Functional As A Concept

We are aware that the two approaches herein specified — American and Latin — may look similar to many observers. However, there is a great conceptual difference between them. In the first case the surgical technique is modified to preserve some neck structures, whereas in the second, a different approach is used to treat the neck with disease confined to the lymphatic system.

This difference may appear terminological and irrelevant when it comes to comparing ''functional'' versus ''modified radical.'' It may be said that, although the rationale is different, the end result is the same: the lymphatic system is removed from the neck, preserving the remaining neck structures. However, the situation becomes more complex when selective neck dissections appear in the surgical scenario.

Selective neck dissections are simple modifications of standard operations, whether they be functional or radical (we will see later that they are more closely related to functional than to radical neck dissection). Selective neck dissections are just technical variations designed to fit the operation to the patient on a more individualized basis. Thus, their potential number is as high as the number of possible modifications to the original procedure. On the contrary, functional neck dissection as described here is a concept, allowing a different approach to the neck.

The key factor for the misunderstanding of functional neck dissection was the mixture between concepts and techniques that took place in the literature. This situation was favored by a linguistic factor that played an important role in all this confusion.

The functional concept reached the American surgeons through the experience of third parties because Osvaldo Suarez never published his ideas in English. Moreover, the few Spanish papers he published did not emphasize the importance of his approach — as often happens with important contributions, the author is the person least aware of the impact of the innovation. The result of this indirect transmission of information was the partial distortion of the implicit message: functional is a concept, not just another modification.

The functional concept implies dissecting along fascial planes, regardless of the nodal regions that may be preserved or included in the resection. Functional means using fascial compartmen-talization to remove the lymphatic tissue of the neck.

The final conclusion for this reasoning is that functional neck dissection should not be identified with a comprehensive type of nonradical neck dissection, but with a conceptual approach to the neck. Whether the surgeon decides to stop above or below the omohyoid muscle in oral cavity tumors, remove or preserve the lymph nodes in the posterior triangle of the neck (lower part of area V) in hypopharyngeal cancer, or resect or spare the submental lymph nodes in laryngeal cancer patients constitutes only minor considerations in regard to the basic principle. Now let us address the relations between the basic functional principle and selective neck operations.

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