OBJECTIVE To review the outcome and incidence of perioperative complications in patients undergoing microvascular free flaps for reconstruction of the head and neck region. METHODS A prospective case series. METHODS An academic tertiary care otolaryngology-head and neck surgery program. METHODS One hundred fifteen patients who underwent 119 consecutive free flaps performed by 1 surgeon during a 32-month period. METHODS Reconstruction primarily by means of radial forearm, fibula, and rectus abdominis flaps (95% of the flaps selected for reconstruction). METHODS The incidence of perioperative reconstructive and medical complications. RESULTS There was 1 perioperative death (0.8%). Among the surviving patients, there was 1 case of complete flap failure, resulting in an overall flap survival of 99.2%. There were 2 additional cases (1.8%) of partial flap necrosis. Perioperative reconstructive complications occurred during 10.1% of the hospitalizations, half of which required additional surgical intervention. Notable perioperative medical complications occurred in 17.1% of the patients. CONCLUSIONS Despite their reliance on small-vessel anastomoses for survival, free flaps are extremely reliable with regard to the incidence of flap necrosis, which contributes to a low incidence of perioperative complications. Selection of flaps that have proven dependability contributes to a successful outcome. While this technique frequently requires lengthy surgery in an elderly patient population, the perioperative mortality) and morbidity are acceptable. Because of their unsurpassed reliability, free flaps have become the preferred method of reconstruction for most patients with major defects in the head and neck region.