Microvascular surgical techniques have been applied to the problem of digital amputation, persistent nonunion and complicated extremity injuries with segmental bone and soft tissue loss. In replantations, adequate bone shortening and fixation with intramedullary pins or rods is mandatory. Proper patient selection, preoperative management of the amputated parts, application of microsurgical disciplines, employment of an organized surgical sequence, and rigid postoperative monitoring has resulted in an 80% viability rate in 121 replantations. Recent advances in the management of skeletal injuries using microvascular techniques include free vascularized bone grafting and salvage of the preamputation limb using free composite grafts of skin, subcutaneous tissue and bone. These free composite grafts techniques are exacting and time consuming. Meticulous planning, preoperative rehearsal and careful coordination between the operating teams make the functional restoration of a severely injured limb possible.