Microvascular reconstruction options for forearm defects are critical in managing benign and malignant tumors. While upper extremity malignancies are rare, musculoskeletal malignancies of the forearm account for 1–2% of cases. Limb salvage procedures have become the preferred method, drastically reducing amputation rates with advances in chemotherapy, radiotherapy, and reconstruction techniques. Comparing limb salvage and amputation outcomes revealed similar survival rates, higher local recurrence, and complications in limb salvage, but greater cosmetic satisfaction. Successful limb salvage requires adherence to fundamental principles, with vascular reconstruction prioritized. Vascularized bone grafts, particularly fibular grafts, offer advantages over nonvascularized alternatives, promoting rapid healing and maintaining mechanical properties. Donor selection is multifactorial, considering tissue compatibility, vascular pedicle adequacy, and potential morbidity. Free vascularized fibular grafting emerges as a reliable method, offering prompt incorporation and suitability for various defects. Preoperative planning, recipient vessel assessment, stable internal fixation, and careful donor site evaluation contribute to successful outcomes. Despite favorable outcomes, complications associated with free vascularized fibular grafts, including graft fracture and reoperations, remain notable. Systemic complications are less explored but may include deep vein thrombosis and pulmonary embolism. This chapter underscores the importance of meticulous planning and advanced reconstruction techniques for successful forearm defect management.