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The internal mammary and thoracodorsal vessels are the standard recipient sites in microsurgical breast reconstruction. We review our series of venous outflow alternatives when these vessels are inadequate or unusable.A retrospective review of all free breast reconstructions was performed from July 2003 through December 2005. Outcomes were measured with regard to re-exploration, flap failure, and fat necrosis, with attention to the timing and side of reconstruction, as well as the presence or absence of radiation therapy.A total of 141 free breast reconstructions were performed during the study period. In seven cases (5%), alternative venous outflow vessels were selected (cephalic or external jugular vein). Nine anastamotic complications occurred, all of which involved the left internal mammary group (statistically significant for venous thrombosis, P = 0.0063) and three flaps failed. All cephalic and external jugular veins remained patent with no flap failures or fat necrosis within this group.The cephalic vein and external jugular vein are excellent alternatives for venous outflow in free breast reconstruction if neither the internal mammary nor thoracodorsal veins are sufficient, especially in left-sided reconstruction.