Objectives <p>Maxillofacial reconstruction using microvascular free flaps is a well-established procedure to restore facial defects across various patients. Elderly patients face increased perioperative risks due to higher prevalence of comorbidities. This study aims to evaluate the characteristics of patients aged ≥ 75 years and assess the impact of advanced age on outcomes in microvascular free flap reconstruction for head and neck defects.</p> Methods <p>A retrospective analysis was conducted on patients who underwent microvascular free flap head and neck reconstruction between April 2017 and July 2023. After matching, patients aged ≥ 75 were compared to those &lt; 75 years regarding comorbidities, surgical and treatment variables, complication rates and outcomes. Multivariate models were developed to test the influence of age on flap complications.</p> Results <p>1050 patients met the inclusion criteria. 290 patients (28%) were ≥ 75 years old. Following case matching, 580 patients (276 females, mean age 74.1 ± 8.9 years) were included in the analysis. Patients ≥ 75 years had higher rates of comorbidities, co-medications and postoperative delirium. No significant differences were observed in flap complications between both groups in univariate analysis. Although one multivariate model suggested a potential non-linear effect of age on flap complications, this was not validated in another model.</p> Conclusions <p>Despite the increased prevalence of comorbidities and perioperative risk factors, microvascular free flap reconstruction remains a safe and viable procedure for elderly patients when performed in a structured setting at a high-volume center, as complication rates do not appear to be directly influenced by age.</p> Clinical relevance <p>Free Flap surgery is a safe procedure in elderly patients.</p>