Pedicle flaps to cover soft tissue defects of the foot, ankle, and lower extremity are invaluable. However, venous congestion and flap necrosis, a common complication, poses greater morbidity to the patient as few remaining options for attempted limb salvage remain. The authors discuss how to prevent flap failure by allowing close observation and strict offloading of the pedicle flap through current external fixation designs. This article also discusses the role of medicinal leeches in reestablishing blood flow through the pedicle flap to prevent tissue necrosis. In addition, the use of hydrosurgery as an innovative technique offers the surgeon another option if faced with pedicle flap necrosis.