The transverse myocutaneous gracilis free flap with a transverse orientation of the skin paddle in the proximal third of the medial thigh region allows the taking, in selected patients, of a moderate amount of tissue for autologous breast reconstruction. The donor-site morbidity is similar to that of a classic medial thigh lift. The indication for this flap in autologous breast reconstruction and the surgical technique will be discussed in this article. From August of 2002 to March of 2003, 10 patients underwent autologous breast reconstruction with 12 transverse myocutaneous gracilis free flaps. The patients’ ages ranged from 26 to 48 years (median, 40 years). Of those, two BRCA-positive women received bilateral breast reconstructions after prophylactic skin-sparing mastectomy, and eight patients received immediate breast reconstruction after skin-sparing mastectomy in early-stage breast cancer. Mean follow-up of the 10 patients was 5 months (range, 1 to 9 months). We had no free-flap failure. Four patients had small areas of ischemic skin necrosis related to very thin preparation of the skin envelope after skin-sparing mastectomy without altering the final aesthetic results. Cosmetic evaluation of the reconstructed breasts and thigh donor site by two plastic surgeons showed good results in nine patients and fair results in one patient. There was no functional donor-site morbidity caused by harvesting the gracilis flap. The transverse myocutaneous gracilis flap is a valuable alternative for immediate autologous breast reconstruction after skin-sparing mastectomy in patients with small and medium-sized breasts and inadequate soft-tissue bulk at the lower abdomen and gluteal region.