What is the evaluation and treatment approach for a patient with a webbed neck?

Evaluation and Treatment Approach for Webbed Neck

The evaluation of webbed neck should include a comprehensive assessment to rule out malignancy, followed by surgical correction using techniques such as Z-plasty or posterior cervical lift for optimal cosmetic and functional outcomes. 1, 2

Initial Evaluation

• Conduct a thorough history and physical examination to identify risk factors for malignancy, including duration of the mass (>2 weeks without fluctuation increases risk), physical characteristics (fixation to adjacent tissues, firm consistency, size >1.5 cm), and other suspicious findings 3
• Determine if the webbed neck is associated with a genetic syndrome, as it commonly occurs in Turner syndrome (most common), Noonan syndrome, and Klippel-Feil syndrome 1, 4
• Assess for other congenital anomalies that may be present with these syndromes, which could modify the surgical approach 4

Diagnostic Workup

• If there are concerning features for malignancy, imaging should be performed with contrast-enhanced CT or MRI to characterize the mass and evaluate its relationship to surrounding structures 3, 5
• Fine-needle aspiration (FNA) is strongly recommended as the initial diagnostic test for tissue sampling if malignancy is suspected, due to its high sensitivity and specificity, minimal discomfort, and low complication rate 3, 5
• Avoid prescribing antibiotics unless there are clear signs of bacterial infection (warmth, erythema, localized swelling, tenderness, fever) 3

Surgical Management

• Surgical correction is the definitive treatment for webbed neck deformity once malignancy has been ruled out 1, 2
• The most commonly documented surgical technique is Z-plasty, which enables adequate extension of scars and improves the contour of the neck 1, 2
• Other surgical approaches include:
  • Posterior cervical lift - involves excision of redundant skin from the posterior neck with advancement of superficial cervical fascia 6
  • Butterfly correction, V-Y plasty, tissue expansion, T to M rearrangement, and subcutaneous fascial excision 2
  • Lateral approach with shift of glabrous skin flap to the back - allows for effective reduction of webbed neck, excision of connective tissue bands, and correction of low hairline on the sides of the neck 1

Surgical Considerations and Outcomes

• The primary goals of surgical management are to create a harmonious cervical profile while restoring the natural hairline 6
• Surgical correction should address both the skin webbing and the low posterior hairline that often accompanies this condition 1, 4
• Modified techniques, such as the modified posterior cervical lift with transfixion of deep fascia and customized excision of redundant tissue, may improve outcomes with less hypertrophic scarring 6
• Potential complications include hypertrophic scarring and recurrence of the webbed neck 1, 2

Follow-up Care

• Regular follow-up is essential to monitor for potential complications such as hypertrophic scarring or recurrence 2
• Patients should be advised about specific criteria that would trigger the need for additional evaluation 3
• A clear follow-up plan should be documented to assess resolution or determine final diagnosis 3

Common Pitfalls to Avoid

• Assuming a neck mass is benign without adequate evaluation, especially in adults 3, 5
• Proceeding directly to open biopsy without first attempting FNA and imaging if malignancy is suspected 5
• Inadequate correction of the low hairline, which is an important component of the webbed neck deformity 1
• Insufficient planning for the surgical approach, which may lead to suboptimal cosmetic outcomes or recurrence 2, 6