PURPOSE: Defect after ablation of hypopharyngeal cancer often requires reconstruction by free tissue transfer. Since neo-hypopharynx is totally buried, various methods have been suggested for monitoring. We propose a modified design of anterolateral thigh (ALT) free flap for reconstruction of pharyngolaryngectomy defect, which has an exteriorized part for clinical monitoring and allows for primary closure. MATERIALS AND METHODS: Three consecutive patients with hypopharyngeal cancer were reconstructed with ALT flap with modified design: 1) distal part of flap was elongated into fusiform shape and used as exteriorized monitoring segment with a deepithelized bridge and 2) proximal part was designed as curve so the maximum width of the flap was reduced to less than 10 cm. RESULTS: Patient 1, 2 had uneventful postoperative course with healthy skin color and fresh pin prick bleeding. In patient 3, defect after cancer ablation was shorter than usual and deepithelized bridge was longer. When the general hemodynamic status of the patient was aggravated in postoperative course, the color of monitoring skin was changed. Viability of the whole flap was confirmed by endoscopy. However, leakage developed after 3 weeks and repair was necessary. In all patients the donor sites were closed primarily. CONCLUSION: By the modified design of ALT flap, clinical monitoring can be possible by examining exteriorized monitoring flap and also donor site can be closed primarily. However possibility of false positive exists and technical caution and patient selection is needed because of danger of leakage.