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1University of Toronto, Sunnybrook Health Sciences Centre, Department of Otolaryngology, Head and Neck Surgery,Toronto; 2McMaster University, McMaster University Medical Centre, Division of Plastic and Craniomaxillofacial Surgery, Hamilton, Ontario Correspondence: Dr Kevin Higgins, Sunnybrook Health Sciences Centre, Department of Otolaryngology, Head and Neck Surgery, 2075 Bayview Avenue, Suite M1 102, Toronto, Ontario M4N 1J7. Telephone 416-480-5104, fax 416-480-5761, e-mail kevin.higgins@sunnybrook.ca The transfer of autogenous, vascularized free-tissue is a cornerstone of modern reconstructive surgery, particularly when dealing with extensive oncological ablations and large post-traumatic defects. A half-century after Jacobson and Suarez (1) described the first sutured microvascular anastomosis, the cumulative efforts of surgeons and researchers have refined free tissue transfer (FTT) into a reliable modality that often provides excellent cosmetic and functional results. In addition to adequate presurgical planning and meticulous dissection technique, the microvascular anastomosis is critically important for successful reconstruction. The reported success rate of FTT ranges from 91% to 99%, with the majority of failures being due to technical errors with vessel anastomosis (2). Indeed, a hand-sewn anastomosis is a technically demanding procedure, particularly when dealing with veins, which prompted investigation into alternative strategies to suture. One example is the microvascular anastomotic coupling device (MACD), an interlocking ring-pin design that is becoming more widely used in FTT. Initial animal studies demonstrated favourable tensile characteristics and healing of coupled vessels (3), and subsequent case series in head and neck, breast and limb reconstructive surgery have reported favourably on MACD utilization. These case series have been limited by smaller numbers and variability in reconstructive subsites; however, recently, several larger series have been published. We sought to systematically review the literature to examine the utility of MACD use in FTT with regard to success rates and optimal applications of this device.