In the fibular osteocutaneous flap, the supplying perforators of the skin paddle are usually from the peroneal artery through the posterior crural septum between peroneus muscles and soleus. 4 The perforators of the peroneal artery are relatively constant, the number of which is usually 1 to 3, generally located in the middle and distal segments of the posterior crural septum. 5 If the perforators of the posterior crural septum are completely absent, some remedial measures should be taken. In this case, we raised a skin paddle based on the peroneal artery tibialis anterior cutaneous perforator, which successfully rescued traditional perforator's absence and avoided exploration for a second donor site, thereby precluding the search for another set of recipient vessels and saving time. The choice of the tibialis anterior cutaneous perforator as a backup was identified by retrograde dissection and confirmed originating from the peroneal artery. The perforator was dissected retrogradely through the peroneus brevis muscle on the surface of the peroneus and flexor hallucis longus emanating from the peroneal artery. The perforator originated from the peroneal artery and entered the anterolateral intermuscular septum through flexor longus and peroneus brevis. Moreover, it has been reported in the literature that the peroneus brevis muscle flap can be retrogradely transposed to repair the soft tissue defects of the lower one third of the leg and the ankle, 6 which provided the anatomical basis of this method.In summary, we report for the first time that the skin paddle from tibialis anterior cutaneous perforator of peroneal artery is reliable and practical for the reconstruction of composite defects, which can be used as a backup skin paddle when the traditional peroneal perforator is absent or lost. FIGURE 2. (A) Surgical imaging of peroneal artery tibialis anterior cutaneous perforator skin paddle. White arrows show the skin perforator. (B, C) The anterior medial side of the fibula used as the outer side of the mandible to shape and fix.