The iliac crest flap, also known as the deep circumflex iliac artery (DCIA) flap, is a versatile choice for bony reconstruction that can provide a substantial amount of vascularized bone along with muscle and skin components if necessary. While traditionally requiring the harvest of surrounding abdominal wall muscles for reliable blood flow to the overlying skin paddle, an improved understanding of the perforator anatomy has allowed for the exclusion of the abdominal wall musculature. This has resulted in decreased soft tissue bulk with improved skin paddle mobility which are important modifications, particularly for head and neck reconstruction. Furthermore, a split iliac crest design that requires harvest of only the inner cortex maintains the muscular attachments of the surrounding abdominal and thigh muscles and results in decreased donor site issues including hernia formation and gait disturbance. A clear understanding of the variations in the anatomy of both the DCIA and its skin perforators is important for a successful flap harvest.