Purpose: Options for improving the distal blood supply of a Transverse Rectus Abdominis Myocutaneous (TRAM) flap are limited. Surgical delay requires an additional procedure. A dual pedicle TRAM flap sacrifices both rectus muscles, leaving a pricey donor site defect. Free flap reconstruction, while minimizing both fat necrosis and abdominal wall complications, poses a 5% risk of total flap loss. Supercharging augments the flap with an additional blood supply by microanastomosis of the inferior epigastric vessels to chest wall vessels. This was initially described for the reconstruction of large chest wall defects and has been met with mixed reviews. We present our series of eighty-one patients who underwent a modified supercharged TRAM flap for breast reconstruction. We describe our experience with this flap and its evolution. Initally, the flap was utilized as a microvascular augmentation of the pedicled flap. We now mainly use this as a free TRAM flap supplemented by a muscle pedicle.

Methods: Between July 1997 and July 2007, Eighty-one patients underwent breast reconstruction with the supercharged TRAM flap by the author. The abdominal wall skin and fat was elevated on the contra-lateral rectus abdominis muscle and fascia. Initially, with the first series of patients, the entire rectus abdominis muscle was elevated. Later, this flap was modified to include only the central one-third of the rectus muscle. The ipsilateral deep inferior epigastric artery and veins were used to microvascularly augment the flap and usually anastomosed to the internal mammary vessels.

Results: A total of eighty-one unilateral breast reconstructions were performed during this ten year period. From 1997-1999, the entire rectus muscle was elevated to support the TRAM flap and supercharged (N=23). Over the next 5 years, we gradually transitioned to using only the central third of the rectus muscle . Due to uncertainty of the portion of rectus muscle harvested, this time period was not included in our analysis. From 2005-2007, only the central third of the rectus muscle was utilized to support the TRAM flap in addition to supercharging (N=14). We compared our data between the early (1997-1999) and late groups (2005-2007). Average operating time was 7 hours. There were no cases of total or partial flap necrosis in either group. 3 patients (13%) from the early group and 2 patients (14%) from the late group developed fat necrosis significant enough for operative excision. 3 patients (13%) from the early group and 1 patient (7%) from the late group developed abdominal wall hernia/bulge. There were 2 (8%) microvascular complications in the early group and 1 (7%) in the late group requiring re-exploration.

Conclusion: The modified supercharged TRAM flap is a reliable way to reconstruct mastectomy defects and the added pedicle blood supply serves as a salvage system in the event of free flap failure. Abdominal wall complications were minimized by elevating only the central third of the rectus muscle and utilizing the ipsilateral inferior epigastric vessels for supercharging.