Evolution of Functional Neck Dissection

Osvaldo Sua rez did a fine job with functional neck dissection. He had a thorough knowledge of neck anatomy, was a great surgeon, and designed a new approach to the lymphatic system of the neck for patients with head and neck cancer. He was also able to teach the operation to those avid surgeons desiring to assist or observe him at surgery. However, he had an important weak point — he did not dedicate enough time to promoting the diffusion of his technique within the scientific community. In fact, he published only a couple of papers that were indirectly related to functional neck dissection. In his most frequently cited paper, ''El problema de las metastasis linfaticas y alejadas del cancer de laringe e hipofaringe,'' he describes the anatomical basis for functional neck dissection, without an in-depth description of the surgical technique.

In his last years he taught the procedure to two prominent disciples. Both were especially interested in the operation for patients with cancer of the larynx because both were otolaryngol-ogists in Latin countries where there is an extremely high incidence of cancer of the larynx — especially supraglottic lesions. The incidence of bilateral neck metastasis in these lesions, along with the need to treat N0 patients, made functional neck dissection the ideal tool for this group of patients. The names of these enthusiastic pupils were Ettore Bocca, from Italy, and Cesar Gavilan, from Spain. They both learned the operation directly from Sua rez. They both understood that this could be the solution to their problems with N0 patients and bilateral neck dissections, and they both adopted functional neck dissection as a new revolutionary approach to the neck.

Cesar Gavilan introduced functional neck dissection in Spain in the late 1960s and early 1970s. Ettore Bocca did the same in Italy. However, Bocca also published his results with functional neck dissection in the English literature. This explains the common association of functional neck dissection with Bocca's name so often found in the Anglo-Saxon countries. However, if one reads carefully Bocca's papers on functional neck dissection, the name of Sua rez is always mentioned.

Functional neck dissection arrived in the United States more than a decade after it had been introduced in Europe, but, more important, it did so through the experience and words of third parties. Thus, part of the message vanished in the process of adaptation to the new environment. Unfortunately, the part missing was the philosophical element of the message, supposedly the less important piece of information; in reality, the core of the new procedure.

The operation soon became accepted as an oncologically safe procedure for the management of the neck in head and neck cancer patients. However, it was considered just a simple modification of the classic procedure described by Crile and was included as one more item in a vast classification of different types of neck dissection. The surgical technique was there, but the concept—the spirit of the procedure—did not reach the head and neck surgeons in the United States. At the time the American surgeons accepted the functional operation they were involved in the development of less aggressive procedures by modifying the radical neck dissection. The work on the ''selective field'' had already started, but this belongs to the American side of the history and has been thoroughly described in the previous section.

CHAPTER

Rationale and Anatomical Basis for Functional and Selective Neck Dissection functional neck dissection, as described by Osvaldo Suarez, is based on the existence of a fascial barrier between the lymphatic tissue and the muscular, glandular, neural, and vascular structures of the neck. This anatomical separation allows the creation of a surgical plane of dissection. The fascial layer invests muscles and organs in the neck, forming planes and spaces where many important structures are crowded together. This fact, known as fascial compartmentalization, holds the rationale for functional neck dissection.

This chapter describes the anatomical bases of functional neck dissection from a practical and surgical standpoint.

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