The distally based sural flap for foot and ankle reconstruction has gradually increased in popularity over the last decade. Along with its increased use comes a parallel increase in the number of reported applications, innovations, and technical refinements. This review is intended to be used as a guide to determine when and how to use the distally based sural flap. Historical perspective, indications and contraindications, preoperative planning, technique, complications, postoperative management, and pearls and pitfalls are summarized below. The distally based sural flap is a useful alternative to free tissue transfer for reconstruction of the foot, ankle, and lower extremity. © 2007 Lippincott Williams & Wilkins, Inc.