Microsurgical procedures for construction of anastomoses present new challenges for anesthetists in the perioperative setting. Despite their increasing importance, so far no perioperative management guidelines for these patients existed. Anesthetists can influence the success of surgery (e. g. successful perfusion of a flap) via an optimal preoperative, intraoperative and postoperative approach. Patients should be carefully evaluated preoperatively for increased risks to avoid poor postoperative outcomes. Perioperatively, the choice of anesthetic procedure as well as the management of fluid infusion, blood glucose, temperature and blood transfusion are of great importance. Adequate analgesia as well as strict control should be performed as soon as possible postoperatively, preferably in a surveillance unit to detect and treat any complications as early as possible.