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The scapular osteocutaneous flap can be used for the reconstruction of a variety of head and neck defects. In this study, we describe use of the reverse-flow scapular osteocutaneous flap in the setting of a vessel-depleted neck.A retrospective review of patients who underwent scapular osteocutaneous free flap reconstruction over a 5-year period revealed 3 patients who underwent reverse-flow osteocutaneous scapular flaps. Indications for surgery included a large recurrent desmoid tumor of the mandible, recurrent alveolar ridge carcinoma, and osteoradionecrosis. All patients had a history of neck dissection and radiotherapy. Exploration of the contralateral neck was required to identify recipient vessels in all cases. Arterial and venous anastomoses were performed to the distal end of the thoracodorsal artery and subscapular vein, respectively, and no vein grafts were required. There were no cases of flap failures or donor site complications.This series demonstrates the safety and efficacy of the reverse flow osteocutaneous flap for complex mandibular reconstruction in cases where recipient vessels are limited.