BACKGROUND: Venous flow-through flaps are well-described options for small defects where donor site morbidity is undesirable or in areas where useful local veins are in close proximity to the defect, particularly in the extremities. However, higher rates of flap loss have limited their utility. The saphenous venous flap in particular has been widely sought as a useful flap, and while arterialization of this flap improved survival rates, congestion has remained a limiting feature. We describe report a modification in the design of saphenous venous flaps, whereby an arterialized flap is provided with a separate source of venous drainage, and demonstrate survival of substantially larger venous flaps than previously reported. METHODS: In five consecutive patients, we describe three main modifications to the saphenous venous flap as previously described: (a) Using arterialized flaps only; (b) Reversing the flap to allow unimpeded flow during arterialization; and (c) Anastomosing additional vein(s) that are not connected to the central vein-especially at the periphery of the flap for true venous drainage. RESULTS: There was a 0 complete flap loss rate (with only one case of superficial partial loss), and ultimately better survival than previous series of saphenous venous flaps described to date. CONCLUSION: The success of these techniques offers the potential to re-establish flow to large segmental losses to axial arteries, offer safe and definitive flap coverage to traumatic wounds, improve the array of flap options in this setting, and minimize donor site morbidity.