Dissecting Through Fascial Spaces

The Latin approach is based on the anatomical compartmentalization of the neck. The fascial system creates spaces and barriers separating the lymphatic tissue from the remaining neck structures. The lymphatic system of the neck is contained within a fascial envelope, which, under normal conditions, may be removed without taking out other neck structures such as the internal jugular vein, sternocleidomastoid muscle, or spinal accessory nerve. The surgical technique that made this possible was initially referred to as functional neck dissection because it allowed a more functional approach to the neck in head and neck cancer patients. However, as previously emphasized, the most important but less well known fact about functional neck dissection is that it represents a surgical concept with no implications regarding the extent of the surgery. Osvaldo Suarez never performed functional neck dissection as the comprehensive type of neck dissection that some have made of it. In fact, the operation he used for cancer of the larynx did not include the submandibular and submental lymph nodes (area I) in the resection, something that now will be considered a selective neck dissection.

The question that arises at this point is, if functional neck dissection was initially designed as a new approach to the neck regardless of the extent of the surgery, why did we make of it just another type of "modified" radical neck dissection? To understand the reasons for this misinterpretation we must take ourselves to the moment when both trends — American and Latin — merged.

The increasing number of reports from European surgeons in the English literature describing the good results obtained with functional neck dissection drew the attention of American surgeons to this procedure. However, the merging of ideas resembled more a collision than a mixture, and the final result was another modification to radical neck dissection. The operation was accepted as an oncologically safe procedure, but the idea was not understood. The battle of functional neck dissection had been won, but the war of the types of neck dissection, the war of the different ways to approach the neck, was lost.

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