The pectoralis major myocutaneous flap has enjoyed a long history of over 40 years utilization to reconstruct a variety of head and neck defects. Despite the attractiveness, feasibility and success rates of free tissue transfer, the role of the pectoralis major myocutaneous flap is irreplaceable in the setting of high-risk patients, the vessel-depleted neck, and in overall poor free tissue transfer surgical candidates. This chapter reviews the pertinent surgical anatomy, flap design and harvest with emphasis on mitigation of donor site morbidity when mobilizing the pectoralis major myocutaneous flap.