The distally based posterior tibial adipofascial flap is a useful option for distal leg and ankle coverage. Traditionally, its dimension is constrained by a length-to-width ratio of 2:1. We have increased this ratio to 4:1 by including the great saphenous vein and saphenous nerve with the flap. These structures with their venoneural network, and their connections with posterior tibial artery perforators, form the vascular axis of the flap. In our series of 21 flaps, 70% (n = 15) had ratios of 3:1 or higher. In remaining 30% (n = 6), the ratio was 2:1, as the defects were more proximal. Complications include one complete flap loss due to compression from tunneling and one superficial tip necrosis. Postoperatively, we performed wet-to-wet dressings, phlebotomy, and delayed skin grafting to optimize flap survival. Of 21 flaps, 20 were healthy after an average follow-up of 24 months.
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