Introduction: Total laryngectomy reconstruction choice is driven by a variety of factors including defect size, location and history of radiation. How reconstruction affects functional outcomes, specifically swallowing, is unclear. This study seeks to determine whether reconstruction method is associated with differences in swallowing outcomes.

Methods: Retrospective review of patients undergoing total laryngectomy at a tertiary referral center. Reconstruction types included primary closure, pectoralis flap, anterolateral thigh (ALT) or radial forearm free flap (RFFF). Pharyngeal transit time (PTT), patient reported dysphagia (EAT-10) and diet tolerated (FOIS) were recorded and compared among patients undergoing primary closure and type of free tissue transfer using unpaired T-test for means and Chi-Square for categorical data.

Results: 95 patients met inclusion criteria. Forty-seven patients (49.5%) underwent total laryngectomy in the salvage setting. Primary closure was used in 36 patients (37.9%). Reconstruction with tissue transfer was used in 59 cases including  ALT (N=33), RFFF (N=4), pectoralis major flap (N=18). There was no difference in EAT-10 scores between the two groups (p=0.498). There was a significant difference in FOIS level, with a higher proportion of patients achieving oral diet (FOIS > 3) with primary closure (p=0.01). Patients undergoing free flap reconstruction had significantly longer PTT compared to primary closure or pectoralis overlay (4.12 sec v 1.93 sec; p=0.009).

Conclusions: While free flap reconstruction is often necessary to prevent complications after total laryngectomy, when primary closure is achievable, these results suggest improved swallowing outcomes with better tolerance of oral diet and shorter pharyngeal transit times.