Given favorable conditions, breast reconstruction with the TRAM-flap yields the best results. However, because of limited blood flow in the flap after dissection, partial flap necrosis occurs frequently. To avoid this, a bipedicled flap has been used. Although complications are substantially fewer, the necessity for improvement of flap perfusion still remains. We have carried out breast reconstruction using the TRAM-flap in 66 cases to date. In two of these, the vascular system of the deep inferior epigastric artery and vein were successfully anastomosed (end-to-side) with the thoracodorsal vessels. Although this technique was more time consuming and entailed cooling, it has proven to adequately protect the flap. Careful dissection and preservation of the deep inferior epigastric vessels is mandatory.