Despite advances in hypopharyngeal reconstruction with free tissue transfer, pharyngocutaneous fistulae occur with an incidence of thirty-five percent; radiation therapy and neck dissection increase the incidence. While two-thirds will close with conservative management, larger fistulae in irradiated fields require surgical treatment to prevent carotid artery rupture. Free tissue transfer is difficult in the re-operated, previously reconstructed, irradiated neck where recipient vessels are scarce. Herein we report a novel technique where a pectoralis major myocutaneous flap with two skin islands is used to reconstruct a pharyngocutaneous fistula. One skin paddle was used to reconstruct the anterior esophageal wall, and the second paddle provided closure of the cutaneous defect. At nine months of follow-up the fistula has not recurred, all of his intake is via the oral cavity, and he has experienced an eleven pound weight gain.