Background: Australia has played a disproportionately large role in the evolution of microsurgical reconstruction. We reviewed the development of microvascular surgery in Australia, from early experimental work to internationally influential clinical practice and training. Methods: A narrative historical review was conducted, drawing on biographical accounts of key Australian microsurgeons and institutional histories of dedicated microsurgery centres. Thematic analysis focused on laboratory innovation, clinical translation and the creation of training pipelines. Results: In the late 1960s and early 1970s, Bernard O’Brien established a small vascular laboratory at St Vincent’s Hospital, Melbourne, which evolved into the Microsurgery Research Centre and later the Bernard O’Brien Institute of Microsurgery. This unit became a global hub for free tissue transfer, limb replantation and microvascular reconstruction, attracting trainees from multiple continents and standardising techniques that transformed limb salvage and complex head and neck reconstruction. Parallel anatomical work by Australian surgeons, particularly the angiosome concept and perforator-based flap mapping, provided the vascular framework underpinning modern flap design and safe tissue transfer in reconstructive surgery. Together, these contributions established Australia as a leader in microsurgery, influencing contemporary practice, research priorities and fellowship training worldwide. Conclusion: Australian pioneers integrated laboratory science, clinical innovation and education to drive the development of microsurgical reconstruction. Their legacy is evident in today’s routine use of free flaps, perforator flaps and complex microsurgical salvage procedures across the globe.