The clinical observation that a free TRAM hemiflap can survive when its vascular pedicle is anastomosed to the deep inferior epigastric vessels of a superiorly based TRAM hemiflap prompted the application of the same principle to improve the vascularity of the contralateral "random" portion of pedicled TRAM flaps. In 12 patients undergoing pedicled TRAM flap breast reconstruction, who were considered at risk for partial flap necrosis, the deep inferior epigastric vessels of the carrier rectus muscle were anastomosed to the contralateral deep inferior epigastric vessels harvested along with a small muscle plug containing three to five perforating vessels to the overlying skin island. A vascular arcade that joined the two sides of the flap was, thus, created, producing the following hemodynamic changes in the contralateral, previously "random" portion of the flap: (1) Direct arterial flow is supplied by the perforators coming from the underlying muscle plug; (2) Venous outflow follows the main and most favorable route to the ipsilateral deep venous system; and (3) The deep fat layer below the Scarpa's fascia, which is independent of the superficial vascular system, is connected directly to the deep system.