Placement of voice prosthesis at the time of trachea-oesophageal puncture is well described using 20-French prostheses. There is debate about the optimal size of the prosthesis with work in the 1980s and 1990s supporting larger prostheses. The rationale was that larger size allowed greater airflow. However, as treatment of laryngeal malignancy has moved towards organ preservation protocols involving chemo-radiation, significant detrimental effects at the puncture site have manifested after salvage laryngectomy as widening fistula tracts. Therefore, there is a theoretical benefit in using a narrower gauge prosthesis initially, preserving the ability to upsize at a later date if required. This paper from Dr Deschler’s team at the Mass Eye & Ear Infirmary reports on 21 cases where a 16Fr transoesophageal voice prosthesis was placed using a secondary puncture technique (Blom-Singer tracheo-esophageal puncture kit) two out of three of the procedures were performed after salvage laryngectomy. Median time from laryngectomy to puncture was 5.1 months (range 1.6-178.6 months). In 100% of cases, the prosthesis was placed successfully. Voice fluency, as assessed by a speech and language pathologist was assessed and rated on a four point scale with the top two tiers being regarded as ‘fluent’ speech. Fluent speech was achieved in 85.7% with a median time to fluent speech of 18.5 days. Postoperative complications are comparable to larger prosthesis with a leak through the prosthesis reported in 14.3%. This paper shows, in a small cohort, that using a smaller gauge prosthesis gives good voice rehabilitation results and has low rates of complications attributable to the prosthesis itself.