Technical Refinements of the J-Shaped Anterolateral Thigh Flap for Voice Reconstruction After Total Laryngopharyngectomy

Background Total laryngopharyngectomy (TLP) results in the loss of natural voice and requires complex reconstruction of the pharyngoesophageal tract. The J-shaped anterolateral thigh flap (J-flap) has been proposed as a reconstructive option that allows simultaneous restoration of swallowing and phonation. However, detailed technical considerations influencing functional outcomes have rarely been reported. This study reports our clinical experience and technical refinements aimed at improving functional outcomes. Methods A retrospective review was performed of patients who underwent TLP reconstruction using a J-flap between February 2019 and September 2025. Surgical design modifications, postoperative complications, and phonatory outcomes were analyzed. Voice quality was evaluated using the GRBAS scale based on recorded voice samples. Results Twenty-five consecutive patients underwent reconstruction using a J-flap. All flaps survived without microvascular thrombosis. Partial flap necrosis occurred in five patients (20%). Initial phonation was achieved in 19 patients (76%). Postoperative stenosis of the phonatory tube occurred in eight patients following adjuvant radiotherapy. Sixteen patients were available for voice assessment, among whom 12 (75%) were able to count from 1 to 10 using a single breath. Seven patients (44%) achieved grade 1 voice quality sufficient for daily communication. Mean GRBAS scores were 1.5 for roughness and 1.9, 2.1, and 1.8 for breathiness, asthenia, and strain, respectively. Conclusion The J-shaped ALT flap represents a feasible option for simultaneous reconstruction of the esophagus and voice after total laryngopharyngectomy. Technical refinements in flap design and tracheostoma integration may improve phonatory success and reduce postoperative complications.