Reconstruction of the ocular surface in patients with limbal stem cell insufficiency (LSI) remains one of the most challenging tasks in ophthalmology. The transplantation of lamellar limbal tissue in total LSI represents an established therapeutic concept, while an abrasion of the conjunctival pannus allowing normal limbal epithelium to recolonize the cornea is the treatment of choice in partial LSI. Surgery must be postponed until an inflammation-free period is reached and lid abnormalities have been corrected. In unilateral total LSI autologous limbal tissue from the healthy eye is transplanted in order to circumvent immunological adverse events. In bilateral total LSI cadaveric or living related allogenic limbal tissue is used for transplantation, in which case systemic immunosuppression and HLA matching are mandatory. The combination with amniotic membrane transplantation and mitomycin C treatment can further improve long-term outcome of limbal stem cell transplantation.