Open repair of aneurysms and dissections involving the aortic arch has traditionally been associated with high rates of morbidity and mortality, primarily because of the complications related to the need to interrupt normal blood flow to the cerebral circulation. Over the past several years, our approach to these operations has gradually changed largely through the introduction of various techniques aimed at reducing the risk of neurologic complications. Key technical changes have included the shift from using retrograde cerebral perfusion to using antegrade cerebral perfusion, the introduction of axillary artery perfusion, and the change from using the patch technique to using the Y-graft technique to reattach the brachiocephalic branches. By using this combination of techniques, surgeons can perform aortic arch replacement with excellent early outcomes. In this update, we summarize the evolution of our surgical techniques and perfusion strategies for performing open repair of the aortic arch.