BACKGROUND Our aim in this retrospective case series was to review the indications, results, and complications of abdominal muscle-sparing free flaps in head and neck cancer reconstruction. METHODS A retrospective review of all head and neck cancer defects reconstructed with abdominal muscle-sparing free tissue transfers from 1999 to 2004 was performed. Data collected included patient demographics, etiology and site of the defect, reconstructive technique, flap size, recipient vessels, complications, reconstructive technique, and clinical follow-up. RESULTS Sixteen patients underwent reconstruction with the deep inferior epigastric perforator (DIEP) flap (n = 11), the superficial inferior epigastric artery (SIEA) flap (n = 4), or the superficial circumflex iliac artery (SCIA) flap (n = 1). Average age was 61 years (range, 41-77 years). The average hospital stay was 7.6 days (range, 6-14 days). The average defect size was 74.5 cm(2) (range, 30-240 cm(2)). No subsequent abdominal wall hernias or other donor site complications occurred after a mean follow-up of 21 months. CONCLUSIONS Muscle-sparing abdominal free flaps are attractive options for head and neck cancer reconstruction. The SIEA and SCIA free flaps have the distinct advantage of eliminating abdominal hernias and other morbidity related to the excision of rectus abdominus fascia or muscle. In addition, the incisions are very low on the abdomen and are more cosmetically pleasing to the patient.