Background <p>Free tissue transfer is considered the gold standard for tongue reconstruction; however, no consensus exists regarding reconstructive strategies. The aim of this study is to identify predictors of early and late complications and analyse evolution of free flap selection in microsurgical tongue reconstruction.</p> Methods <p>A retrospective analysis of 126 consecutive patients undergoing microsurgical tongue reconstruction between 1986 and 2022 was conducted. For each patient, data regarding the defect, reconstructive strategy, and complications were recorded and patients stratified accordingly. Statistical analysis, including multivariate logistic regression, was conducted to identify predictors of complications.</p> Results <p>A high overall complication rate was observed, with only 33% of patients healing uneventfully. The radial forearm flap showed low early but higher late complication rates, whereas the anterolateral thigh flap had fair early and late complication rates despite its dimensions. The osteocutaneous fibula (OCF) flap exhibited high overall and flap-related complication rates, although the majority of these were minor. Larger flap size (<i>p</i> = 0.047), mandibulectomy (<i>p</i> = 0.019), and procedural time (<i>p</i> = 0.023) were significant predictors of complications.</p> Conclusions <p>Based on our findings, reducing operative times and standardising surgical strategies may be important to limit complications and improving outcomes in tongue reconstruction. The extent of resection should be reasonable and optimised with precise surgical planning and neoadjuvant therapy. The RFF is recommended for small defects, the ALT flap for larger defects, and the OCF flap for cases involving associated bone reconstruction.</p> <p> Level of Evidence: Level III, therapeutic study</p>