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Currently, increasingly reconstructive surgeon consider the failure rates of perforator propeller flaps especially in the distal third of the lower leg are too important and prefer to return to the use of free flap at first line option with failure rates frequently lower than 5%. So, we performed a systematic review with meta‐analysis comparing free flaps (perforator‐based or not) and pedicled‐propeller flaps to respond to the question “what is the safest coverage for distal third of the lower limb?”

This review was conducted according to PRISMA criteria. From 1991 to 2015, MEDLINE®, Pubmed central, Embase and Cochrane Library were searched. The pooled estimations were performed by meta‐analysis. The homogeneity Q statistic and the I² index were computed.

We included 36 articles for free flaps (1,226 flaps) and 19 articles for pedicled‐propeller flaps (302 flaps). The overall failure rate …