Ecosystem restoration in highly complex, human-dominated estuaries rests on a strong conceptual foundation of sustainability, ecosystems, and adaptive management of human-induced environmental impacts. Successful application involves evaluating uncertainty, incorporating place-based information, and engaging diverse constituencies in the planning process. That means integration of technical knowledge with an understanding of the “cultural milieu” inherent in all estuaries, that is, the intensity of human activity and impacts plus socioeconomic factors relevant to restoration goals. Operational definitions of what constitutes acceptable ecosystem conditions and current baselines are critical yet rest in large measure on cultural values and socioeconomic considerations. Resources for long-term monitoring and research to assess performance and ecosystem condition are paramount. Unprecedented population growth promises additional stressors on estuarine environments worldwide, making maintenance of present conditions difficult. The art of good, practical ecosystem restoration as a management tool at multiple geographic scales promises to play a crucial role in sustainability goals.