Introduction: Thigh reconstruction after oncological resection represents a challenge in terms of ideal morphological and functional outcomes to aim for. Very few papers presented a comprehensive approach to this topic, most of them being only small cases series. The purpose of this article was to review our institutional experience in the field of thigh soft‐tissue reconstruction, proposing an algorithm to choose the most convenient pedicled or free flap approach according to the different clinical scenarios and the specific morpho‐functional requirements of the case.Patients and methods: The authors retrospectively reviewed patients who received flap reconstruction for thigh soft‐tissue defects after oncological resection between 2014 and 2021. Demographic and operative data were recorded. Twelve months post‐operatively, patients were asked to rate the esthetic and functional outcomes of the reconstructive procedure on a 5‐point Likert scale. Additionally, for patients receiving a free functional muscle transfer to restore quadriceps or hamstring function, recovery was evaluated with the Medical Research Council Scale for Muscle Strength.Results: Seventy flap reconstructions of the thigh were, respectively, performed after sarcoma (n = 43), melanoma (n = 13) and non‐melanoma skin cancer (n = 14) resection. Pedicled flaps were used in 55 patients: 46 perforator flaps (32 ALT, 4 AMT, 4 PAP, 2 TFL, 2 MSAP, 2 DIEP) and 9 muscle or myocutaneous flaps (4 medial gastrocnemius, 2 gracilis, and 3 VRAM). Microsurgical reconstruction was performed in 15 patients for extensive defects (2 SCIP, 1 latissimus dorsi—LD, 1 thoracodorsal artery perforator—TDAP, 1 ALT, 2 DIEP flaps) or when >50% of the quadriceps or hamstring compartments were resected (eight free functional muscle transfer including five vastus lateralis, two LD, and one rectus femoris). Extensive defect surface, previous irradiation and neoadjuvant chemotherapy appeared to be predictors of free flap reconstruction. Complication (49% vs. 26.6%; p > .05) and readmission rates (32.7% vs. 13.3%; p > .05) were comparable between pedicled and free flap groups, as well as complications severity scores according to Clavien‐Dindo classification (1.15 vs. 1.29; p > .05). However, patients with previous irradiation experienced worse outcomes when receiving pedicled rather than free flaps in terms of reintervention (87.5% vs. 28.6%; p = .04) and readmission rates (87.5% vs. 14.29%; p = .01), and severity of surgical complications. Overall patients' satisfaction was high, with esthetic and functional mean score of 4.31 and 4.12, respectively (p > .05). In the FFMT group, M5, M4, M3, and M2 strength was observed in 3, 3, 1, and 1 patients, respectively.Conclusion: Oncological thigh defects are usually well addressed with pedicled perforator flaps. Microsurgical reconstruction offers reliable and reproducible results in extensive defects and in previously irradiated fields or when functional restoration is indicated.

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