The most natural results in breast reconstruction are those completed with versions of the TRAM flap. The Transverse Rectus Abdominal Musculocutaneous Flaps are designed to use the extra skin and fat of the abdomen to create the ideal soft and normal appearing breast. It’s the patient’s own tissue so implants are usually never needed. The microsurgical Tram procedures are among the most sophisticated operations done in plastic surgery. They are very technically demanding sewing very small blood vessels together, but the results are often fabulous and the abdomen muscles remain mostly functional. This patient had a skin sparing mastecomy with a Tram flap and supercharged microsurgery component where an additional anastamosis of blood vessels improves blood flow and can enhance results and flap viability.