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PURPOSE/OBJECTIVE:Complex posterior defects often present significant reconstructive challenges, particularly due to the scarcity of suitable recipient vessels. In these cases, an arterialized saphenous vein transfer can facilitate flap perfusion when direct anastomosis is not feasible. This study presents our institutional experience using an arterialized saphenous vein transfer for microvascular free flap (MVFF) reconstruction of posterior defects. METHODS:We retrospectively reviewed consecutive patients who underwent posterior MVFF reconstruction using an arterialized saphenous vein transfer. Patient demographics, comorbidities, defect etiologies (including trauma, silicone injection, malignancy, and congenital abnormalities), flap types, and perioperative outcomes were collected through manual chart review. RESULTS:(±73). Arterialized saphenous vein transfer arterial inflow sources included the descending branch of the lateral femoral circumflex artery (n = 6), deep inferior epigastric artery (n = 1), and transverse branch of the superficial femoral artery (n = 1). Average operative time was 11:00 h (±2:50); median hospital stay was 12 days (range: 6-76). There were no flap losses. One patient required two flap explorations; two patients required postoperative blood transfusions. At a mean follow-up of 1247 days (±393), all flaps had healed, including persistent minor wounds in the two silicone injection cases. CONCLUSIONS:Arterialized saphenous vein transfers enabled durable, successful MVFF reconstruction in complex posterior defects and represent a reliable option in anatomically challenging scenarios.