In microvascular reconstructive surgery the patency of the recipient vessels is the key to successful outcome. In head and neck surgery there is often a lack of adequate recipient vessels as a result of chemoradiation therapy and ablative surgery. To overcome this it is crucial to identify vessels of adequate length and diameter outside the field of injury. We report our experience with cephalic vein transposition for drainage of seven free flaps—six intestinal and one osteocutaneous—for head and neck reconstruction. In five cases the cephalic vein was used during the free flap transfer and in two cases in salvage re-exploration surgery. All flaps survived completely. The anatomical course and location of the cephalic vein allow good patency and straightforward harvesting. Its vascular properties are predictive of reduced incidence of complications such as flap congestion and failure. We suggest that the cephalic vein offers a high venous flow drainage system for large free flaps and advocate its use in free intestinal transfer in the vessel-depleted neck as well as in re-exploration surgery. © 2009 Wiley-Liss, Inc. Microsurgery 2009.