Neck dissection through a facelift incision

Robot-assisted versus conventional neck dissection in head and neck cancers: A systematic review and meta-analysis

BACKGROUND

Advances in technology have enabled neck dissection techniques that reduce aesthetic impact while maintaining oncological safety. This study compares perioperative outcomes between robotic neck dissection via retroauricular/modified facelift incision (RNDRM) and conventional neck dissection via anterolateral cervical incision (CND).

METHODS

Studies were selected from PubMed, Embase, and Cochrane Library. Data from studies comparing RNDRM and CND were extracted and analyzed using a random-effects model.

RESULTS

The meta-analysis included eight studies with 421 cases. The RNDRM group had a longer operative time (mean difference [MD], 69.11; 95 % confidence interval [CI] 37.92 to 100.30) and higher cosmetic satisfaction (MD, 2.03; 95 % CI, 1.48 to 2.57), along with a higher risk of marginal mandibular nerve injury (risk difference [RD], 0.08; 95 % CI 0.01 to 0.15). No significant differences were found in operative blood loss (MD, 15.35; 95 % CI - 7.39 to 38.10), days of drain placement (MD, 0.49; 95 % CI, -0.02 to 1.00), drainage volume (MD, 15.29; 95 % CI, -45.22 to 75.79), overall lymph node yield (MD, -1.09; 95 % CI, -3.18 to 1.00), positive lymph node yield (MD, -0.61; 95 % CI, -2.20 to 0.98), length of hospital stay (MD, 1.07; 95 % CI -0.06 to 2.20), or regional recurrence (RD, 0.00; 95 % CI -0.05 to 0.05), with similar rates of other complications.

CONCLUSION

RNDRM offers better cosmetic outcomes but requires longer operative time and has a higher risk of marginal mandibular nerve injury than CND. It may be an alternative for selected patients, with surgery choice needing discussion between patient and surgeon.

Lateral approach is a more aesthetical option for radical resection of BSCC: assessment of its surgical, oncological, functional, and aesthetic outcomes

Background

The purpose of this study was to introduce a modified lateral approach for combined radical resection of buccal squamous cell carcinoma (BSCC) and evaluate its surgical, oncological, functional, and aesthetic outcomes in comparison with the conventional lower-lip splitting approach.

Methods

This single-center study retrospectively reviewed 80 patients with BSCC, of which 37 underwent the lateral approach and 43 underwent the conventional approach. Surgical, functional, oncological, and aesthetic evaluations, as well as follow-ups, were recorded and compared.

Results

Compared to the conventional approach group, the lateral approach group had a longer surgical time (P = 0.000), but there was no significant difference in other surgical and oncological parameters. Moreover, the scar in the head and neck had a significantly discreet appearance in the lateral approach group, whose satisfaction was better than those in the conventional approach group (P = 0.000). Other oral function parameters, postoperative mouth-opening, and 3-year survival rate were not significantly different between the two groups.

Conclusion

The lateral approach could provide superior aesthetic results while maintaining equal surgical, functional, and oncological outcomes compared to the conventional approach for radical resection of BSCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02519-1.

Comparing Technical Feasibility of Non-robotic Retroauricular Versus Transcervical Approach Neck Dissection in Oral Cancers-a Preliminary Single Institute Experience

Recent advances in minimal access/invasive surgeries in head and neck (robotic/endoscopic assisted) allow neck dissection without a visible scar through a retroauricular approach unlike conventional approach giving visible scar and its sequelae. We retrospectively reviewed prospectively collected data of 80 neck dissections in 72 patients from April 2017 to June 2018 for all newly diagnosed squamous cell carcinoma of oral cavity. We compared between the operative and postoperative outcomes in open- and endoscopic-assisted retroauricular approach (RA) in these patients undergoing neck dissections. Thirty-two out of seventy-two patients underwent retroauricular (RA) approach neck dissection while 40/72 patients underwent conventional open approach neck dissection. RA group had more early staged oral cancers 20/32 (62.5%) as compared to 9/40 (22.5%) in the open approach (p = 0.025). Average nodal yield and nodal yield according to levels were not statistically different in both groups. Nodal failure in both groups was also not statistically significant (p = 0.82). Postoperative complications like marginal weakness, hematoma, microvascular-related problems, and wound problems were not significantly related to the type of approach. We recommend in select group of early oral cancers the retroauricular-assisted neck dissection as minimally invasive, cost-effective, and oncologically safe approach for a scar-free neck surgery.

