(4) The internal jugular vein is isolated by blunt dissection and then doubly
clamped, ligated with medium silk, and divided with Metzenbaum scissors. A transfixion
suture is placed on the lower end of the vein.
(5) The common carotid artery and vagus nerve are identified. The fatty
areolar tissue and fascia are dissected away, using Metzenbaum scissors and fine
tissue forceps. Branches of the thyrocervical artery are clamped, divided, and ligated.
(6) The tissue and fascia of the posterior triangle are dissected, beginning at
the anterior margin of the trapezius muscle, continuing near the brachial plexus and the
levator scapulae and the scalene muscles. During the dissection, branches of the
cervical and suprascapular arteries are clamped, ligated, and divided.
(7) The anterior portion of the block dissection is completed. The omohyoid
muscle is severed at its attachment to the hyoid bone. Bleeding is controlled. All
hemostats are removed, and the operative site is covered with warm, moist laparotomy
(8) The sternocleidomastoid muscle is severed and retracted. The
submental space is dissected free of fatty areolar tissue and lymph nodes from above
(9) The deep fascia on the lower free edge of the mandible is incised; the
facial vessels are divided and ligated.
(10) The submaxillary triangle is entered. The submaxillary duct is divided
and ligated. The glands with surrounding fatty areolar tissue and lymph nodes are
dissected toward the digastric muscle. The facial branch of the external carotid artery is
divided. Portions of the digastric and stylohyoid muscles are severed from their
attachments to the hyoid bone and on the mastoid. The upper end of the internal
jugular vein is elevated and divided. The surgical specimen is removed.
(11) The entire field is examined for bleeding and then irrigated with warm
saline solution. Penrose drains are placed in the wound and brought out through a stab
wound, and #12 Fr catheters may be used.
(12) The flaps are then approximated with interrupted fine silk sutures. A
bulky pressure dressing is applied to the neck. Gauze dressings are applied to the
wound edges and covered with sterile fluffed gauze to provide even pressure. A wide
gauze roller bandage is wrapped snugly around the neck and in some cases encircles
the head. The dressing may then be covered with elastic bandage that is wrapped
around the neck and anchored to the chest wall.