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Soft tissue reconstruction of distal third leg, heel and ankle region is a challenging problem because of poor vascularity and limited mobility of skin. The reverse sural artery with ideal flap thickness, minimal donor site morbidity, lack of functional muscle loss, short recovery time, wide arc of rotation and safe vascularity makes it a preferable flap for covering such defects. AIMS AND OBJECTIVES: To study various modifications of distally based reverse sural artery flap to suit the defects and for better survival of flaps. RESULTS: It is a retrospective study conducted in our institute to cover the distal leg and foot defects.60 cases of distal leg defects exposing vital structure who underwent reverse sural artery flap coverage were included in the study .5 of the 60 flaps had complete flap necrosis and another11 flaps had partial necrosis.73.4% of the flaps survived during the follow up period of 1 years with good functional outcome. CONCLUSIONS: Reverse sural artery flap with its modifications is a good flap for the defects of distal leg, heel and ankle defects. KEY WORDS: Reverse sural artery flap, modifications, distal leg defects. Mesh terms: Reverse sural artery flap, modifications, distal leg defects. INTRODUCTION:Soft tissue reconstruction of the lower third leg, ankle and foot region is a challenging problem. The major problem is the poor vascularity and limited mobility of the skin. Tendon, bone and hardware are frequently exposed because of the thinness of subcutaneous tissue making possibility of skin grafting a poor option. A durable flap with good skin texture, reliable vascularity, good arc of rotation, ease of dissection with minimum donor site morbidity is the most desired option for covering such defects.The different local flaps for hind foot defects including dorsalis artery flap 1 , abductor hallucis and abductor digiti minimi muscle flaps 2,3 have inadequate tissue and limited arc of rotation thereby limiting their frequent use. Medial plantar artery flap is an excellent option for weight bearing heel but its involvement in trauma frequently precludes its use.Locoregional flaps for lower leg and ankle defects such as the peroneal artery flap, anterior tibial artery flap and posterior tibial artery flap 4-6 have the disadvantage of sacrificing a major artery in already traumatized limb. Supramalleolar flap 7 is another option but its reliability is questionable in compromised vascularity. Morbidity and operative times are increased in technically demanding microvascular surgeries 8,9 . Ideal flap thickness and quality, minimal donor site morbidity, the lack of functional loss, short recovery time , the wide arc of rotation and safe vascularity are the significant advantages of the reverse sural artery flap.Masquelet et al 10 Introduced the sural flap in 1992 with concise description of relevant anatomy and the surgical procedure. After the work of Masquelet et al distally based sural fasciocutaneous flap has become a mainstay in the reconstruction of the lower leg, ankle and ...