In the decades since the first microvascular free-tissue transfer, a new era of soft-tissue reconstruction, innovation, and challenges has developed. The treatment of complex 3-dimensional defects in the head and neck has evolved beyond local and distant tissues to engage a surgical realm previously reserved for organ transplantation. Daniel S. Alam, MD, and colleagues present the first successful near-total face, maxilla, and palate transplant. In an operative field depleted of viable recipient vessels from the patient's initial trauma and the ensuing 23 previous reconstructive surgical procedures, the authors detail their considerations in vascular and defect analysis, allograft design, and operative approach. In addition, they highlight the joint transfer of the midfacial skeleton and soft tissues based solely on the facial arterial system in this salvage operation.