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Free tissue transfer has become a safe and reliable means for repairing soft tissue and bony defects of the head and neck region. Although the success rate is high, the incidence of postoperative complications is common. One significant complication is postoperative hematoma formation. However, few published studies have addressed its incidence, etiology, or outcome. We performed a retrospective analysis to investigate this issue.A retrospective review was conducted of 293 consecutive microvascular free tissue transfers in the head and neck region in a single institute from January 2013 to December 2015. Patients with postoperative hematoma were identified, and demographic data, perioperative conditions, medications, and outcomes were evaluated by chart review.A total of 34 patients (11.8%) had postoperative hematoma. Compared with the patients without hematoma, this group had a longer hospital stay (P = 0.06) and required more secondary procedures (P = 0.001). The use of nonsteroidal anti-inflammatory drugs (NSAIDs; P < 0.001) was associated with a higher incidence of hematoma formation. Among the 34 patients with hematoma, 16 (47.1%) had flap compromise and underwent emergent reexploration. The salvage rate was higher than that in the nonhematoma group (87.5% vs 59.3%, P = 0.086).Postoperative hematoma after head and neck microvascular reconstruction is not a rare complication and may lead to poor outcome and more complications. The avoidance of NSAIDs preoperatively may prevent hematoma formation. Surgeons should be alert to this situation, and immediate return to the operative room for hematoma evacuation is necessary. Early intervention may contribute to a high salvage rate.