The internal jugular vein has been the preferred recipient vein in head and neck microsurgical reconstruction. However, recent reports have demonstrated internal jugular vein occlusion after functional neck dissection. The purpose of this article is to demonstrate and discuss the possibility of recipient internal jugular vein occlusion after free tissue transfer. Of 58 patients who received an end-to-side venous anastomosis with the internal jugular vein, four cases of recipient internal jugular vein occlusion were detected during the early postoperative period. Although the success rate of end-to-side anastomosis with the internal jugular vein may be high, microsurgeons should be aware of the possibility of internal jugular vein occlusion.