Otolaryngologic flap reconstructive surgery, while lengthy, risky and complex, can be performed with a high degree of safety. Flaps can be categorized based on their blood supply. For head and neck surgery patients, a group of patients have been well characterized as gaining the most benefit from free flap reconstructions. The anesthetic management includes careful planning of difficult airway issues such as tracheostomy if the airway is compromised, considerations to positioning, understanding of surgical sites, choice of intraoperative monitoring, considerations related to the length of surgery and thermoregulation, flap perfusion considerations, planning postoperative care and level of care. This is in addition to considerations related to coexisting morbidities in this elderly population, who commonly present with tobacco and alcohol abuse. Clear communication with otolaryngology colleagues will help greatly for proper planning and execution of these considerations, helping to ensure a favorable outcome.