We describe a novel technique for closure of a large, persistent, pediatric tracheocutaneous fistula using a thyroid ala cartilage graft. Case report and review of the literature. We report 2 cases of large (>4mm), pediatric tracheocutaneous fistulas, in which primary closure of the tracheal defect would have caused critical airway narrowing and were managed with an anterior laryngotracheal reconstruction with a thyroid ala cartilage graft and closure of the tracheocutaneous fistula. The patients were extubated immediately postoperatively and maintained successfully closed fistulas with no clinically significant airway compromise. One of the considerations in pediatric tracheocutaneous fistula closure is to assess how the airway luminal diameter will be affected by primary closure of the tracheal defect. If primary closure of the tracheal opening causes critical airway narrowing because of a large tracheocutaneous fistula, a thyroid ala cartilage graft may be used for laryngotracheoplasty and allow for primary closure with a layered closure of the overlying strap muscles and soft tissue.