Since the introduction of the TRAM flap by Dr. Carl Hartrampf 20 years ago, this operation has proved to be the most successful in producing a natural breast after mastectomy. In recent years, the free TRAM flap has been used more frequently due to better profusion of the tissues and less significance of the donor site. This has been accompanied by increasingly widespread familiarity with microsurgical technique. The details of the free TRAM flap harvest and insertion, along with breasts shaping, will be presented in this video. The pedicle TRAM flap continues to be useful for bilateral breast reconstruction and in patients with certain types of scarring. The double pedicled TRAM will be presented to demonstrate its versatility.