Use of the facelift incision for excision of non-tuberculous mycobacterial lymphadenitis in children

OBJECTIVES

To present cases of pediatric periparotid nontuberculous mycobacterial lymphadenitis excised through a facelift incision in order to review the advantages of this approach to parotidectomy. We also aim to discuss scenarios in which to forgo the facelift incision in favor of a traditional modified Blair incision.

METHODS

Retrospective series of seven consecutive patients who underwent parotidectomy for nontuberculous mycobacterial lymphadenitis between 2013 and 2018.

RESULTS

The series included three uses of the facelift incision and four uses of the modified Blair incision, which was specifically selected for cases of bulky lymphadenopathy anterior to the masseter muscle. All cases of Modified Blair incision involved circumferential dissection of the marginal mandibular branch of the facial nerve. The facelift incision permitted complete removal of disease in cases located posterior to the masseter as well as neck dissection as inferiorly as level III. Post-operatively, temporary marginal mandibular nerve weakness was seen in all cases of Modified Blair incision. Scar widening was most notable in patients who required skin excision or dermal curettage.

CONCLUSION

The facelift incision offers a more hidden scar. This may serve as an alternative approach to parotid surgery in young children with nontuberculous mycobacterial lymphadenitis, except in cases of bulky disease anterior to the masseter muscle for which optimal exposure of the marginal mandibular nerve via a modified Blair incision is warranted.

In vivo and in vitro neck dissection specimen labelling: a new method for precise orientation of specimens

As the main anatomical and radiological landmarks are lacking in neck dissection specimens, orientation and labelling of the lymph node levels becomes very important for precise histopathological reporting. A few labelling techniques for neck dissection specimens have been described previously, which can aid the histopathologist in orienting the specimen. However, a combined method of specimen labelling in which the ND specimen is labelled during the operation and once it has been resected would improve specimen orientation. This article describes a technique of in vivo and in vitro labelling of neck dissection specimens that specifies the levels of the lymph nodes with proper anatomical landmarks. This technique eliminates the grey areas between levels II and III and between levels III and IV, which are difficult to identify precisely in neck dissection specimens. This technique is easily reproducible and represents a useful tool in attaining precise pathological reporting.

The Latest Advancements in Selective Neck Dissection for Early Stage Oral Squamous Cell Carcinoma

OPINION STATEMENT

The management of cervical lymph node metastasis remains a crucial component of the treatment of head and neck cancers. However, the proper management of clinical N ₀ cases with early-stage oral squamous cell carcinoma (OSCC) remains undefined. In the advent of minimally invasive techniques in the 1980s, these techniques have gained popularity among numerous surgeons in all fields of surgery. Although there are no randomized controlled trial data comparing the outcomes of minimally invasive techniques (endoscopically assisted selective neck dissection (SND), robot-assisted SND) with conventional techniques, encouraging evidence from several studies suggests that both endoscopically assisted SND and robot-assisted SND are safe, minimally invasive techniques with achieved short-term oncologic outcomes and can reach a better cosmetic outcome than conventional SND. In this review, we also compare the indications, surgical approaches, and relative advantages and disadvantages of conventional SND, endoscopically assisted SND, and robot-assisted SND to provide surgeons with a means to better consider these techniques for the treatment of early-stage OSCC.

Surgical approaches in neck dissection: Comparing functional, oncologic and aesthetic aspects of transverse cervicotomy to Paul André's approach

BACKGROUND

Surgical approaches in neck dissection: comparing functional, oncologic and aesthetic aspects of transverse cervicotomy to Paul André's approach.

