Table 1: Conclusion.

Defect size





pharyngeal mucosal width remaining

> 3.5 cm


Primary closure [1]




Risk of stricture

< 3.5cm and > 1cm

Pectoralis major myocutaneous pedicle flap


Versatile workhorse flap.

Resistant to radiotherapy.

Donor site co-morbidity. Bulkiness


Radial forearm free flap


Long pedicle

Donor site poor cosmetic appearance.

Colour mismatch. Hair bearing skin Complex procedure

< 1cm

Completion circumferential




Circumferential defect




Lower anastomosis above the clavicle

Free Jejunal transfer

Useful in case the pulled-up stomach cannot reach the Pharynx

Laparotomy required Anastomosis stricture Swallowing problems due to hyperperistalsis.

Wet sounding voice



Gastro omental free flap



Anastomosis stricture Requires laparotomy Complex procedure. Marked comorbidities


Tubed radial forearm free flap.












Tubed ALT

Long pedicle Thin flap

Better if tubed over a salivary bypass










Large skin/fascia paddle

Long pedicle Thin flap

High rate of leakage and stricture.

Poor function (swallowing & speech) Hair bearing skin

Colour mismatch Donor site comorbidity







Poor function (swallowing & speech) Hair bearing skin

Colour mismatch

Previously untreated cases

Tubed ALT over a salivary bypass tube

Advantages of ALT plus lowest rate of leakage and stenosis with more satisfactory voice and swallow function



Post chemo/radiotherapy (Salvage) Procedures








Additional Free flap (ALT)

Omentum can be wrapped around the anastomosis to decrease risk of leakage and fistula



Resurface the skin in case of extensive radiotherapy

damaged skin

Requires laparotomy Marked comorbidities Complex surgery





Complex surgery Prolonged theatre time

Circumferential defect


Lower anastomosis below the clavicle




Gastric pull through


Colonic transposition flap




Higher reach Can reach oropharynx




5-15% mortality

30-55% morbidity

3-23% fistula rate

Pharyngeocutaneous fistula (PCF)

Vascularized tissue transfer from outside the irradiated area


Sandwich technique

Decreased PCF rate from 30% by half




Manage resistant PCF

Additional surgical procedure

Small to medium size defects

Submental flap


Minimal donor site morbidity

Non complicated procedure

Not suitable for larger defects

May be not feasible if post radiotherapy