The replacement of significant lengths of tracheal tissue still remains the unrivalled 'holy grail' of thoracic surgery. As a result of continuous developments and improvements in tracheal surgery throughout the last five decades, most tracheal lesions can now be resected and primary reconstruction effected safely. Today, very few patients present extensive tracheal lesions that necessitate tracheal replacement. The spectrum of tracheal substitutes ranges from autologous tissue flaps and patches to synthetic stents and prostheses to tissue-engineered scaffolding. In this review, the clinical achievements and conceivable developments of applying human allografts and biological and artificial prostheses will be discussed.