The surgical toolbox for reconstruction of the head and neck continues to expand, particularly with free flap reconstruction. However, the need for locoregional flaps is important in many situations. The lower island trapezius flap has waxed and waned in its use but is still a critical component of the reconstructive paradigm for complex wounds of the lateral and posterior skull base. The knowledge of the complex vascular anatomy is critical to understand to be able to use this successfully as a reconstructive flap, in particular the dominance of the main vascular supply from the dorsal scapular artery.