METHODS

This single-center retrospective study compares a new transverse incision for cervicotomy to the classical approach described by Paul André in neck dissections. The evaluation criteria were: number of lymph nodes analyzed, operative time, complications, patient satisfaction and aesthetic aspects of the scar.

RESULTS

A total of 34 patients were included in this study, from September 2009 until January 2015. The number of lymph nodes analyzed is not affected by this new approach compared to the classical one (P=0.9). The scar has a significantly more discreet appearance in the transverse cervicotomy group (P=0.023) likewise; patient satisfaction is higher in this group (P=0.006).

CONCLUSIONS

Aesthetic and functional impairment can be reduced using this new transverse cervical approach hidden in the natural creases of the neck described by Langer.

Neck Dissection Technique Commonality and Variance: A Survey on Neck Dissection Technique Preferences among Head and Neck Oncologic Surgeons in the American Head and Neck Society

Introduction Neck dissection (ND) technique preferences are not well reported. Objective The objective of this study is to educate practitioners and trainees about surgical technique commonality and variance used by head and neck oncologic surgeons when performing a ND. Methods Online survey of surgeon members of the American Head and Neck Society (AHNS). Survey investigated respondents' demographic information, degree of surgical experience, ND technique preferences. Results In our study, 283 out of 1,010 (28%) AHNS surgeon members with a mean age of 50.3 years (range 32-77 years) completed surveys from 41 states and 24 countries. We found that 205 (72.4%) had completed a fellowship in head and neck surgical oncology. Also, 225 (79.5%) respondents reported completing more than 25 NDs per year. ND technique commonalities (>66% respondents) included: preserving level 5 (unless with suspicious lymph nodes (LN)), only excising the portion of sternocleidomastoid muscle involved with tumor, resecting lymphatic tissue en bloc, preservation of cervical sensory rootlets, not performing submandibular gland (SMG) transfer, placing one drain for unilateral selective NDs, and performing a ND after parotidectomy and thyroidectomy and before transcervical approaches to upper aerodigestive tract primary site. Variability existed in the sequence of LN levels excised, instrument preferences, criteria for drain removal, the timing of a ND with transoral upper aerodigestive tract primary site resections, and submandibular gland preservation. Results showed that 122 (43.1%) surgeons reported that they preserve the submandibular gland during the level 1b portion of a ND. Conclusions The commonalities and variances reported for the ND technique may help put individual preferences into context.

Robotic Thyroidectomy

Objectives

Robotic thyroidectomy using remote access approaches has gained popularity with patients seeking to avoid neck scarring and enhanced cosmetic satisfaction. The aim of this study was to compare the efficacy and advantages of a postauricular facelift approach vs a gasless unilateral axillary (GUA) approach in robotic thyroidectomy.

Study Design

Case series with chart review.

Setting

University tertiary care hospital.

Subjects and Methods

We retrospectively analyzed the data of 65 patients who underwent robotic thyroidectomy with or without central neck dissection using a GUA approach (45 patients) or a postauricular facelift approach (20 patients) between September 2013 and December 2014. We excluded patients who underwent simultaneous lateral neck dissection or completion thyroidectomy.

Results

Robotic procedures were completed without being converted to an open procedure in all patients. There were no significant differences in terms of patient and tumor characteristics, extent of thyroidectomy and central neck dissection, operative time, complications, and postoperative pain between the 2 approaches, except the higher female ratio in the GUA approach group (female ratio, 95.6% vs 75%, P = .042). Cosmetic satisfaction evaluated by a questionnaire was not significantly different between the 2 groups, and most patients of both groups (85.7%) were satisfied with postoperative cosmesis.

Conclusion

Both GUA and postauricular facelift approaches are feasible, with no significant adverse events in patients, and result in excellent cosmesis. However, a GUA approach seems to be superior when performing total thyroidectomy using a unilateral incision based on the preliminary result.

