The posterior tibial artery free flap was first described in 1983 but not used in head and neck reconstruction until 1991. While used extensively in extremity reconstruction, the posterior tibial artery free flap remained largely underutilized in head and neck reconstruction until the 2000s. The arterial supply of the flap derives from the posterior tibial artery with drainage via the associated venae comitantes. Like the forearm, the anatomy of the posterior tibial artery is relatively consistent and includes the benefit of a long pedicle, large caliber vessels, the potential for perforator-based reconstruction, a well-concealed donor site, and a thickness between a forearm flap and an anterolateral thigh flap.