The demand for the breast reconstruction continues to grow following the acute increase in the incidence of breast cancer in Korea. The pedicled transverse rectus abdominis musculocutaneous (TRAM) flap is one of the most commonly used methods among the autologous breast reconstruction options. A pedicled TRAM flap consists of the lower abdominal skin, subcutaneous fat tissue, and one of the rectus abdominis muscles. The blood flow to the flap is supplied through the muscle perforators, which should be strictly selected and preserved. This flap can provide sufficient healthy tissue, which can create the most ideal breast shape. Although the free flap has largely replaced the pedicled TRAM flap, the latter has also evolved with increased understanding of anatomy and physiology. Furthermore, if refined techniques are applied, complications can be minimized and comparable outcomes can be achieved. Besides all the advantages of autologous tissue breast reconstruction, the most distinct feature of the pedicled TRAM flap over the free flap is simplicity of flap elevation and elimination of the microsurgical crisis. The pedicled TRAM flap is still a competitive procedure, yielding consistent results with acceptable complication rates for most patients and should be considered as a primary option for breast reconstruction.