Introduction: Negative pressure therapy has been promoted as a method of simplifying care and reducing the extent of soft tissue reconstruction in complex extremity wounds. The role of this new therapy has yet to be defined. A cohort of patients receiving negative pressure therapy and free tissue transfer was evaluated. Methods: All patients undergoing soft tissue reconstruction of the extremities are entered into a prospective database. A subset of patients treated with both negative pressure wound therapy and free tissue transfer was analyzed. Results: From 6/99 to 2/02, 16 patients with extremity wounds were treated with negative pressure wound therapy and free tissue transfer: 14 males and 2 females, 14 lower extremity and 2 upper extremity wounds. Wounds occurred as a result of trauma (13), vascular insufficiency (1), a brown recluse spider bite (1), and therapy for soft tissue sarcoma (1). Major complications requiring reoperation occurred in 7 (44%) patients: total flap loss (2), persistent osteomyelitis (1), abscess (1), tibial non-union (1), hematoma (1), and loss of skin graft (1). Complications did not appear to be related to age, co-morbidities, method of injury, or MESS. The mean number of days between injury and soft tissue reconstruction for the patients without complications was 48 (4 – 165) compared to the patients with complications, 101 (17-224). The mean number of days of negative pressure therapy for patients without complications was 14 (2 – 90), compared to 49 (8 – 100) for patients with complications (p < 0.05). Conclusion: Although negative pressure therapy has a role in the management of complex extremity wounds, delayed soft tissue reconstruction continues to have a high complication rate. Negative pressure wound therapy will probably reduce the need for emergency free flaps, but does not change the basic principles of extremity reconstruction: adequate debridement and early soft tissue reconstruction.