Reconstruction after extensive resection of the tongue remains a surgical challenge. Free soft-tissue transfer is now favored for head and neck reconstruction following cancer resection. However, the choice of either free tissue transfer (FTT) or of the pedicled Pectoralis Major Musculocutaneous Flap (PMMF), the workhorse in head and neck reconstruction, remains controversial. The purpose of this study is to assess the post-operative outcomes after radical ablative surgery and reconstruction for patients with a tongue cancer. We conducted a retrospective comparison of two different reconstruction techniques. From January 2000 to December 2006, 70 consecutive patients with tongue cancer had been treated with curative intent by extensive ablative surgery and soft-tissue reconstruction. Sixty percent of tumors were T3 or T4. We compared the post-operative outcomes of both populations: 25 patients underwent FTT and 45 underwent pedicled PMMF. Fifty-seven men and 13 women with a mean age of 55 years constitute the study population. The two groups were comparable in terms of age, gender, and addiction. The choice of flap technique was independent of the ASA scale (p=1.00), the weight of comorbidities (p=0.13), previous radiation therapy (p=0.09), the T-stage (p=0.44) or N-stage (p=0.21). Apart from the rate of flap necrosis, which occurred significantly more often in the PMMF group (p=0.02), post-operative complication rates did not differ between the two groups. The success rate of FTT was 96% (24/25). The duration of the post-operative stay was longer after use of the pedicled flap technique, but the difference did not reach statistical significance (mean duration in days: 23.2 vs. 18.1; p=0.10). Both groups did not differ as regards duration of use of a feeding tube (p=0.84) or of tracheostomy (p=0.54). Local disease-free survival was also similar (p=0.65). The two groups were similar in terms of patients' characteristics. The reliability of free flaps was higher than that of PMMF. The assessment of our practice in the case of extensive tongue defect suggests that reconstruction with free soft-tissue transfer, whenever feasible, should be the first-choice treatment option.