Distally based sural fasciocutaneous flap is traditionally raised by the retrograde method. This article introduces the anterograde–retrograde method for harvest of the flap and describes our experience on altering the flap plan. A total of 159 flaps in 154 patients were elevated by the anterograde–retrograde approach that harvest of the flap began with exploring the peroneal artery perforators nearby the pivot point before the upper and bilateral edges of the flap were incised. Partial necrosis occurred in 16 (10.1%) flaps, and marginal necrosis developed in 10 flaps. Nine flaps were redesigned with adjusted pivot point and skin island. The anterograde–retrograde approach for harvest of the flap can accurately locate the perforator, readily adjust both the pivot point and skin island if necessary, and thus improve reliability of the flap. This approach is particularly applicable for elevation of the flap without preoperative localization of the perforators by means of the Doppler. © 2012 Wiley Periodicals, Inc.