Purpose: Difficult defects of the lower extremity are frequently treated with free tissue transfer or pedicled flaps that sacrifice blood supply to the extremity. Recent advances in the understanding of the vascular anatomy of the lower extremity have ushered in a new era of reconstruction. Fasciocutaneous and adipofascial flaps based on both distal ankle perforators and neuro-venous pedicles will be described to close difficult distal defects. Methods: Multiple operations have been performed by the author utilizing perforator-based adipofascial flaps. Six flaps for the distal lower extremity will be discussed in terms of indications, technique and outcome. Results: Case 1 is a distally based flap used to cover a chronic burn of the medial malleolus. The flap incorporates the greater saphenous vein and saphenous nerve and has perforators from the posterior tibial artery at its base (1a-d). Case 2 uses a distally based posterior calf flap including the lesser saphenous vein and sural nerve to cover a lateral ankle defect (2a-d). It incorporates perforators from both the peroneal and posterior tibial arteries. The same type of flap is used in Case 3 (3a-d) and tunneled to cover a medial tibial fracture. Case 4 is an example of a “sural” flap. A fasciocutaneous flap incorporating the sural nerve and lesser saphenous vein is used to reconstruct an achilles defect (4a-d). Case 5 is an example of a proximally based adipofascial flap used to cover a distal tibia fracture. Its blood supply derives from perforators of the anterior tibial artery (5a-d). Case 6 demonstrates a proximally based flap used to cover an Achilles defect (6a-d) with posterior tibial perforators as its blood supply. Conclusions: Perforator based adipofascial and fasciocutaneous flaps are a viable alternative to free or pedicled flaps in lower extremity reconstruction and represent an important addition to the plastic surgeon’s armamentarium.

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