Robotic-assisted selective and modified radical neck dissection in head and neck cancer patients

INTRODUCTION

Recently, several authors introduced various methods and published feasibility studies on novel robotic-assisted neck dissection techniques for head and neck cancer patients. Cosmesis and general appearance have become important concerns of cancer patients today. Especially in the head and neck area, a conspicuous scar can reduce patient satisfaction after surgery. With conventional neck dissection techniques, a long scar in the neck is unavoidable. Therefore, the development of robotic assisted neck dissection provides the patients with a scarless neck in these situations. However, there are some limitations of the application of these techniques in their current stage of development.

METHODS

This study was performed using a systematic literature review.

RESULTS

The reviewed clinical studies show that robotic-assisted neck dissection yields similar functional and early oncologic outcomes to that of conventional neck dissection, as well as excellent cosmetic satisfaction of patients. Despite these benefits, some disadvantages can be observed, in terms of longer operation times as well as higher procedure costs.

CONCLUSION

Besides the similar oncologic and functional outcomes compared with the open procedure so far, more prospective, controlled, multicenter studies are required to establish robotic-assisted neck dissection as an alternative standard and to justify its added costs beyond the cosmetic advantages.

Approaches of robot-assisted neck dissection for head and neck cancer: a review

Robot-assisted surgery is being increasingly used by surgeons because of its enhancement of visualization, precision, and articulation compared with conventional minimally invasive techniques. In recent years, robot-assisted neck dissection (RAND) has begun to be used as an alternative method of neck dissection, one of the classic surgical procedures in the area of head and neck surgery. Currently, there are four kinds of approaches for RAND: (1) modified facelift or retroauricular incision, (2) combined transaxillary and retroauricular incision, (3) transaxillary incision, and (4) transoral incision. RAND may help perform minimally invasive surgery and achieve excellent cosmetic results as well as the desired oncologic outcomes, and this requires selecting an appropriate approach based on the different needs of neck dissections. Although experienced surgeons wishing to avoid large cervical incisions in patients can safely perform RAND, there are still quite a few limitations; in particular, surgical morbidity and oncologic outcomes should be verified by further prospective clinical trials with longer follow-up periods. Also, RAND needs to be standardized and its use disseminated. In this review, we introduce the applications of different approaches for RAND and their indications and determine whether RAND can be more beneficial compared with conventional surgeries.

Current philosophy in the surgical management of neck metastases for head and neck squamous cell carcinoma

Neck dissection is an important treatment for metastases from upper aerodigestive carcinoma; an event that markedly reduces survival. Since its inception, the philosophy of the procedure has undergone significant change from one of radicalism to the current conservative approach. Furthermore, nonsurgical modalities have been introduced, and, in many situations, have supplanted neck surgery. The refinements of imaging the neck based on the concept of neck level involvement has encouraged new philosophies to evolve that seem to benefit patient outcomes particularly as this relates to diminished morbidity. The purpose of this review was to highlight the new paradigms for surgical removal of neck metastases using an evidence-based approach.

Robot-assisted excision of branchial cleft cysts using a postauricular facelift approach

Various approaches have been employed to avoid visible scars in the neck, along with the development of robotic and endoscopic techniques. We have employed a technique of robot-assisted excision of branchial cleft cyst (BCC) via a postauricular facelift approach. We present three patients with 2nd BCC who underwent robot-assisted excision of mass. All operations were performed successfully without complication. Postoperative cosmesis was excellent and all patients were satisfied with their scars which were concealed by hair and auricle. Robot-assisted excision of BCC is technically feasible and will be helpful for patients with BCC who wish to hide any visible scarring.

