The free rectus abdominis musculocutaneous (RAMC) flap is one of the most favored flaps for reconstructive surgeries because of fewer anatomical variations and easy and safe flap elevation. A vertically-designed RAMC flap is usually harvested with a pair of inferior epigastric artery and vein for head and neck reconstruction. Congestive complications of an RAMC flap are rarely seen with the ordinal method of flap harvest. We have experienced three cases of flap congestion during flap elevation in the last nine years. In case 1, the elevated RAMC flap with engorgement of the superficial inferior epigastric vein was salvaged with super drainage venous anastomosis. In case 2, the flap could not be salvaged and required replacement with an anterolateral thigh flap. In case 3, although the flap was transferred without additional procedure, partial necrosis of the flap developed postoperatively. Flap congestion can develop even in one of the safest flaps for various reasons. It is important to take occasional RAMC flap congestion into consideration to avoid further complications.
