Background: Due to the wide spectrum of lower extremity defect presentation, various reconstructive techniques are available. Classic adipofascial flaps are still a second choice. The authors described a new multistage reconstructive approach with perforator-based pedicled adipofascial flap. Methods: This retrospective study analyzed data of 23 patients undergoing adipofascial flap reconstruction after distal leg trauma between June 2017 and January 2020. A reconstructive approach with an adipofascial flap followed by a skin graft was used in all patients. Patients were divided into two treatment groups, and in only one treatment group, an acellular dermal matrix was placed above the adipofascial flap during the first stage of the reconstruction. Negative pressure wound therapy was applied to both groups. Surgical technique, outcomes, and complications were discussed. Results: All patients achieved complete healing, and no flap loss was reported. Minor complications occurred in four patients; all were treated conservatively on outpatient basis. The surgical and aesthetic results were evaluated as satisfactory from both patients and professionals. However, the group treated with acellular dermal matrix showed a lower complication rate, and resulted significantly more satisfied with the overall results and in several domains of the questionnaire administered postoperatively (P < 0.05). Conclusions: The adipofascial flap is a safe and effective approach for the reconstruction of small-to-medium-sized defects of the distal lower extremity. Our two-stage reconstructive approach maximizes the pearls offered by the established technique; the dermal matrix guarantees a layered reconstruction optimizing the surgical and aesthetic outcomes of the skin graft with minimal donor site morbidity.