Total laryngectomy is still the final therapeutic solution in cases of locally advanced laryngeal cancer, as well as in cases of therapeutic failure of organ-sparing surgery or radiation therapy. Following excision of the larynx, the remaining pharynx is reconstructed to obtain continuity of the upper digestive tract. One of the most common complications in these patients, despite constant refinement of the procedure, is the development of a pharyngo-cutaneous fistula. These fistulas prolong hospital stay and often require a second surgical procedure, increasing morbidity and cost for the patient, while diminishing his quality of life. Some risk-factors have been identified, but only some may be corrected before surgery to lower this risk. Managing the fistula once present depends on multiple factors, essential being the size of the fistula as well as the position and concomitant factors, with options ranging from conservative measures to aggressive reconstructive surgery with local miocutaneous flaps. Modern vocal rehabilitation with T.E.P. (tracheo-esophageal puncture) and vocal prosthesis placement presents a new challenge – because of the risk of developing a tracheo-esophageal fistula, with an even higher risk for the patient because of tracheal aspiration. Understanding healing mechanisms of these structures is key to proper management of this complication.