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Method of direct clinical monitoring of tissue perfusion in free tissue reconstruction of pharyngeal defects.To describe a novel and effective method of incorporating a cutaneous skin paddle into laryngopharyngectomy reconstruction for direct clinical monitoring of anterolateral thigh free flaps.Retrospective review of pharyngoesophageal reconstruction for laryngopharyngectomy defects performed between August 1, 2008, and March 1, 2011, using the anterolateral thigh flap.Tertiary care academic medical center.Consecutive patients undergoing laryngopharyngectomy where free tissue transfer is indicated.Anterolateral thigh free flap reconstruction with suprastomal cutaneous monitoring paddle.Postoperative complications, including flap failure, fistula, and stricture. Postoperative functional outcomes of swallowing and vocal capability were also measured.Twenty-one patients (mean age, 62.2 years; range, 39-81 years) underwent total laryngectomy with near-total or total pharyngectomy and immediate reconstruction with an anterolateral thigh free flap. The reconstructions included a cutaneous monitor paddle distal to the pharyngoesophageal anastomosis. Twenty patients were treated for squamous cell carcinoma and received either adjuvant or neoadjuvant radiation therapy. There were no partial or total flap losses. A late pharyngocutaneous fistula occurred at 6 weeks in 1 patient (5%), requiring exploration, and anastomotic stricture occurred in 4 patients (19%). All patients except 1 were able to swallow solid foods at a mean follow-up of 11.1 months. Nineteen patients (90%) underwent tracheoesophageal puncture and attained an intelligible voice. One patient (5%) had stomal stenosis requiring surgical management.The suprastomal cutaneous monitoring paddle enables direct monitoring of an otherwise buried reconstructive flap. This method allows direct clinical observation for microvascular compromise without a need for further procedures and without any increase in morbidity or compromise of speech and swallow functions.4.