The availability and quality of recipient vessels in head and neck microvascular reconstruction is critical to the success and viability of free tissue transfers. Patients with a history of a previously treated neck with surgery, radiation, chemotherapy, or combination of these modalities often have altered cervical anatomy with adverse and sometimes extreme tissue effects. Severe fibrosis, altered tissue planes, microvascular changes, and locoregionally advanced tumors that necessitate sacrifice of key neurovascular structures may render patients’ necks depleted of suitable recipient vessels. A variety of vascular options (arterial and venous) remain available within the vessel-depleted neck (VDN) to overcome these unique and challenging scenarios and optimize chances for microvascular success.