The distal lower extremity and foot have long been recognized as problematic areas for reconstruction. Unreliable blood supply and paucity of local donor tissue often preclude the use of local and regional flaps. As a result, free tissue transfer has become the mainstay of treatment for the traumatized lower limb over the past few decades.1,2 Goals of reconstruction are to provide stable soft-tissue coverage, preserve plantar sensation, and allow for bipedal ambulation with normal weight bearing. Although free tissue transfer permits the movement of composite tissue to meet the specific needs of the defect, drawbacks to this procedure include longer operative times, potential donor site morbidity, and the requisite for qualified surgeons with microsurgical experience.3 Reliable alternatives are beneficial to shorten operative times and to accommodate those cases in which either the patient is not an appropriate surgical candidate or free tissue transfer cannot be performed. The reverse superficial sural artery flap (RSSAF) is a distally based fasciocutaneous or adipofascial flap that is increasingly being used for coverage of defects that involve the distal third of the leg, ankle, and foot. First described by Donski and Fogdestam4 and later championed by Masquelet et al,5 the RSSAF has become a popular option for many of these difficult wounds. A significant advantage of this flap is a constant blood supply that does not require sacrifice or manipulation of a major artery to the lower limb.6 Touted for its reliability and ease of dissection, the RSSAF is often reputed to have a favorable complication profile as evidenced by a recent meta-analysis that found 82% of flaps heal without any flap-related complications.7 However, the RSSAF is often at risk for venous congestion, as it relies on communication between the venae comitantes of the sural nerve and the lesser saphenous vein, thus circumventing the valves of the deep venous system.8 A growing consensus among reconstructive surgeons is that impaired venous drainage of the RSSAF is one of the preeminent factors that contribute to flap necrosis in the early postoperative period.7,9 It has been shown that flap survival was improved by various modifications to the operative technique that enhanced venous outflow of the RSSAF, and that these changes reduced the use of leech therapy.7,10–16 A number of studies have established the utility of the RSSAF in lower extremity and foot reconstruction over the past 30 years.9,17–23 Despite promising results from these early reports, our initial outcomes with the RSSAF, as performed by 6 fellowship-trained microvascular surgeons, were discouraging. We observed a high rate of venous congestion in an early group of patients, who did not respond to traditional rescue therapies of leg elevation and leech application (Fig. (Fig.1).1). Before abandoning use of the flap, we discussed this common issue among several surgeons from different institutions, and a few modifications were made to our operative technique. We hypothesized that increasing pedicle width would enhance venous drainage and improve flap survival. Herein, we describe our early experience with the RSSAF that resulted in a significant number of flap failures and the subsequent changes we made that led to better outcomes. Fig. 1. Representative flaps requiring leech therapy for critical venous congestion. (A) Partial flap loss because of venous congestion of an island-type reverse superficial sural artery flap (RSSAF) to the heel in a patient with an open calcaneal fracture. After ...