A retrospective assessment of 50 vascularized composite tissue transfers was carried out with 48 patients. Factors responsible for improved tissue survival included (1) the evaluation and proper selection of recipient vasculature, (2) the increased dependence on the vacularized latissimus dorsi musculocutaneous flap, and (3) the frequent use, wherever possible, of an end-to-side arterial anastomisis. Specific indications for reconstruction of the lower extremity with vascularized composite tissue include (1) avulsive injuries to the distal tibia and foot, (2) the failure of conventional methods, (3) the treatment of extensive chronic osteomyelitis, (4) deficiency of both soft tissue cover and skeletal support, (5) the restoration of form and contour with minimal secondary deformity of the donor site, and (6) extensive loss of soft tissue only. Reconstruction of the lower extremity with vascularized tissue is a reliable method with acceptable patient and tissue morbidity statistics that should be considered when specific indications are present.