Free tissue transfer has become a routine part of reconstructive surgery. To study the evolution of free flap procedures for breast reconstruction in a city hospital setting (Bellevue Hospital Center in New York City), we reviewed the records of all patients who underwent breast reconstruction with free tissue transfer from 1/1/1990 to 12/31/2001. In this hospital, residents provide the majority of patient care under direct attending supervision and participation. The following parameters were examined: Type of flap, length of stay, operative time, delayed vs. immediate reconstruction, need for blood transfusion, use of anticoagulants, comorbid conditions, and complication rate. Procedures performed during the last two years were compared to those of the first ten years of the study. 46 patients underwent breast reconstruction with free flaps during the study period; 33 during the first ten years and 13 during the last two years. There was a decrease in the length of hospital stay and number of blood transfusions over the recent years. There was an increase in the number of patients requesting immediate breast reconstruction. The anesthesia records documented a trend towards shorter operative times. The length of the procedures for immediate and delayed reconstructions was similar. Aspirin was used in nearly all cases. Free flaps have become the procedure of choice when autologous breast reconstruction is desired. TRAM flaps remain the most often used tissue for this purpose. We conclude that microvascular free tissue transfer is a reliable and safe option for post-mastectomy reconstruction at a city hospital. The establishment of a comprehensive and multidisciplinary breast cancer team is an important factor for better patient education and higher degree of satisfaction. Pre-operative planning and coordination between the ablative and reconstructive teams have resulted in shorter operative times, improved aesthetic results utilizing skin sparing mastectomy techniques, and better patient outcome. Based on the findings of this study (shorter operative times and decreased need for blood transfusion), we do not consider routine pre-operative autologous or donor-directed blood donation as necessary or cost effective.