Oral squamous cell carcinoma is one of the more common cancers worldwide. Surgery is the mainstay of treatment and often these patients have had adjuvant therapies. In spite of improving five year survival rates, local recurrent progressive disease is still encountered. If there is no distant metastatic spread the best results are still obtained with aggressive regional resection and reconstruction. Indeed, that may be the only curative option. With the emphasis on patient rehabilitation and return of oral function, reconstruction is now most commonly achieved with microvascular free flaps. There is a definite paucity in literature regarding the outcomes in this cohort of patients with recurrent disease. The authors retrospectively analysed 32 patients that had been heavily pre-treated and had developed disease in the head and neck. All these patients had undergone at least two modalities of treatment including surgery, radiotherapy and or chemo radiation or cetuximab therapy. All 32 patients had resection and free flap reconstruction with an antero lateral thigh, fibula, radial, or a scapula free flap. All the patients recovered well, but a further 26 procedures were necessary. The most common one was unsalvageable free flap failure. Seven cases, i.e. 24.1% had free flap loss, five of these went on to further free flap reconstruction and two had a pedicled myocutaneous flap reconstruction. Complete histological excision was achieved in only 50% of the cases. Fifty percent of patients died during the follow- up period. Survival was 38% and disease free survival was 30% after 24 months. Recurrent disease was observed in 69% of cases, although histopathological margins were a significant predictor for this. This is a well written paper that confirms the difficulty in treating pretreated patients. It confirms poorer outcomes of microvascular free flaps in these patients as well. As expected the authors echo the thought that the disease processes in these patient exhibits different biological behaviour.