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The authors reviewed the outcome of 12 patients who underwent soleus flap reconstruction of distal third lower extremity defects. Nine of the 12 patients achieved a healed, stable wound; however, several flaps and multiple additional procedures were often required. One of the 12 patients experienced soleus flap loss and two of the patients required below-knee amputations. Failure of limb salvage was related to traumatic injuries or comorbid conditions such as peripheral vascular disease, smoking, and planned radiation. They conclude that these factors should be considered relative contraindications to the use of the soleus flap in the distal third of the leg, and that free flap coverage is the most reliable option for these high-risk patients.