Lower extremity (LE) reconstruction presents unique challenges due to complex wound environments, compromised vascularity, and high functional demands. Compared with other anatomic regions, free flap reconstruction in the LE demonstrates higher complication and failure rates. Early microsurgical intervention improves outcomes, though negative pressure wound therapy can bridge to delayed coverage. In oncologic patients, radiation and chemotherapy impair tissue quality and recipient vessels, necessitating meticulous planning and vessel selection outside the zone of injury. Anatomic location influences reconstructive options, ranging from local flaps to free tissue transfer. Risk stratification models, such as the A-Sarc score, support evidence-based reconstructive decision-making.