Skin blood flow in the free TRAM flap has been shown to be superior to that in the pedicled TRAM flap, and in 1990 the free TRAM flap was adopted as the procedure of choice for breast reconstructions. The findings in the first 50 patients whose breasts were reconstructed with free microvascular TRAM flaps are reported. Although 92% of the patients had undergone previous axillary operation and 78% had received radiotherapy, recipient vessels could be found in all axillae. Fortyeight patients had unilateral and two bilateral reconstructions, Reduction or mastopexy was performed on the opposite breast in 50% of the patients. One flap was lost. Skin edge necrosis was found in two patients. Acceptable results with good symmetry or slight asymmetry were achieved in 96%. Seven patients had abdominal laxity due to use of Gore-Tex sutures for closure. Abdominal wall complications ceased once the suture material was changed. The complication rate decreases quickly, as experience increases. Nineteen immediate postoperative or later complications occurred in the first 25 free TRAM flap patients but only 5 in the second 25 patients. The free TRAM flap results in fewer skin problems and is an easier operation for the patient than a pedicled TRAM.