Fourteen face transplants have been performed worldwide since the procedure was successfully introduced in 2005. Vascularized composite tissue allotransplantation may now be considered a viable option for the repair of complex craniofacial defects, for which the results of autologus reconstruction remain suboptimal. However, the benefits must be balanced against the risks inherent in major surgery and the adverse effects of lifelong immunosuppression. In this article, we review the current practice and areas of controversy in facial vascularized composite tissue allotransplantation with particular respect to the unique immunobiology of this procedure. We also describe promising recent advances in immunotherapy and tolerance induction strategies that may soon reach clinical application.