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No sponsorships or competing interests have been disclosed for this article. Objective. Assess the efficacy of free flap reconstruction per-formed at a low-volume program and evaluate how volume and outcomes have changed over 20 years. Study Design. Case series with chart review. Setting. Tertiary academic medical center. Subjects and Methods. A retrospective chart review was per-formed at a tertiary care academic program on all free tissue flaps from the primary reconstructive surgeon over 20 years (1993-2013). In total, 136 procedures were obtained from operative notes, billing codes, and chart data-bases. Outcome variables included procedure success and complications. Patients stayed in general intensive care unit and hospital floor units. Results. Flap success was 92.6 % of all cases. In the past 13 years, 70 flaps were performed with 3 failures (96 % suc-cess rate). Take-back rate was 16 % of total cases with a flap recovery rate of 60%. Postoperative failure occurred after 72 hours in 60 % of cases. Nearly 60 % of patients experienced a complication of any type or severity. Twenty percent had a flap complication while maintaining viability, with half of these being partial dehiscence. Systemic complications affected 20 % of all cases. The average hospital stay for noncomplicated patients was 13 days. There was 1 postoperative mortality. Fibula and radial forearm were the most common flaps at 44 % and 26%, respectively. Conclusion. Free flap reconstruction of the head and neck can be performed by appropriately skilled surgeons with acceptable outcomes in low-volume settings. Success rate appears to increase as clinical experience is gained