BACKGROUND The gracilis myocutaneous free flap provides an alternative for autologous breast reconstruction. It avoids abdominal donor-site morbidity, allows for a quicker recovery, provides an alternative to the thin patient with a hidden and acceptable donor site, and allows for supine positioning for harvest and inset in a timely fashion. METHODS A retrospective review was conducted of all autogenous postmastectomy reconstructions performed between January of 2005 and March of 2008. All patients receiving gracilis myocutaneous flap reconstruction for postmastectomy defects were included in this study. Office and hospital charts were reviewed. RESULTS Twenty-seven gracilis flaps were performed during the study period. Average patient age was 50.4 years (range, 35 to 63.4 years), and average body mass index was 25.6 (range, 19.4 to 35.5). Of the 21 patients, 9.5 percent had hypertension, 19 percent smoked, none were diabetic, 14 percent were obese, and 4.8 percent had documented cardiovascular disease. Outcomes included a flap success rate of 100 percent, average operating time of 4.9 hours for unilateral (15 patients) and 6.7 hours for bilateral (six patients) flaps, intraoperative arterial thrombosis rate of 13.6 percent, average hospital stay of 3.75 days, major complication rate of 7.4 percent, and average follow-up of 7 months. CONCLUSIONS The gracilis myocutaneous free flap provides an alternative breast reconstruction option for today's breast cancer patient. It allows for a quick harvest in the supine setting, creation of a moderate breast volume, consistent anatomy, and acceptable donor-site morbidity with good contour.