Background A pectoralis major flap is one of the standard tools for the reconstruction of defects of the head and neck. Despite the technical advancement in free tissue transfer in head and neck reconstruction, the benefits of a pectoralis major flap should not be overlooked. The purpose of this study is to evaluate our 17 years of experience in reconstructing defects of the head and neck region using the pectoralis major flap. Methods We retrospectively reviewed the medical records of 112 patients (120 cases) who underwent pectoralis major flap operations for head and neck reconstruction during a period ranging from 1994 to 2010. Results In our series, no total necrosis of the flap occurred. Of the total cases, 30.8% presented with flap-related complications. Major complications occurred in 20% of all of the cases but were then all successfully treated. The male sex was correlated with the occurrence of overall complications (P=0.020) and major complications (P=0.007). Preoperative albumin levels of <3.8 g/dL were correlated with the formation of fistula (P=0.030). Defects of the hypopharynx were correlated with the occurrence of major complications (P=0.019) and the formation of fistula (P=0.012). Secondary reconstructions were correlated with the occurrence of overall complications (P=0.013) and the formation of fistula (P=0.030). Conclusions A pectoralis major flap is still considered to be a safe, versatile one-stage reconstruction procedure in the management of the defects of head and neck and the protection of the carotid artery.