Introduction: The potential of the medial calf integument, as donor site for a free flap based on musculocutaneous branches of the medial sural artery, was first identified by Taylor and Daniel, following cadaver investigation. In 1981, Pontén described the fasciocutaneous sural flap as a reconstructive option for soft tissue loss of the lower extremity, particularly around the knee. Two years later, Donski and Fogdestram presented the distally based fasciocutaneous flap from the sural region followed by Montegut and Allen who considered the sural artery perforator flap as a viable alternative for the gastrocnemius myocutaneous flap. The sural flap proved a considerable versatility at the level of the lower leg (from the knee to the ankle and heel) as well as for other anatomical regions. The most common usage of the flap is for the distal-third defects of the leg. Materials and method: A group of 10 patients with soft tissue losses at the ankle or heal due to a various etiopathogeny represented by cancer excision, trauma, unstable scars, chronic osteomyelitis, in which a microsurgical free transfer had no indication or was not wanted, was presented. Our group reported a 30% complication rate in a high-risk patient population, including patients with diabetes mellitus, peripheral vascular disease, and venous insufficiency. Results: All the defects were covered successfully, without major complications. Usually, only a minor margin of the tip of the flap was lost, which was easily solved with a guided secondary healing. Most flaps showed a slight venous congestion, which cleared in a few days. The functional result was very good in all the patients, while the aesthetic appearance was acceptable even in female patients. Discussion: An ideal indication of a reverse sural flap may be a defect over an intact but partially exposed Achilles tendon. Conclusions: The sural reverse flap is useful in the ankle and foot soft tissues reconstruction whenever we have reasons not to use a microsurgical free transfer. Venous congestion with consecutive partial or complete flap loss is a common complication, so this would not be recommended in patients with obvious acute or chronic venous stasis. The reverse sural island flap should no longer be regarded as a flap of secondary choice to free tissue transfer, but as an equally valuable alternative for small and midsized defects around the ankle and heel.

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