We describe the indications and preoperative precautions, intraoperative tips, and pitfalls of elevation of vascularized fibula graft, including some case examples. The indications for the vascularized fibula graft are diverse including reconstruction after resection of tumor, congenital pseudoarthrosis of tibia, and trauma. Pre-operative planning and evaluation are important for a successful result. The key to the operation is to identify the running pattern of the perforator in the preoperative evaluation using ultrasonography and find it between the soleus and peroneal muscles, so that the flap can be safely elevated. If the perforator is difficult to dissect, the flap can be abandoned, or other vascularized bone grafts can be considered. Vascularized fibula graft, especially when performed as free flap, is a technically demanding procedure that requires microsurgical techniques. It should be mastered by surgeons performing reconstructive surgery.
