The distally based sural flap (DBSF) has become increasingly used in reconstruction of the foot and the lower leg. In DBSF, however, flap failure rates may be increased especially when applied to high-risk patients with vascular disturbance such as diabetes mellitus or peripheral arterial disease. Delay procedure has been used to prevent flap necrosis and other complications. We report our modifications of delayed DBSF. We created five delayed DBSFs in five patients. Our standard delay procedure has two stages. In the first stage, the flap is raised except for the pedicle. In the second stage, the entire flap including the pedicle is raised after 7-12 days. In 2 patients, DBSFs were raised by another method, involving re-anastomosis of the short saphenous vein (SSV) to relieve critical flap congestion combined with our standard delay procedure. Flap elevation with re-anastomosis of the SSV was followed by ligation of the SSV after 6-10 days and then by raising of the entire flap at 13-14 days after the initial procedure. All of the flaps took completely. Our modifications of delayed DBSF were useful for high-risk patients with vascular disturbance such as diabetes mellitus or peripheral arterial disease.