Among 328 patients who underwent free flap reconstruction after excision of head and neck cancer between January 2005 and January 2010, total necrosis of flap occurred in 15 patients. The initial surgeries for primary lesions included total pharyngolaryngoesophagectomy in 7 patients, total maxillectomy in 2 patients, partial maxillectomy in 2 patients, and tumor incision by the pull-through method in 2 patients. The totally necrotized flaps included 7 free jejunum, 3 rectus abdominis musculocutaneous (RAMC) flaps, 2 anterolateral thigh flaps, and 2 fibular bone flaps. For the free jejunum, all the patients were reoperated promptly after free jejunum necrosis was observed. Free flap reconstruction was performed in 10 patients; of 6 patients who received a free flap, the graft survived in 5 patients. In the free jejunum group, there were no differences in length of hospital stay and diet consistency between those receiving free jejunum and those receiving pectoralis major musculocutaneous flap reconstruction, but endoscopic dilatation was necessary in the pectoralis major musculocutaneous flap group. Considering functional and cosmetic aspects, free flap retransplantation is desirable as a salvage strategy for total flap necrosis. When free flap reconstruction is difficult, a pedicled flap may be an option if some degree of function and cosmetic effects can be maintained.