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Hemifacial microsomia (HFM) is a sporadic congenital malformation of the craniofacial structures derived from the first and second branchial arches. The incidence of HFM has been reported to range from 1 in 3,0001 to 1 in 26,0002 live births, making HFM the second most common congenital malformation in the face after cleft lip and/or palate. An 11-year-old girl came at Galeazzi Institute (Milan) in January 2017. She presented left hemifacial microsomia with absence of the left ramus of mandible and the left temporomandibular joint (tmj), part of the zygomatic arch, hypoplasia of the lateral and inferior orbital bone and of the zygomatic bone. She also presented a medial canthal dystopia. She underwent to costochondral bone graft and calvaria bone graft for reconstruction of part of the mandible and the TMJ. An emi-Le Fort I, emi-Le Fort III, and sagittal segmental osteotomy of the right mandible were performed to improve the correct occlusion. Traditionally, the costochondral graft has been considered the gold standard for ramus-condyle reconstruction in the pediatric mandible when appropriate. Some studies cite growth unpredictability and ankylosis as concerns with rib. Further studies examining carefully the factors predicting graft growth, such as size of cartilage cap, surgical technique, and postoperative physiotherapy, are warranted.