. Operative surgery. less extensive disease the upper or lower flap may be employed alone;or one may be fashioned with a pedicle in a position the reverse of thatshown in the figure. The incision for a single flap should approximatelycorrespond to the circumference of the tumor, which is then exposed in itsentirety by division of the sterno-mastoid below the point where it is enteredby the spinal accessory nerve. The flap consists of skin, subcutaneoustissue, platysma, and fascia. The Johns Hopkins Hospital (Mitchell)* plan of practice may bebriefly expressed as follows: The
. Operative surgery. less extensive disease the upper or lower flap may be employed alone;or one may be fashioned with a pedicle in a position the reverse of thatshown in the figure. The incision for a single flap should approximatelycorrespond to the circumference of the tumor, which is then exposed in itsentirety by division of the sterno-mastoid below the point where it is enteredby the spinal accessory nerve. The flap consists of skin, subcutaneoustissue, platysma, and fascia. The Johns Hopkins Hospital (Mitchell)* plan of practice may bebriefly expressed as follows: The Operation.—Make a curved incision (Fig. 896) from over themastoid process, forward along the anterior border of the sterno-mastoidmuscle, thence slightly backward to the middle of the clavicle; make atransverse incision along the upper border of the clavicle, forming with thepreceding, a T-shaped outline; dissect back the skin, uncovering a quad- * Johns Hopkins Hospital Bulletin, July, 1902. T32 OPERATIVE Fig. 896.—Skin incision for complete removal of glandsof neck. rilateral area, through which all parts of the neck can be easily reached;divide the subcutaneous fascia and the platysma of the angle between theposterior border of the sterno-mastoid muscle and the clavicle, along witha few of the posterior fibres of this muscle, and turn the tissues back, ex-posing the external jugular vein; ligature, divide, and turn aside this vein,thus exposing the key to the operation —the omo-hyoid muscle; seize and divide the omo-hyoidand (using the upperpart as a retractor) pullaside the posterior borderof the sterno-mastoid, thuspermitting the dissectionto be carried up alongthe internal jugular andposterior border of thesterno-mastoid to the pos-terior branch of the spinalaccessory; remove the dis-eased glands from thenerve, leaving them con-nected with those above,and continue the wholedissection from the medi-an line and below, upward and outward. In some mstances the
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