In the field of orthopaedic surgery, the lower leg is often treated by free vascularized tissue grafts. In performing these grafts for reconstruction of the lower leg, the anterior tibial artery and its venae comitantes are frequently selected as anastomosing recipient vessels. However, due to the deep location of the anterior tibial vessels, it is extremely difficult to accomplish antegrade microsurgical anastomoses between the donor vessels and the anterior tibial vessels. This technical difficulty often leads to the possibility of immediate postoperative arterial and venous occlusion. To resolve this problem, the idea of a reverse-flow island flap has been applied to the free vascularized tissue grafts for reconstruction of the lower leg, based on both artery and vein reconstructed with retrograde blood flow. To evaluate clinical outcomes of the procedure mentioned, the postoperative results of 14 patients were reviewed. The free vascularized grafts consisted of seven vascularized fibular grafts with peroneal flaps, six vascularized latissimus dorsi myocutaneous flaps, and one vascularized groin flap. Venous congestion of the flap was not observed and all flaps survived. Bone union was obtained in seven patients treated with vascularized fibular grafts. There were no serious postoperative complications. Distally-based free vascularized tissue grafts in the lower leg are useful procedures in reconstruction of massive bone defects and osteomyelitis of the tibia, and for skin defects on the anterior aspect of the lower leg.