What is the recommended approach for Modified Radical Neck Dissection (MRND) incisions?

Modified Radical Neck Dissection (MRND) Incisions: Recommended Approaches

For Modified Radical Neck Dissection (MRND), the recommended approach is to use either a comprehensive or selective neck dissection based on the extent of nodal disease, with incisions designed to provide adequate exposure while preserving critical structures and minimizing morbidity. 1

Classification of Neck Dissections

Modern neck dissection approaches are classified as either:

1. Comprehensive Neck Dissection:

   • Removes all lymph node groups (levels I-V) that would be included in a classic radical neck dissection
   • Whether the sternocleidomastoid muscle, jugular vein, or spinal accessory nerve is preserved does not affect the classification as comprehensive
   • Typically recommended for patients with extensive nodal disease (N3) 2, 1

2. Selective Neck Dissection:

   • Removes only specific lymph node groups at highest risk for metastases based on the primary tumor site
   • Tailored according to the primary tumor location:
     • Oral Cavity: Levels I-III (sometimes including superior parts of level V)
     • Oropharynx, Hypopharynx, Larynx: Levels II-IV (and level VI when appropriate)
   • Typically performed for N0 disease or cases with low neck tumor burden 2, 1

Incision Selection

The choice of incision depends on several factors:

1. Standard Approach: Extended collar incision is commonly used for most MRND procedures 3

2. For High Lesions: When lymph node metastasis is present at the upper bifurcation of the carotid artery, a modified MacFee incision may be preferred 3

3. For Extensive Disease: When access to multiple levels is required, particularly for comprehensive neck dissection, a single extended transverse incision provides adequate exposure 4

4. Alternative Approaches:

   • Retroauricular approach has been developed for better cosmetic results in selected cases 4, 5
   • Extra-thyroideal space approach (MRND vets) through a traditional Kocher incision may be considered for papillary thyroid carcinoma cases, offering lower morbidity and better cosmetic results 6

Key Surgical Principles

• Preserve critical structures when possible (jugular vein, sternocleidomastoid muscle, and accessory nerve) to conserve function and cosmesis 3

• Avoid taping of the carotid artery or sternocleidomastoid muscle unless tumor invasion is present 3

• For therapeutic dissections, the extent of neck dissection depends on the primary tumor location and the level of nodal involvement 2

• Bilateral neck dissection may be necessary for tumors at or near the midline and/or for tumor sites with bilateral drainage 2

Complications and Considerations

• MRND procedures carry risk of complications including shoulder dysfunction, lymphedema, cosmetic deformity, and wound healing issues 1

• Salvage neck dissection after prior treatment has increased risk of complications including delayed wound healing, skin necrosis, and carotid exposure 2, 1

• Careful preoperative assessment of the extent of disease is essential for proper planning of the incision and extent of dissection 2

• Knowledge of neck anatomy, precise staging, prognostic evaluation, and surgical experience are necessary for successful MRND 3

By following these guidelines for MRND incisions and approaches, surgeons can achieve optimal oncologic outcomes while minimizing morbidity and preserving quality of life for patients requiring neck dissection.