Purpose: Early oral feed initiation following head and neck surgery involving microvascular reconstruction is a topic of significant debate. Historically, patients are kept “nil-by-mouth’ for 6-12 days to minimise the risk of post-operative fistula formation. Conversely, recent studies spearheaded by Enhanced Recovery After Surgery programmes have shown early feeding to optimise physiological function, reduce stress response and facilitate recovery and healing. Nevertheless, the ideal timing for oral feeding is uncertain and its effects on post-operative complications and hospital length-of-stay (LOS) remains contentious. Methods: A systematic review of Medline, Embase, Cochrane, and Scopus was conducted for studies comparing outcomes and LOS of early vs delayed oral feeding following head and neck surgery involving microvascular free-tissue transfer. Within five post-operative days was defined as early feeding. Fixed and random effects meta-analyses were utilised. Results: Ten studies involving 1163 patients were included. There was a significantly lower risk of fistulas (4.1% vs 10.3%) (RR=0.46; 95% CI 0.26 to 0.81; P=0.008) and pneumonia (7.2% vs 12.1%) (RR=0.60; 95% CI 0.36 to 1.00; P=0.049) with early feeding. LOS was also shorter after early feeding (x̄=9.9 vs 13.1 days) (MD=-4.10, 95% CI -7.07 to -1.14; P=0.007). There was no significant difference in flap failure, haematoma or dehiscence. Conclusions: Starting oral feeding within five days is associated with better or similar outcomes and shorter LOS than later feeding. While further prospective trials targeted to the mucosal site and feed progression is required to provide more specific recommendations, surgeons should consider early oral feeding.