Three significant advances are responsible for the recent evolution in breast reconstruction. The first of these is the introduction of the transverse rectus abdominis musculocutaneous (TRAM) flap, which made reliable autologous breast reconstruction a reality. The subsequent application of microsurgical principles to this procedure brought further refinements in terms of improved blood supply and lessened donor site morbidity. Finally, the wide acceptance of the skin-sparing mastectomy by oncologic surgeons has allowed further progress in the aesthetic possibilities that can be realized by the plastic surgeon. The authors discuss each of these factors and provide an overview of the current state of the art of autologous free tissue breast reconstruction.