The resection of head and neck cancer often creates multilayer defects including epithelial lining as well as soft tissue loss. While the advent of microvascular free flap methods has greatly improved reconstructive options, we are still limited in the range and nature of flaps available. The radial forearm free flap (RFFF), while providing reliable epithelial coverage, lacks bulk. Flaps such as the rectus abdominis, in contrast, offer excessive bulk and atrophy over time requiring over-correction. Defects with skin/mucosa and soft tissue loss (parotid/skin, near total glossectomy, etc) are not ideally reconstructed by either of these options. Alternative flaps such as the lateral arm flap can be used but require more tedious dissection and the use of smaller caliber, less reliable vasculature. We report here a series of 12 patients with various head and neck defects reconstructed with a RFFF with pedicled proximal forearm fat as a method of combined skin/soft tissue reconstruction. All flaps were successfully transferred with no peri-operative complications. Fifteen to 60 cc of additional soft tissue was harvested with this method. A wide range of defects including skin/soft tissue, tongue, and orbital defects were reconstructed. Adipose/soft tissue bulk was maintained at the range of our follow up (2 to 11 months). Functional and aesthetic outcomes were acceptable in all patients. The composite RFFF/vascularized fat flap provides a simple, reliable method of reconstruction of soft tissue defects in the head and neck with improved outcomes compared with that of the rectus abdominis flap and the traditional RFFF.