Although free flap has largely replaced pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, the latter has also evolved by increased understanding of anatomy and physiology. We report the outcomes in 500 consecutive pedicled TRAM in Asian patients performed by a single surgeon, providing incidences of complications and ideas of prevention. Fascia was minimally harvested with full width of muscle. The eighth intercostals nerve was severed and back-cut was made at the lateral belly. Anterior rectus sheath was directly repaired. Breast complication occurred in 24.6% with the most common being skin envelope necrosis. Major flap loss occurred in 1 (0.2%), and the incidence of fat necrosis was 14.2%. Abdominal complication rate was 16.4%, and bulging occurred in 3%. Exercise performance was almost completely restored after 1 year. Pedicled TRAM is still a competitive procedure with overall flap survival rate of 99.8%, yielding consistent results with acceptable complication rates for most patients under experienced hands.