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After studying this article, the participant should be able to: (1) Describe the anatomy of the posterior lower leg as it is relevant to the distally based sural flap. (2) Describe the basic surgical technique of the distally based sural fasciocutaneous flap. (3) Understand the common complications associated with the sural flap and their approximate incidences in both a healthy and a multimorbid patient population. (4) Describe how skin, fascia, and muscle can be used to customize the sural flap for different purposes. (5) Understand the various modifications of the sural flap that have been described in the literature.Over the past decade, the distally based sural flap has become increasingly used in reconstruction of the foot and lower leg. The rise in popularity of this flap has been paralleled by an increase in the number of cases, innovations, and technical refinements reported in the medical literature. This review summarizes the 79 publications in the English language literature on the subject of the distally based sural flap. The anatomical studies are summarized in a unified description of the relevant flap anatomy. The flap’s indications and composition and a variety of modifications are described. Technical aspects are discussed and clinical insight to minimize complications is provided. In conclusion, the distally based sural flap offers an alternative to free tissue transfer for reconstruction of the lower extremity.