Main types of incisions on the neck
The choice of surgical incision depends directly on the topography of the target organ and the nature of the pathological process. All surgical approaches are divided into several main categories.
Transverse (cosmetic) incisions A classic example is the Kocher collar incision. The main rule for performing them is to place the incision line strictly along the direction of the natural skin folds of the neck. This particular group of approaches best meets cosmetic requirements, as healing occurs with the formation of a thin, practically invisible scar.
Longitudinal incisions The choice of a longitudinal direction is due to the fact that most internal organs of the neck, as well as the main neurovascular bundles, have a longitudinal arrangement.
- Incisions passing along the anterior or posterior margin of the sternocleidomastoid muscle (m. sternocleidomastoideus) are the most appropriate and safest for approaching large vessels and nerves.
- Median longitudinal incisions provide an exceptionally good and symmetrical access to the larynx and trachea. However, their use is limited by a significant disadvantage: after healing, they leave a rough, aesthetically unacceptable, and very noticeable scar.
Combined incisions Such approaches are indicated for extensive and traumatic interventions, for example, when it is necessary to remove deep cervical lymph nodes.
- Technique: the standard horizontal collar incision is supplemented by longitudinal incisions (directed upwards and downwards) at its ends.
- Execution variants: oblique-longitudinal incisions with a horizontal extension can be used, as well as T-shaped approaches (a combination of a horizontal line with vertical ones).
- Disadvantage: these approaches are characterized by high traumatism and inevitably leave extremely noticeable scars.
Principle of "staggered" (stepped) tissue dissection
To improve the final cosmetic appearance of the postoperative scar and reliably prevent the formation of through, retracted, and fixed scars, the principle of stepped tissue dissection is actively used in neck surgery.
Execution Technique:
- Superficial layer is dissected strictly in a single plane as a single block. This block includes: skin, subcutaneous adipose tissue (SAT), superficial fascia, and the platysma (m. platysma).
- Deep layers of tissues are opened with a displacement. The surgeon makes an incision at a distance of 0.5–1.0 cm from the edge of the initial skin wound.
Examples of applying the principle:
- When performing a median approach, the line of incision of the linea alba cervicis must not projectionally coincide with the initial skin incision.
- During a collar approach, the second and third fasciae of the neck are opened in a longitudinal direction, whereas the underlying sternohyoid muscles are transected transversely, creating a cross of directions.
Exceptions to the rules: If the surgical intervention is performed for life-threatening conditions (e.g., deep neck phlegmon accompanied by purulent tissue melting, or emergency removal of deep lymph nodes), cosmetic requirements and the stepped principle are completely disregarded for the sake of speed and adequacy of exposure.
Topography of surgical approaches
Depending on the purpose of the operation and the affected organ, standardized incision lines are used on the neck:
- An incision running parallel to the lower jaw margin.
- Infrahyoid collar approach (used for approaches to the pharynx).
- Collar approach intended to expose the superior thyroid artery.
- Median longitudinal approach (for the trachea and larynx).
- An incision along the anterior margin of the sternocleidomastoid muscle (m. sternocleidomastoideus).
- Classic collar approach to the thyroid gland.
- An incision made parallel to the upper edge of the clavicle.
To understand the meaning of the "staggered" approach, imagine proper brickwork: the seams in adjacent rows never coincide. Similarly in the neck: the incisions of the superficial layer (up to m. platysma) and the deep fasciae are displaced relative to each other by 0.5–1.0 cm to avoid the formation of a single through and retracted scar.
Class and exam questions
Why are longitudinal incisions most commonly used for working with neck vessels?
This is directly due to the anatomy: major blood vessels and nerve trunks are located longitudinally in the neck. An incision along the edge of the sternocleidomastoid muscle allows for their safest exposure.
What is the main disadvantage of the median longitudinal approach?
Although this approach provides an excellent view of deep structures (larynx, trachea), it does not meet aesthetic standards and leaves a very noticeable, rough scar after healing.
Is it always necessary to follow the principle of "staggered" tissue dissection?
No. In life-threatening conditions (e.g., deep phlegmons), the speed of the operation and adequate exposure come first, so cosmetic requirements are disregarded.
What else to study on this topic
- Surgical anatomy of the neurovascular bundles of the neck
- Topography of the cervical fasciae and their clinical significance
- Surgical technique and approaches in tracheostomy
- Topography of the deep cervical lymph nodes
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