The authors reviewed 43 double level tibial lengthenings by Ilizarov technique in 34 consecutive patients (6-31 years old), and investigated the factors affecting regenerate bone healing to determine the optimum ratio of distraction rate or magnitude of lengthening at the proximal and distal osteotomy sites. Length gain averaged 6.1 cm (range, 2.5-12.3 cm), equivalent to a 28% increase of the segment. The variables investigated included age, gender, concomitant deformity correction, etiology, and the amount of length gain. The healing index averaged 1.8 months per centimeter proximally and 2.8 months per centimeter distally. Age and the amount of length gain affected the healing index at proximal and distal lengthening sites. However, the proximal to distal healing index ratio, which averaged 0.72, was not affected by any parameters investigated. This study suggests that to minimize external fixation treatment time, the distraction rate, or amount of length gain, of the distal osteotomy site should be approximately 3/4 that of the proximal site in the double level tibial lengthening.