Free-flap reconstruction after total circular pharyngolaryngectomy aims to restore swallowing and phonation. However, functional outcomes vary depending on type of flap and surgical technique, and no consensus recommendations currently exist.

A systematic review was conducted following PRISMA guidelines. Studies reporting functional outcomes for swallowing and/or phonation after total circular pharyngolaryngectomy reconstructed with free flaps were included. Data were synthesized descriptively, as methodological heterogeneity precluded meta-analysis.

Seventy-one studies, for more than 3800 patients, were analyzed. The mean rate of functional swallowing was 87%, and was higher with digestive flaps (JFF, ICFF, GOFF). Voice recovery averaged 60%, with higher rates for flaps incorporating a phonatory tube or shunt (RFFPT, ICFF, JFF with shunt). Fasciocutaneous flaps (ALT, RFF) provided satisfactory functional outcomes for both swallowing and phonation.

Digestive flaps appeared to be preferable for optimizing swallowing, whereas techniques incorporating a phonatory shunt improved voice recovery at the cost of a more complex procedure. Fasciocutaneous flaps provided a good trade-off for swallowing and voice quality. The heterogeneity of the studies and lack of standardization limited the strength of the recommendations. Multicenter prospective studies are needed to confirm these findings.