Many series evaluate diverse groups of pediatric patients with various defects and an assortment of free flaps; however, others focus specifically on head and neck reconstruction. An early review from Toronto, Ontario, Canada,2 examined mandibular reconstruction with the fibula free flap. The authors' series of 10 flaps in children aged 5 to 17 years showed 100% flap survival with class I occlusion in all patients. Problems with soft-tissue contouring were a primary concern. While series such as this have shown viability and success of the fibula free flap in children, questions arise concerning use of this flap in a young population. For example, should reconstruction be immediate or delayed? One group3 found that a delayed reconstruction led to worse cosmetic and functional results owing to fibrosis, and they recommended immediate reconstruction in cases of tumor removal, or soon after debridement with traumatic etiologies of tissue loss. Another question is whether the fibula flap will affect maxillofacial growth in the growing child, and if orthognathic surgery will be needed in these patients. Some recommend further surgery and planned mandibular osteotomies based on the initial age of the patient at the time of the free flap.4,5 However, a study from M. D. Anderson Cancer Center, Houston, Texas,6 found that malocclusion was uncommon and none of the patients included in the study needed further orthognathic surgery. The fibula flaps “accommodated” to the continued mandibular growth as long as the mandibular growth plates were not removed or injured. This group recommended removing reconstruction plates once bony union was proven in order to promote further growth/remodeling. Herein, we will review our favorable experience in this patient population.