Skin loss about the foot and ankle is notorious for creating a difficult challenge for limb salvage. Local tissue rearrangements rarely prove satisfactory, so a free flap as a solution can be readily justified. Distally based flaps utilizing unviolated ipsilateral proximal lower limb donor territories offer new possibilities in lieu of the complexity of microsurgery. Yet some unique disadvantages must be acknowledged particularly for island flaps, depending on retrograde circulation via major collateral source vessels, where venous congestion can occur and risk of limb devascularization may be unacceptable. Antegrade perfused, distally based flaps nourished by a single septocutaneous perforator or communicating branches may be more reliable options. This introduction to these three potential types of distally based lower extremity flaps is intended to promote this concept with appropriate reservations as another relatively simple alternative for wound coverage in the lower extremity.
