Reconstruction of the first ray is challenging because of poor skin laxity, bone and tendon exposure, and limited local flap options. Repair using full- or split-thickness skin grafts is generally not an option because of the bone and tendon exposure. Reconstructive options using local flaps from the distal foot area are restricted owing to insufficient soft tissue. Many reconstructive options have been described to overcome these difficult situations. We present 2 cases in which the great toe and first ray defect were repaired using a reversed first dorsal metatarsal artery island flap. The findings from these clinical cases and anatomic studies have shown that the reversed first dorsal metatarsal artery island flap is an alternative and suitable option for reconstruction of soft tissue defect of the distal foot, especially first and second ray defects, because it is thin and simple, has anatomic characteristics similar to those at the recipient site, and results in minimal donor site morbidity.