Large, complex lower-extremity defects in the region of the Achilles tendon occur when tendon loss or disruption is complicated by damage to surrounding structures, including soft tissue, vessels, or bone. The surgical approach to these complex defects has evolved from simple amputation to the recognition that satisfactory reconstruction has three components: functional reconstruction of the tendon, importation of vascularized soft tissue, and skin coverage. Many techniques have been developed to address these difficult reconstructive goals, which often require multiple procedures or complicated single-stage operations. Microsurgical advances have begun to reduce the complexity of Achilles tendon region reconstruction, and excellent results can be obtained which restore function, form, and cosmesis with minimal morbidity.