Background Reconstructions the soft-tissue defects of the distal lower extremities in the elderly patients (≥ 60 years old) are full of challenges because of many comorbidities. The purpose of this study was to report the clinical application of the distally based sural flap in the elderly patients, and to verify the reliability of this flap in the elderly patients. Methods Between March of 2005 and December of 2019, 53 patients aged over 60-year-old and 55 patients aged 18 to 30-year-old who

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... derwent the procedure have been included in this study. The reconstruction outcomes, medical-related complications, flap viability-related complications and potential risk factors are compared between the group A (≥ 60 years old) and group B (ranging from 18 to 30 years old). Results The partial necrosis rate in group A (9.43%) is higher than group B (9.09%), but the difference is not significant (P > 0.05). The constitute ratio of the defects that were successfully covered using the sural flap alone or combining with simple salvage method (i.e., skin grafting) is 96.22% and 98.18% in group A and B, respectively (P > 0.05). The differences of the risk flaps factors that affected the survival of distally based sural flap were not significant between group A and B (P > 0.05). Conclusions The distally based sural flap can be effectively used to repair the soft-tissue defect of the lower extremity in the elderly patients. It is safe and reliable to harvest and transfer the flap in one stage, and the delay surgery is not necessary.