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Many surgeons are hesitant to use interposition vein grafting in head and neck microvascular free flap surgery because of concerns for elevated risk of flap loss.The authors conducted a review of patients who underwent head and neck free flap reconstruction between 2005 and 2015. The effect of vein grafts on flap compromise and flap loss was analyzed using univariate and multivariate models.A total of 3240 free flaps were performed. Vein grafts were used in 241 flaps (7.4 percent). The free flap compromise rate was 14.5 percent with vein grafts and 3.4 percent without vein grafts (p < 0.001). The free flap loss rate was 6.4 percent with vein grafts and 1.1 percent without vein grafts (p < 0.001). Radiation therapy, chemotherapy, prior neck dissection, prior free flap, osteoradionecrosis, and multiple free flap surgery were more frequent within the vein graft group (all p < 0.001). Despite this, vein grafting was associated with an increased risk of flap compromise (adjusted OR, 4.8; 95 percent CI, 3.2 to 7.3; p < 0.001) and flap loss (adjusted OR, 5.5; 95 percent CI, 3.0 to 10.2; p < 0.001) on multivariable analysis. Individual review of each flap loss within the vein graft group identified no cases of thrombosis caused by anastomotic technical errors, arguing against the requirement of an additional anastomosis as a cause for loss of vein-grafted free flaps.An increased risk of free flap compromise and loss is associated with use of vein grafts. However, a 93.4 percent success rate was still achieved in notably more challenging cases where vein grafting was deemed necessary taking into consideration the pertinent risks and benefits.Therapeutic, III.