Flap selection for circumferential pharyngeal reconstruction

Six systematic reviews and meta-analyses (2019-2025) have compared reconstructive options for circumferential pharyngeal defects following total laryngopharyngectomy. This narrative review synthesises their findings, examines where they conflict and why their conclusions diverge, and weighs factors that fall below systematic-review level but affect flap selection.

Free jejunal flap (FJF) demonstrates the lowest fistula rate (8-11%); in the largest network meta-analysis (1357 patients), FJF had a 93% probability of ranking first for fistula avoidance. Tubed anterolateral thigh (ALT) showed non-significant trends toward lower flap failure and 30-day mortality. Differences in fistula rates between FJF and ALT vary with analytical method. Stricture rates overlap (FJF 11-20%, ALT 13-19%) and should not drive flap choice. Adjuvant radiation therapy is associated with a near five-fold increase in FJF stricture; this concern recedes in salvage cases. The U-shaped pectoralis major flap had the lowest stricture rate in the network meta-analysis.

Flap selection requires balancing fistula risk against perioperative mortality and donor-site morbidity, modified by defect extent, thigh adiposity, anticipated radiation therapy, and institutional experience. No randomised trials exist. Progress will require prospective comparative data and regionalisation.