AbstractBackground:The objective of this study was to compare the free muscle‐musculocutaneous flaps and free perforator skin flaps used for soft tissue reconstruction of the lower extremities.Methods:Fifty‐three patients whose skin and soft tissue of the lower extremities had been reconstructed were divided into two groups: a perforator flap group, reconstructed using anterolateral thigh (ALT) free flap (23 cases), and a muscle‐musculocutaneous flap group, in whom latissimus dorsi and rectus abdominus muscle‐musculocutaneous free flaps were used (30 cases). Postoperative complications, long‐term results, and donor site morbidities were studied in the two groups.Results:Complete flap survival was 78.3% with four total and one partial flap loss in the ALT group and 90.0% with one total and two partial failure in the muscle‐musculocutaneous flap group. Muscle‐musculocutaneous flaps were the flaps of choice in Gustillo grade IIIB‐C injuries and for reconstruction of more proximal localizations. ALT was preferred in relatively younger patients and was typically used for coverage of the distally localized defects. Flap complication rate was significantly higher in the ALT group, but the overall complication rate was similar between the groups.Conclusion:ALT perforator flap is a precious option for lower extremity soft tissue reconstruction with minimal donor site morbidity. Nevertheless, the beginners should be attentive to an increased rate of flap complications with the ALT flap and free axial muscle‐musculocutaneous flaps would still be the tissue of choice for coverage of leg defects for a surgeon before gaining enough experience with perforator flap dissection. © 2009 Wiley‐Liss, Inc. Microsurgery 2010.