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We review here our substantial experience in using Alexis Carrel’s technique with a geometrical optimization for microsurgical end-to-end anastomoses. The technique used for microsurgical end-to-end anastomoses is described. We performed a retrospective analysis of head and neck free flaps where we used the described microsurgical anastomoses technique at Bufalini Hospital in Cesena, Italy. Patients’ demographic data, intraoperative findings, and postoperative progress, including complications, were accurately recorded. We also recorded the cases where vessel size discrepancy was observed intraoperatively, either arterial or venous. The described technique has been used in 300 consecutive flaps in the last 18 years, with an average of 16 free flaps per year. No significant problems were encountered using this simple technique. Comprehensive flap survival was 98%. We had 5 free flap failures, and in all cases, the main problem was not related to the microvascular anastomoses. Vessel size discrepancy was recorded in 25% of the total. Alexis Carrel’s technique for microvascular end-to-end anastomoses is still a very efficient end safe technique. Our geometrical optimization of it is a useful trick to keep in mind for the microvascular surgeon, especially in hospitals with a small volume of microsurgical procedures per year. Level of evidence: Level III, therapeutic study.