Minimally invasive selective neck dissection: a prospective study of endoscopically assisted dissection via a small submandibular approach in cT(1-2_N(0) oral squamous cell carcinoma

BACKGROUND

Selective neck dissection (SND) in clinical N0 (cN0) cases of oral squamous cell carcinoma (SCC) has been performed by surgeons using a retroauricular or modified facelift approach with robotic or endoscopic assistance. However, these procedures provide cosmetic satisfaction at the cost of possible maximal invasiveness. In this prospective study, we introduced and evaluated the feasibility as well as surgical invasiveness and cosmetic outcome of endoscopically-assisted SND via a small submandibular approach.

METHODS

Forty-four patients with cT1-2N0 oral SCC (OSCC) were randomly divided into two groups of endoscopically-assisted SND and conventional SND. Perioperative and postoperative outcomes of patients were evaluated, including the length of the incision, operating time for neck dissection, estimated blood loss during the operation, amount and duration of drainage, total hospitalization period, total number of lymph nodes retrieved, satisfaction scores based on the cosmetic results, perioperative local complications, shoulder syndrome, and follow-up information.

RESULTS

The mean operation time in the endoscopically-assisted group (126.04 ± 12.67 min) was longer than that in the conventional group (75.67 ± 16.67 min). However, the mean length of the incision was 4.33 ± 0.76 cm in the endoscopically-assisted SND group, and the amount and duration of drainage, total hospital stay, postoperative shoulder pain score, and cosmetic outcomes were superior in the endoscopically-assisted SND group. Additionally, the retrieved lymph nodes and complications were comparable.

CONCLUSIONS

Endoscopically-assisted SND via a small submandibular approach had a longer operation time than the conventional approach. However, endoscopically-assisted SND was feasible and reliable while providing minimal invasiveness and satisfactory appearance.

Robot-assisted level II-IV neck dissection through a modified facelift incision: initial North American experience

BACKGROUND

Cosmesis is of increasing importance to the otolaryngology patient population. This is the first report of clinical outcomes of robot-assisted neck dissection by North American groups.

METHODS

This is a retrospective case-control study. Cases included three patients who underwent isolated, ipsilateral robot-assisted neck dissection. Operative time, estimated blood loss, lymph node retrieval, total drainage, hospital stay and complications from this group were compared against the outcomes of six consecutive patients who underwent conventional neck dissection.

RESULTS

Operative times were longer in robot-assisted neck dissection (mean 234 min) compared with the conventional neck dissection (mean 110 min). There were no significant differences between the two groups in other outcomes.

CONCLUSIONS

Robot-assisted selective neck dissection of levels II-IV is feasible through a modified facelift incision. Our initial data suggest that this procedure is surgically sound. It should be applied by experienced surgeons who wish to avoid a cervical incision.

Robotic Selective Neck Dissection by a Postauricular Facelift Approach

Objectives

The aim of this study was to investigate the feasibility and efficacy of robot-assisted neck dissection by a postauricular facelift approach in head and neck squamous cell carcinoma (HNSCC), compared with conventional neck dissection.

Study Design

Case series with chart review.

Setting

University tertiary care hospital.

Subjects and Methods

Thirty HNSCC patients with clinically node negative necks (cN0) who underwent robot-assisted selective neck dissection (SND) by a postauricular facelift approach (11 patients, 12 necks) or conventional neck dissection (19 patients, 21 necks).

Results

The mean age was lower in the robotic group ( P = .030). However, the distributions of gender and TNM stage did not differ between the two groups. The robotic SND was completed successfully in all patients. The mean operative time was longer in the robotic group (215 ± 56 min) than the conventional group (144 ± 43 min) ( P < .001). The mean numbers of lymph nodes removed were 25.0 ± 7.4 and 28.9 ± 8.2 in the robotic and conventional group, respectively ( P = .192), and the number of lymph nodes removed at each level also did not differ between the 2 groups. In addition, there was no significant difference in postoperative complications between the 2 groups, but cosmetic satisfaction was higher in the robot group ( P = .002).

Conclusions

Robot-assisted SND by a postauricular facelift approach is comparable to conventional neck dissection in selected patients with cN0 HNSCC and results in excellent postoperative cosmesis.