The skin incision is made one to two centimeters above the clavicle and parallel to it. The platysma muscle is then divided using electrocautery. Dissection continues in the layer deep to the platysma and a self-retaining retractor is placed. The dissection then continues medially toward the border of the sternocleidomastoid muscle. The SCM is retracted medially. Dissection then continues through the adipofascial tissue along the SCM and the omohyoid is identified. The belly of the muscle is then transected using cautery. Further dissection at the medial aspect of the surgical field reveals the internal jugular vein. The lateral edge of the vein is cleared. An Army-Navy retractor is placed to move the vein medially. The dissection is carried medially down toward the anterior scalene muscle, which lies at the base of the surgical field. A distal vein is clipped and ligated. The fatty tissue within level 5B that contains the lymph nodes is carefully dissected free from surrounding tissue while maintaining its attachment to the vascular pedicle. The dissection is continued from medial to lateral and from superior to inferior. Here, the dissection is continued laterally as the lymph nodes are isolated on the pedicle. The flap is grasped and retracted. The distal transverse cervical artery and vein are identified. Vascular clips are placed on the most distal aspect, first on the artery and then on the vein. Plants are applied to the distal pedicle as these vessels may occasionally be used for anastomosis. The distal vessels are then ligated. Dissection continues toward the proximal end of the pedicle. The flap is isolated on the proximal transverse cervical artery and vein. Note the phrenic nerve as it runs along the surface of the anterior scalene muscle. Deeper in the left neck, the thoracic duct is visualized. Examples of typical donor sites following subcutaneous lymph node transplant to harvest.

surgical procedure

internal jugular vein

lymph node transplant

phrenic nerve

thoracic duct