The pelvic and perineal regions are affected by a heterogeneous spectrum of pathologies, many with a tendency to recur. Extensive mutilation carries physical, sexual, and psychological sequelae. Primary reconstruction reduces morbidity and shortens recovery. Modern management calls for a multidisciplinary approach. Not uncommonly, patients come with previous surgery and/or chemoirradiation. They may also be elderly and debilitated. The literature on reconstruction of the perineum can be confusing because knowledge has evolved by an accumulation of isolated short reports of individual methods. This led to the lack of a unifying basis for nomenclature and a failure to relate specific techniques to their roles in repairing particular types of defects. This article gives an overall summary of the approaches in a structured and rational manner. Defects of the external pelvis and perineal lining are usually amenable to coverage with local or regional fasciocutaneous flaps, if primary closure or skin graft is not appropriate. These flaps depend on the integrity of the vascular territories of the internal pudendal, the upper medial thigh plexus, or the descending branches of the inferior gluteal. The location and extent of the resection usually determine the requirements of the reconstruction and may dictate the choice of options. When defects are pelviperineal, particularly when the vagina needs to be reconstructed, myocutaneous flaps are of proven advantage in dealing with both the resurfacing as well as providing the bulk needed to fill the pelvic cavity after extensive resections. The rectus, gluteus, and gracilis are the best known options. Owing to the intrinsic limitations with the gracilis flap, the rectus and gluteus flaps have largely superseded its role in most situations. The rectus flap, in particular, provides good bulk as well as reliable skin. The use of muscle sparing flaps based on the perforator principle in suitable instances has increasingly been reported. The role of free tissue transfer, however, remains limited to isolated situations not amenable to current standard techniques. New and innovative reconstructive modifications keep appearing and larger scale series are needed for more evidence-based information on the outcomes achieved.