Free tissue transfer has become a routine method for the reconstruction of a variety of defects and is commonly employed in both the university and community hospital setting. Free tissue transfer has most often been reported in adult patients and is used to reconstruct defects caused by trauma, tumor, or vascular insufficiency. Several series have reported on free tissue transfer specifically in children, addressing both the similarities and differences employed in the special patient population. This article reviews common microsurgical practices used in treating pediatric patients and discusses etiologies, donor site selection issues, technical considerations including recipient site selection, and the potential for growth disturbances at both the recipient and donor sites.