Of 114 patients who had TRAM flap breast reconstruction, 46 (40 percent) had preexisting abdominal surgical scars. Sixty-six free TRAM flaps and 9 pedicled TRAM flaps were performed in the 46 patients. The records were analyzed to determine what impact, if any, abdominal scars had on postoperative complications. There were no reconstructive failures or significant (>25 percent) flap losses. Eight minor complications occurred in 7 patients (15 percent). The incidences of abdominal-wall weakness (4.3 percent), partial flap loss (4.3 percent), minor fat necrosis (4.3 percent), and donor-site wound problems (4.3 percent) were acceptable. Subcostal scars and multiple abdominal scars were found to predispose to skin complications. Right lower paramedian scars precluded free TRAM flaps because of damage to the inferior epigastric vessels in three of three patients. Both obesity (p = 0.003) and smoking (p = 0.05) were associated with a greater risk of wound-healing complications. We conclude that with certain technical modifications, TRAM flap reconstruction is a safe and effective procedure in patients with abdominal scars.