Background The purpose of this study was to determine whether free flap volume decreases or increases in the long-term postoperative period. Methods We used a retrospective analysis of 17 patients to measure muscle and fat volume in free flap with 3-dimensional (3D) images using the AZE Virtual Place Lexus64. Results Seventeen patients underwent free flap reconstruction with rectus abdominis musculocutaneous flaps (n = 11) or anterolateral thigh flaps (n = 6). Median follow-up was 28.9 months (range, 2.148.4 months). Total flap volume was significantly decreased in flaps including =40% muscle (p = .011). Mean final muscle volume was 50% at an average of 12 months. Final fat volume was significantly higher for cases with no evidence of disease (mean, 116.7%) than for died-of-the-disease cases (mean, 70.3%; p = .007). Conclusion Use of free flaps with a high ratio of fat to muscle is sustainable and can gain volume over time, as transplanted fat can increase depending on host condition. (c) 2011 Wiley Periodicals, Inc. Head Neck, 2011