Vascularized bone transfers are the ideal bone graft since they provide their own blood supply and all necessary osteoinductive, osteoconductive, and osteoprogenitor elements. These attributes allow them to be used in compromised recipient sites. When used as onlay grafts to augment skeletal contour they provide the best opportunity to maintain volume. Vascularized bone grafts used to provide mechanical stability are most often used to reconstruct the mandible after portions of it have been removed for tumor and further treated with radiation therapy. The considerable number of free bone graft donor sites allows considerable flexibility in design for mandibular reconstruction. In instances in which complex composite defects in the mandible, and particularly the maxilla, exist, restoring a well-vascularized soft tissue milieu with a free soft tissue transfer allows successful skeletal reconstruction with nonvascularized bone grafts. Vascularized bone allografts are a theoretically appealing way to reconstruct large bone defects. At this time their benefits are outweighed by the toxicity of current immunosuppressive therapy.