Flap-related complications in lamellar refractive surgery, particularly thin, irregular, and buttonhole variants, present unique intraoperative challenges despite technological advancements. While femtosecond lasers have significantly reduced their occurrence (0% in recent studies versus 0.06–2.6% with microkeratomes), these complications demand careful management due to their potential impact on visual outcomes. Key risk factors include steep corneas (>46.00 D), intraoperative suction loss, and preexisting corneal pathology, with buttonholes often manifesting as central epithelial “islands” and thin flaps showing irregular stromal dissection patterns. Prevention strategies emphasize surgical precision: maintaining optimal suction, corneal lubrication, and avoiding ultrathin flaps (<100 μm). The real-time visualization capabilities of femtosecond lasers allow early detection of gas breakthrough or opaque bubble layers, enabling timely intervention. When encountered, the gold-standard approach involves immediate procedure termination, flap repositioning without manipulation, and postponing ablation. Subsequent treatment options include delayed PRK or repeat LASIK after 3–6 months, which demonstrate superior outcomes compared to immediate enhancement attempts on compromised flaps. This chapter underscores the importance of preoperative risk assessment, intraoperative vigilance, and conservative management. Ongoing refinements in laser precision and flap monitoring promise to further enhance procedural safety while maintaining the efficacy of refractive corrections.