PURPOSE: Soft tissue cover of the distal extremities remains a challenge for the reconstructive plastic surgeon. Complex traumatic defects often require the importation of well-vascularized soft tissue. Today, free tissue transfers for reconstruction of distal one-third of lower extremity remain the gold standard; however, they are not always possible based on extent of zone of injury and possible previous failure. To our knowledge, there is no discussion of distally based, cross-leg, sural artery island flap as a salvage to free tissue transfer in lower extremity reconstruction in the American literature. METHOD: This is a case study with real clinical application based on appropriate patient selction. RESULTS: We present a clinical case of 39 year-old male who presented to trauma service with a mangled lower extremity after being involved in a motorcycle accident. He had sustained a significant loss of soft tissue along with comminuted tibial and fibular fracture. After appropriate orthopedic treatment including a placement of external fixator, this patient underwent free rectus abdominus muscle flap and split thickness skin graft for soft tissue coverage. However, post operatively, his free tissue transfer experienced partial necrosis and loss which left an 8 X 6 cm defect on anteromedial, distal one third of the lower extremity with exposed tibia. Due to his extensive zone of injury he was not a candidate for a second free tissue transfer. Subsequently, he underwent a distally based, cross-leg, sural artery Island flap with successful soft tissue reconstruction. CONCLUSION: In conclusion, we recommend that a distally based, cross-leg, sural artery island flap should be considered a viable option for limb salvage in a select cohort of patients who are not a good candidate for free tissue transfer for soft tissue reconstruction. The distally based lower-leg fasciocutaneous and adipofascial local flaps, described by Masquelet et al, offer an easy and reliable surgical option to free flaps in presence of distal third soft tissue defects of the leg and foot. Compared to the traditional cross-leg technique, the cross-leg island flap with a subcutaneous pedicle based on the sural neurovascular bundle has provided a major improvement in flap mobility.