This review focuses on the complex pathophysiology of the burn injury and its effects on lower extremity reconstruction in acute burns. Multiple aspects of burn care are discussed in conjunction with lower extremity reconstruction principles. Key discussion points include considerations for acute management such as full thickness burn injuries with exposure of critical structures, circumferential injuries, high voltage electrical injuries, the risk for compartment syndrome, strategies for meticulous wound care and infection prevention, adequate excision, early definitive or temporary coverage. The role of reconstructive options including skin substitute, skin grafting, local flaps, free flaps, amputations and late consequences is reviewed.