vein after, helps to maintain the appropriate tension for the procedure. The scalpel must be moved obliquely with respect to the vein, with the blade pointing away from its wall (Fig.13.9b). Whilst the fascia is being released, the facial, lingual, and thyroid veins should be gently ligated and divided. Other small vessels might be cauterised by bipolar coagulation without risk of bleeding (Fig.13.9c).

The surgeon must be extremely cautious to avoid injuring the vein at the cranial and caudal end of the dissection. At these levels, the traction exerted to facilitate the dissection of the fascial envelope produces a folding of the wall of the internal jugular vein that can be easily sectioned at the touch of the scalpel blade. In addition, care must be taken in the

Fig. 13.9 Dissection of the carotid sheath. (a) Incision of the carotid sheath over the vagus nerve. (b) Dissection of the internal jugular vein. (c) The internal jugular vein is already freed and its branches ligated.

(d) Dissection of the carotid arteries. (1) vagus nerve; (2) internal jugular vein; (3) common carotid artery; (4) ansa cervicalis; (5) spinal accessory nerve; (6) hypoglossal nerve; (7) superior thyroid artery

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lower part of the neck, where the thoracic duct on the left side and the lymphatic duct in the right side (if present) course and must be preserved, avoiding a chyle stula.

When the internal jugular vein is completely isolated, the dissection continues medially over the carotid artery. In the upper part of the eld, the hypoglossal nerve appears crossing the carotids. The superior thyroid artery can be found coursing in an anteromedial direction. Care must be taken to avoid inadvertent injury of these structures (Fig.13.9d). Once the specimen is completely separated from the great vessels, it remains attached only to the strap muscles.

13.4.8 Dissection oftheStrap Muscles

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The supercial layer of the cervical fascia is incised in the midline, from the upper border of the surgical eld to the sternal notch. Unlike the rest of the procedure, the dissection is here performed from medial to lateral. The fascia of the strap muscles is dissected in a lateral and inferior fashion until the sternohyoid and omohyoid muscles are freed from its fascia (Fig.13.10). The anterior jugular vein and occasionally the Kocher’s vein (a variable vein communicating the supercial and deep venous system) should be ligated and transected before the specimen is ultimately released from the strap muscles.

Remark that although this step has been described at the end of the operation, it may be performed in a different moment according to the needs of the surgery and the location of the primary tumour.

Fig. 13.10 Dissection of the strap muscles. (1) midline; (2) specimen; (3) sternohyoid muscle; (4) suprahyoid muscles

Fig. 13.11 The neck after a comprehensive FND. (1) sternocleidomastoid muscle; (2) omohyoid muscle (retracted); (3) digastric muscle; (4) levator scapulae muscle; (5) scalene muscles; (6) internal jugular vein; (7) carotid artery; (8) transverse cervical artery; (9) spinal accessory nerve; (10) hypoglossal nerve; (11) posterior branches of the cervical plexus; (12) brachial plexus

13.4.9 Closure oftheWound

Once the FND is completed, the neck is carefully inspected for any bleeding or surgical sponges. A large suction catheter is placed in each side and the skin is closed in two layers: the platysma muscle, with absorbable buried sutures, and the skin with staples.

A moderately tight dressing is applied with compressions in the supraclavicular fossa, since this is the area where most serohaematomas develop (Fig.13.11).