How To: Tunneled Submental Island Flap for Reconstruction of Endoscopic Nasopharyngectomy Defects

The skin paddle was de-epithelialized and passed to the nasopharyngectomy defect through the parapharyngeal corridor along the surface of a one-inch Penrose drain. To pass the flap, a traction suture was placed on the distal end of the skin paddle. Under endoscopic visualization, the flap was pushed cranially through the parapharyngeal space while pulling on the traction suture until it was seated in the surgical defect. Flap inspection revealed bleeding from its de-epithelialized surface, confirming the integrity of the vascular pedicle. Manipulation of the flap demonstrated that no further measures were necessary to secure it within the defect. Flap stabilization was provided by the tethering effect of the vascular pedicle within the narrow transposition corridor. The previously harvested NSF was rotated to cover exposed bone in the clival recess. Absorbable nasal packing was placed anterior to the flap in the maxillary sinus, maintaining patency of the nasopharynx. A temporary tracheostomy was performed to ensure a safe airway in the immediate post-operative period.

The final pathology was consistent with squamous cell carcinoma, and margins were reported negative. The patient underwent an endoscopic biopsy of the superior ITF four months after the procedure due to an area with concerning residual disease. This biopsy required partial mobilization of the SMIF, which was well integrated and possessed a robust blood supply. No residual disease was identified in the biopsy, and the patient had no evidence of disease 12 months after surgery.

CONCLUSION

Endoscopic nasopharyngectomy exemplifies both the technical progress in expanded endoscopic skull base surgery and its novel reconstructive challenges. The SMIF is well suited for reconstruction of nasopharyngectomy defects and may be useful more broadly for reconstruction of volumetric defects of the central skull base.