Chemoradiation (CRT) has become the mainstay for locally advanced laryngeal cancer since the RTOG 91-11 trial. Unfortunately there is still a substantial demand for salvage laryngectomies, which have a higher complication rate, the most notable being pharyngocutaneous fistula (PCF). Several small studies have suggested that using vascularised tissue from outside the radiation field reduces the risk of PCF; this systematic review aims to identify evidence for this. The authors are a distinguished international group, who have carried out a vigorous systematic review. The search strategy is clearly described; inclusion criteria and excluded studies are clearly detailed. The outcome considered, the presence or absence of PCF, is not subject to bias. Ultimately seven articles (591 patients) made the grade and were included in the analysis. The PCF incidence was 31.2% in the primary closure group compared with 22.2% in the flap reconstruction group. PCF carries a significant morbidity, increases hospital stay and may lead to death. The reduction of the incidence by one-third is a significant finding; this paper is essential reading for all head and neck surgeons and should inform future practice in salvage total laryngectomy.