Despite advances in head and neck reconstruction with free tissue transfer techniques oropharyngocutaneous fistulas continue to present challenging and potentially lethal complications. We present a classification system for these fistulas and the management of nine patients who developed critical oropharyngocutaneous fistulas after microsurgical head and neck reconstructions following tumor extirpation or injury from corrosive agents. Our indications for the management of the fistulas were primarily dependent on their specific location. Three peristomal (Type I) and six midneck (Type II) fistulas were considered critical due to their risk of aspiration pneumonia and carotid artery blow-out, respectively. Using the concept of a "tissue-plug" for fistula repair, a dermal component of either a deltopectoral (5) or pectoralis major (4) pedicled flap is guided through the fistula with an appropriately sized gallstone dilator and used to "plug" the tract both internally and externally. Traction is placed on the internal dermal component by way of a non-absorbable suture and tied over an external bolster with no sutures placed directly in the surrounding friable tissue. There were no partial or total flap losses. There were two fistulas recurrences in patients who had received postoperative radiation therapy. One of the fistula recurrences was felt to be due to tumor recurrence within the previous fistula. All patients resumed oral feeding except for the patient with suspected tumor recurrence. We conclude that using the tissue-plug technique in the management of critical oropharyngocutaneous fistulas serves not only to effectively obliterate the tract but also to augment vascularity and volume in already damaged, ischemic, and deficient tissues.