Coverage of defects of the distal third portion of the leg and foot remains a challenge for surgeons. The difficulty results from the limited mobility and availability of the overlying skin, the weight-bearing requirements, and the relatively poor circulation of the skin. From January 2008 to December 2009, 10 patients had defects of the foot and ankle covered using the 2-stage expanded reverse sural flap. Of these 10 patients, 6 had at least 1 risk factor for compromised wound healing, such as diabetes mellitus, peripheral arterial disease, venous insufficiency, tobacco smoking, or age older than 40 years. Flap necrosis was observed in only 1 patient (10%). Venous congestion was noted in 2 patients (20%) by the third postoperative day, 1 of whom responded to postural elevation of the extremity and 1 to medicinal leech therapy. Although it is a 2-stage procedure that requires wound dressing during the expansion, we strongly suggest the use of the expanded reverse sural flap for defects too large to be primarily closed, especially in patients older than 40 years with risk factors such as diabetes mellitus, peripheral arterial disease, or venous insufficiency. (C) 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.