The never-ending story: single versus dual venous anastomoses in microsurgical radial forearm free flap for head and neck reconstruction. A meta-analysis.

The radial forearm free flap (RFFF) remains a cornerstone in head and neck reconstruction. Despite various venous anastomotic techniques, including single and dual anastomoses, venous compromise continues to be the leading cause of free flap failure. Advocates of dual venous anastomoses suggest it may reduce venous compromise, but its effectiveness remains debated. This study systematically reviews and meta-analyzes the impact of single versus dual venous anastomoses on flap failure, venous compromise, and salvage success in head and neck microsurgery. Following PRISMA guidelines, two authors independently searched PUBMED, Web of Science, CENTRAL, and Google Scholar up until February 2, 2024. After screening 7248 articles, 14 studies met inclusion criteria. Data analysis was performed using the 'metafor' package in Rv.4.3.1. The odds ratio for flap failure between single and dual venous anastomoses was 1.52 (95 % CI 0.82-2.22; p < 0.001), and for venous compromise, 0.85 (95 % CI 0.18-1.53; p < 0.03), indicating a higher rate of flap failure and venous compromise in the single venous anastomosis group. This study suggests dual venous anastomoses that significantly reduce flap failure and vascular compromise in RFFF for head and neck reconstruction. However, no clear preference was observed regarding salvage success rate between the two techniques. Our analysis focused on dual (deep/superficial) versus single anastomosis, without distinguishing the specific venous types used, due to high heterogeneity among the included studies.