Lower extremity reconstruction is challenging, especially in elderly patients with comorbidities such as atrial fibrillation. Pedicled perforator flaps offer a reliable alternative to free tissue transfer and musculocutaneous flaps, minimizing donor site morbidity and avoiding microsurgical techniques. We report the case of an elderly patient with new onset atrial fibrillation who underwent reconstruction of a lower extremity defect using a peroneal artery perforator flap. Despite the absence of an audible Doppler signal intraoperatively, the flap survived completely. Although studies have shown that both new-onset and preexisting atrial fibrillation increase the risk of free tissue transfer failure and patient mortality, to our knowledge, no previous cases have described perforator flap reconstruction in patients with atrial fibrillation. This case demonstrates that peroneal artery perforator flaps can be safely and effectively used in an elderly patient with atrial fibrillation, highlighting their feasibility even when preoperative Doppler signals are absent.