AbstractBackgroundMicrovascular free flaps are becoming the reconstructive option of choice for many head and neck defects. Many previous studies have examined factors predicting free flap survival. No study has compared differences in free flap survival when anastomosed to the internal or external jugular systems.MethodsRetrospective review of all free flaps performed at an academic medical center by a single head and neck microvascular surgeon during the period July 1995 to December 1999. Flaps were closely monitored postoperatively and taken back to the operating room urgently for arterial insufficiency or venous congestion.ResultsOn hundred fifty‐six free flaps were performed during this time period. Sixty‐five free flaps were anastomosed to the external jugular (EJ) vein and 86 to the IJ system (62 to the proximal common facial vein, 17 end‐side on the IJ, and 7 to other branches). Five had either two venous anastomoses or were anastomosed to other veins and were excluded from statistical analysis. Six (4%) vascular thromboses occurred; 5 were venous and 1 arterial. Success by group was 99% for IJ anastomosis (1 arterial thrombosis) and 92% for EJ anastomosis (5 venous thromboses, p = .03). Urgent anastomotic revision and reperfusion salvaged 5 of the 6 flaps (overall success 99%).ConclusionsAlthough the overall success rate (96% success with 99% success with salvage) is comparable to other large series, microvascular free flaps anastomosed to the external jugular vein failed at a significantly higher rate than those anastomosed to the IJ system. This suggests that the IJ system should be used as a recipient vessel when feasible. © 2001 John Wiley & Sons, Inc. Head Neck 23: 475–478, 2001