Complications of total laryngectomy can have serious implications for the final outcome of treatment, including pharyngocutaneous fistula. We conducted a retrospective study of surgical techniques to determine how to best prevent or decrease the incidence of pharyngocutaneous fistula following total laryngectomy. We reviewed the hospital records of all patients who had undergone total laryngectomy for laryngeal carcinoma at Ghaem Hospital in Mashhad, Iran, from March 1989 through February 2005. We identified 88 such patients-80 men and 8 women. We divided this cohort into two groups according to the type of pharyngeal defect closure they received. A total of 37 patients-31 men and 6 women (mean age: 61.4 ± 5.9 yr) underwent primary closure along with a sternocleidomastoid muscle (SCMM) flap (flap group). The other 51 patients-49 men and 2 women (mean age: 61.3 ± 4.4 yr)-underwent standard primary closure without creation of an SCMM flap (nonflap group). Overall, postoperative pharyngocutaneous fistula occurred in 9 of the 88 patients (10.2%)-1 case in the flap group (2.7%) and 8 cases in the nonflap group (15.7%). The difference between the two groups was statistically significant (p < 0.001; odds ratio = 0.612, 95% confidence interval = 0.451 to 0.832), independent of other factors. We found no correlation between fistula development and age (p = 0.073), sex (p = 0.065), or tumor location (p = 0.435). Likewise, we found no correlation between tumor location and either sex (p = 0.140) or age (p = 0.241). We conclude that including an SCMM flap in the surgical process would significantly decrease the development of fistula, regardless of age, sex, and tumor site.