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Simple Summary: Reconstruction after the wide margin excision of a malignant tumor located in the posterior trunk has been considered challenging in the past. The paucity of conventional local donor sites and the concomitant increase in reconstructive requests, following progress in oncologic surgery, have combined to necessitate innovative solutions to cover even large defects by means of locoregional flaps. The advent of perforator flaps significantly increases the range of options available for reconstruction in this difficult area, thus minimizing donor site morbidity. The aim of this article is to summarize the current trends in the reconstruction of soft tissue defects in the posterior trunk. Background: The posterior trunk has been considered a challenging area to reconstruct following soft tissue tumor excision because of the shortage of local donor sites. The advent of innovative procedures such as perforator flaps has radically changed this perspective and offered a new approach to the problem. Methods: Upon a review of the literature and the personal experiences of the senior author, an algorithm is developed according to the most updated procedure, combined with more conventional options that maintain a role in decision-making. Results: The upper back latissimus dorsi and trapezium flap are still the most reliable approaches, while perforator flaps based either on the circumflex scapular arteries or the transverse cervical artery represent a more refined option. In the middle third, few indications remain for the reverse latissimus dorsi, while the gold standard is represented by local perforator flaps based on the posterior intercostal system. In the lower back, conventional VY advancement flaps are still a safe and effective option in the sacral area, and perforator flaps based on posterior intercostal arteries, lumbar arteries and superior gluteal arteries are the first choice in most cases. Conclusions: Using perforator flaps significantly improved soft tissue reconstruction in the posterior trunk. [ABSTRACT FROM AUTHOR]