Many studies have demonstrated the benefits of post-mastectomy breast reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap. Initially, surgeons offered this reconstructive option to patients with early disease with good results. TRAM flaps in advanced cancer patients were often only considered for complex chest wall defects following an extensive resection. Good results in this select population without interference with adjuvant therapies (chemotherapy and radiation therapy) led surgeons to more frequently offer the TRAM flap to all patients including those with advance disease. This study presents the author’s experience with TRAM flap breast reconstruction in patients with Stage III-IV breast cancer over a 10-year period, including an informal survey of patient satisfaction. 21 patients were identified with a mean age of 48.6 years (range 35-73 years). All patients had stage III disease, except one who had stage IV breast cancer. A total of 26 TRAM reconstructions were performed by the same surgeon. Post-operative complications included fat necrosis (3 patients), hematoma (1 patient), cellulitis (1 patient), poor donor site healing (2 patients), and seroma (1 patient). Follow-up time from time of TRAM reconstruction to survey averaged 6.5 years (range of 2-10 years). Of these 21 patients, 9 (42.9%) died primarily due to metastasis. Only 1 patient had definite local recurrence of the tumor. The average interval of time between TRAM flap and death was 3.7 years (range 1-6.5 years). The average recovery time before patients were able to return to normal activities or work was 10.6 weeks (range 3-36 weeks). 8 patients and 3 surviving family members participated in the patient satisfaction survey for a total of 11 completed surveys. Of the 11 patients or family’s that completed the survey, 11 (100%) would repeat the TRAM reconstruction. The results of this study indicate that patients with locally advanced breast cancer would consider reconstruction if offered the option again and have a lengthy disease free interval following their reconstruction.