Introduction: The selection of suitable recipient vessels for microvascular reconstruction of the head and neck region is important for flap survival. The purpose of this study is to evaluate a set of factors related to the recipient artery and vein and to determine how these factors influence flap survival. Materials and Methods: This is a retrospective review of 82 patients over a 4-year consecutive period. Included were 56 men and 26 women with a mean age of 54 years (range: 10 to 85 years). Indications for microvascular reconstruction included tumor ablation (n=59), trauma (n=12), and other (n=11). Flaps included the latissimus dorsi (n=21), radial forearm (n=18), rectus abdominis (n=15), fibula (n=10), parascapular (n=6), lateral arm (n=5), and other (n=7). Recipient arteries included the facial (n=30), superficial temporal (n=19), superior thyroid (n=17), carotid (n=5) and other (n=11). Recipient veins included the jugular system (n=30), facial (n=24), superficial temporal (n=19), superior thyroid (n=6), and other (n=3). Factors considered relevant to the vessels were analyzed and included: diabetes mellitus, tobacco use (> 10 cigarettes/day), prior irradiation, timing of the reconstruction, use of a vein loop or graft, and type of vascular anastomosis. Statistical analysis was performed with logistic regression analysis. Results: Factor analysis demonstrated diabetes mellitus in 7 (8.5%), tobacco use in 18 (22%), immediate reconstruction in 62 (76%), delayed reconstruction in 20 (24%), vein loop in 6 (7%), and vein graft in 2 (2.4%). The arterial anastomosis was end to end in 77 (94%) and end to side in 5 (6%). The venous anastomosis was end to end in 71 (86%) and end to side in 11 (14%). Total flap survival was obtained in 77 of 82 (94%). Flap loss was due to venous thrombosis in 4 and arterial thrombosis in 1. Statistical analysis demonstrated that anastomotic failure was associated with a vein loop (2 of 5, p=0.03), venous end to side (1 of 5, p=0.004), and tobacco use (3 of 5, p=0.03). Anastomotic failure was not related to diabetes mellitus, previous irradiation, method of arterial anastomosis, and timing of reconstruction. Conclusions: Flap failure in the head and neck may be minimized by use of vein grafts when pedicle length is insufficient. Vein loops are associated with increased failure. Patency of the venous anastomosis in increased when end to end rather than end to side. Tobacco use should be avoided prior to microvascular reconstruction of the head and neck.