The single-pedicled transverse rectus abdominis musculocutaneous (TRAM) flap is prone to partial flap loss and fat necrosis, especially in high-risk groups such as patients who smoke, irradiated patients, and obese patients. Possible methods to increase the reliability of the TRAM flap include the free TRAM, the double-pedicled TRAM, and the surgically delayed TRAM. When we traveled overseas to an underserved area we were largely unable to implement these options due to limitations in equipment, supplies, and the length of our trip. We encountered a combined fat necrosis and partial flap failure rate of 27% (3 of 11 patients) in a group of heavily irradiated patients. On subsequent trips we employed a technique of acute ischemic preconditioning of the TRAM flap in 5 high-risk patients and 1 low-risk patient with good results. Although this preliminary experience is too small to draw conclusions about clinical efficacy, it does demonstrate the feasibility of performing ischemic preconditioning in a musculocutaneous flap in a clinical situation.