OBJECTIVE: We conducted a systematic review and meta-analysis to compare venous couplers and hand-sewn techniques for venous anastomosis in head and neck reconstruction. DATA SOURCES: PubMed/MEDLINE and Scopus, databases were searched for relevant publications. Additionally, a manual search was performed in Google Scholar and through reference lists. REVIEW METHODS: Retrospective and prospective cohort studies were included. Odds ratios (ORs) and mean differences (MD) were calculated with their 95% confidence intervals (CIs) for each study comparing the 2 groups (coupler vs hand). The inverse variance method was used to combine the effect sizes from the individual studies. RESULTS: A total of 14,053 patients undergoing 14,270 head and neck free flap reconstructions were included from 52 studies. A total of 6080 flaps were performed using a coupling device for the venous anastomoses, while 8190 flaps were performed with the hand-sewn technique. No significant difference was found for the venous thrombosis rate (OR: 1.06, 95% CI: 0.65-1.72), and reoperation rate (OR: 0.93, 95% CI: 0.51-1.70), but a significantly lower failure rate was measured for the coupler group (OR = 0.34, 95% CI: 0.20-0.58). A nonsignificant lower operative time was found for venous anastomoses (MD: -20.5, 95% CI: -51.7 to 10.7) and total surgery (MD: -23.7, 95% CI: -344.3 to 296.8) for the coupler group. CONCLUSION: Despite the slight advantages observed with venous couplers, the overall outcomes of both techniques are excellent, and the choice of anastomotic technique should be guided by surgeon preference.