Purpose: Currently the possibilities for autologous breast reconstructions are limited in general to the tissue sources of the lower abdomen and the superior gluteal region. A common draw back of these methods is the visible donor site scar. Whereas the scar of the transverse myocutaneous gracilis (TMG) free flap with a transverse orientation of the skin paddle in the proximal third of the medial thigh region is totally hidden in the natural crease of the thigh. The TMG-flap allows in selected patients to take a moderate amount of tissue for autologous breast reconstruction. The incision lines and the donor-site morbidity is similar to a classic medial thigh lift. The indication for this flap in autologous breast reconstruction and the surgical technique will be discussed. Methods: From 8/2002 to 5/2003, 15 autologous breast reconstructions with the TMG-flap were performed in 12 patients. The patients’ ages ranged from 26 to 48 years with the median age of 40 years. 3 BRCA-positive women received a bilateral breast reconstruction during prophylactic skin-sparing mastectomy, and 9 patients received immediate breast reconstruction after skin-sparing mastectomy in early-stage breast cancer. Results: Mean follow up of the 12 patients was 7 months (range 1 to 10 months). We had no free-flap failure. Four patients had small areas of ischemic skin necrosis related to very thin preparation of the skin envelope after skin-sparing mastectomy without altering the final good aesthetic results. There was no functional donor-site morbidity caused by harvesting the gracilis flap and a very inconspicuous donor site scar was encountered. Conclusion: The TMG-flap is a valuable alternative for immediate autologous breast reconstruction after skin-sparing mastectomy in selected patients and has become the first choice option for small to moderate breast reconstructions even before tissue sources from the lower abdomen and gluteal region. We are convinced that this method will win recognition in the next years for it’s technical ease compared to the demanding perforator surgery and the most pleasing donor site.