Defects in the distal third of the lower leg and ankle are difficult problems to solve. Many partially successful solutions have been found. Even such elegant and successful approaches as free muscle transfer have downsides, including operative time, sacrificed muscle, and a small complete failure rate. An ideal solution to these lower extremity problems would be a flap that replaced the lost tissue with like tissue, that was reliable and rapid, and that handled contamination well. There have been a small cohort of recent reports on the use of a reverse sural artery flap for reconstruction of the distal lower extremity and heel. With its theoretical advantages in mind, the distally based sural artery flap was used in 2 patients with significant distal lower extremity wounds and exposed bone or hardware. Both flaps were successful and went on to complete healing. One of the flaps that had been taken quite proximal showed a very small area of flap tip (proximal in this reverse flap) necrosis. This flap necrosis gives some indication of the proximal extent of the flap.
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