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Free-flap outcomes in lower extremity reconstruction carry the lowest anastomotic success rates compared with other anatomical sites. Despite their advantages over traditional nonperforator flaps, free perforator flaps have only recently become established in this area due to the additional challenges faced. It is therefore crucial to assess the anastomotic outcomes of perforator and nonperforator free flaps.We performed a single-center retrospective cohort study and combined this with a meta-analysis of the relevant literature. We evaluated three flap anastomotic outcomes: reexploration, operative salvage, and flap failure rates.Between January 2010 and June 2015, our center managed 161 patients who underwent lower extremity free-flap reconstruction, which included 76 perforator flaps and 85 nonperforator flaps. The perforator flaps had higher reexploration rates compared with the nonperforator flaps, but this was not statistically significant (18.4 and 10.6%; p = 0.18). Perforator flaps had a higher flap salvage rate but were not statistically significant (78.6 and 22.2%; p = 0.374). Lastly, although not statistically significant, perforator flaps had a lower rate of complete failure due to anastomotic complications (3.9 and 8.2%; p = 0.336). The meta-analysis included 12 studies (inclusive of the index study) and found no statistical difference in all three outcomes.Our meta-analysis is the first reported study and serves as an indication that free perforator flaps in lower extremity are as reliable as their traditional nonperforator counterparts. This does come with the prerequisite appreciation of the anatomical variations, the delicate handling of these flaps, and a low threshold for reexploration.