In the recent decades, microsurgical reconstruction has evolved from simple survival of the affected extremity to the improvement of functional and aesthetic outcome. This review retraces the main contributions to the advances of microsurgery for reconstruction of upper and lower extremities and limb preservation. In the upper extremity,it is important to restore fine motility, together with allowing prompt mobilization. In the lower limb, care must be taken in the reconstruction of weight-bearing areas and the aim must be proper ambulation and shoe wearing. Local perforator flaps can be considered for medium size defects. They provide thin coverage and can be performed in short operating time. Their use, though, is often limited by tissue availability. Free flaps allow to overcome this problem and, thanks to the recent development in the study of perforator vessels, the microsurgeon can choose the flap with the most appropriate characteristics. Chimeric flaps can accomplish simultaneous reconstruction of different tissue components and large bone defects often require vascularized bone reconstruction. When dealing with limb preservation it is very important to consider residual functionality. Functioning muscle transfer and targeted muscle re-innervation can be performed in these cases. A useful reconstructive tool in severely damaged limbs with limited blood supply is the use of cross-leg free flaps. In conclusion, extremity reconstruction and limb preservation are reaching new heights thanks, not only to the work of plastic surgeons, but also to the new developments in other fields of study such as oncology, traumatology, radiology and medical engineering.