Purpose of Review <p>Immune checkpoint inhibitors have transformed management of recurrent and metastatic head and neck squamous cell carcinoma. As immunotherapy becomes increasingly incorporated into treatment algorithms, surgeons encounter a growing population requiring salvage surgery after prior immunotherapy exposure. This review examines reconstructive considerations and proposes an evidence-informed framework for perioperative decision-making.</p> Recent Findings <p>Salvage reconstruction morbidity is driven primarily by radiation-induced tissue injury, malnutrition, and defect complexity. High-quality evidence supports vascularized tissue (particularly onlay techniques) for reducing pharyngocutaneous fistula after salvage laryngectomy. Emerging neoadjuvant and adjuvant immunotherapy data suggest checkpoint inhibitor exposure does not reproduce the fibrotic or obliterative vascular injury characteristic of radiation therapy. Direct data addressing salvage surgery after immunotherapy failure remain limited.</p> Summary <p>Reconstruction after salvage surgery in immunotherapy-exposed patients should prioritize established salvage principles while incorporating immunotherapy specificconsiderations including immune-related adverse events and nutritional optimization. This review synthesizes current evidence and identifies critical gaps requiring prospective investigation. </p>