Plastic reconstructive surgeries involving flap reconstruction and microvascular anastomosis are technically demanding. Comorbidities such as diabetes, arterial insufficiency, anaemia and immunosuppression are common and increase the risk of ischaemia/reperfusion injury and vascular thrombosis. The anaesthetic goals are optimizing flap perfusion, improving flap survival and facilitating patients’ recovery. Intraoperatively, haemodynamic stability is maintained with goal-directed fluid therapy and judicious use of vasopressors. To minimize vasoconstriction, measures to maintain normothermia, adequate analgesia, sympatholytic regional anaesthesia and anti-emetic prophylaxis are employed. Prophylaxis for systemic venous thromboembolism and anastomotic thrombosis can be achieved with low-molecular-weight or unfractionated heparin and/or aspirin. Protocol-driven postoperative care with flap perfusion monitoring can reduce complications and facilitate recovery.