The flat tip of an optical fiber is a unique and unconventional platform for micro and nanotechnologies. The small cross-section and large aspect ratio of the fiber provide an inherently light-coupled substrate that is uniquely suited to remote, in vivo and in situ applications. However, these same characteristics challenge established fabrication technologies, which are best suited to large planar substrates. This review presents a broad overview of strategies for patterning the flat tip of an optical fiber. Techniques discussed include self-assembly, numerous lithographies, through-fiber patterning, hybrid techniques, and strategies for mass manufacture, while the diverse applications are discussed in context throughout.