Summary: Breast reconstruction has evolved significantly during its short, 40-year history. What began as limited reconstruction through the use of local skin flaps has now become an entire array of procedures including novel autologous flaps and new techniques in implant/expander use. Throughout this evolution, the primary goal of reconstruction has always remained the same: to recreate the most natural breast mound possible. In the early 1980s, autologous tissue was at the forefront of breast reconstruction, and the pedicled transverse rectus abdominis myocutaneous (TRAM) flap quickly became the reconstructive method of choice for tissuebased reconstruction. Despite the advent of microsurgery, advances in perforator-based flap design, and increasing procedural complexity, the pedicled TRAM flap is still one of the most common methods of autologous reconstruction performed today. In properly selected patients, the pedicled TRAM flap can provide a natural appearing breast mound with limited morbidity and superior patient satisfaction.