Background Technical advancements and increasing experience in the management ofsoft tissue defects in lower extremities have led to the evolution ofdecisional reconstructivealgorithms. Both propeller perforator flaps (PPFs) and free flaps (FFs) proved to be usefulmethods of reconstruction for lower extremities defects, offeringalternative reconstructivetools. We present a case series of PPFs and FFs for reconstruction of lower limbs defects,analyzing and comparing treatment and outcomes.Methods Through a retrospective analysis, we report our experience in performingPPFs or FFs for reconstruction of soft tissue defects of the lower extremities, in patientsadmitted between 2010 and 2015 at the Department of Plastic and ReconstructiveSurgery, University of Palermo. In these patients, we evaluated location and causes ofdefects, types of flaps used, recipient vessels, complications, time to healing, andaesthetic outcome.Results A primary healing rate was obtained in 13 patients for PPF and 16 cases for FF.Revision surgery for partial skin necrosis was required in eight cases (PPF: four and FF:four). Recovery time and hospitalization period were eventually shorter in patients withFFs, due to lower rate of complications and revision surgery.Conclusion In the past years, our indications for reconstruction with PPFs in the lowerlimb have become more restricted, while we favor reconstruction with FFs. Recommendationsare provided to orient surgical treatment in small, medium, and largelower limb defects.