Postoperative pulmonary complications (PPC) following major head and neck surgery are frequently encountered. Indeed, surgery in the head and neck area itself has been identified as a risk factor for these complications. Microvascular reconstruction is a widely accepted and proven technique, while it is operator dependent; it is always a major undertaking for patients and the medical team. Postoperative complication were increase hospital stay, morbidity and mortality. This is an excellent study looking retrospectively at 648 patients that underwent free flap reconstruction in a university hospital in Germany. The authors sought to identify diseases of the respiratory system that affected the postoperative clinical course of the patient. There were some interesting outcomes. As expected, male gender, alcohol use, an ASA score greater than 2 and older patients (greater than 70)+, were more likely to develop PPC. Higher BMI, pre-existing hypertension, and surgery lasting greater than 500 minutes were at higher risk. Patients that had tracheostomies and patients that received more intraoperative fluids were at higher risk. An intraoperative transfusion of blood or of blood products too raised the incidence. With the advent of the perforator flaps and more advanced super micro surgery, more complex reconstruction is being undertaken. The perforator flaps can be more time-consuming to raise and I think this be should be considered and other factors that increase the timing of the surgery. This is a fascinating paper; it is well written and clearly set out. The study is a retrospective one but still worth reading and helps to identify patients with higher risk of developing PPC. It is also certainly worth bringing this paper to the attention of the anaesthetists and internist that help in the care of these patients.