Free radial forearm flaps have many advantages and thus remain the dominant multi-purpose flap used in the reconstruction of maxillofacial soft tissue defects. This report summarizes our experience over 20 years of applying free radial forearm flaps and illustrates four stages of technical improvement regarding the selection of the anastomotic veins at the donor site and at the recipient site in addition to the choice of the method to be used for flap harvest. We believe that the key to improving the transplantation success rate for free radial forearm flaps is based on the following factors. First, the branches of the internal jugular vein are the preferred targets for anastomosis at the recipient site. Second, during flap harvest, it is necessary to retain the external fascia between the arteries and veins. Third, it is necessary to select veins in two vascular systems of different depths for concurrent anastomosis.
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