Some women electing immediate bilateral postmastectomy breast reconstruction have inadequate autologous tissue to achieve an aesthetic result and also wish to avoid tissue expansion or a back scar. These patients are candidates for reconstruction using free transverse rectus abdominis musculocutaneous (TRAM) flaps and breast implants. Since November 1993, 5 women have been reconstructed bilaterally with a combination of free TRAM flaps and adjustable saline breast implants. Each patient was young (age, 29–47 years) and of slender body habitus. During the procedure, the implants were placed in a submuscular pocket formed by the pectoralis major, the serratus anterior, and the muscular portion of the TRAM flap. Careful approximation of the serratus anterior to the lateral border of the pectoralis major muscle created a reliable layer of tissue to protect the vascular pedicle of the TRAM flap from contact with the implant. The saline chambers of the implants were filled to 60% to 80% capacity at the time of surgery. TRAM flap skin was tailored to precisely replace missing breast envelope, and subcutaneous fat increased implant coverage, creating a mound with normal-appearing ptosis. There were no occurrences of microvascular thrombosis. Three patients experienced prolonged formation of serous fluid, with 2 patients requiring late aspiration of a serosa after drain removal. Although there were no documented infections, 1 patient experienced postoperative erythema of the mastectomy skin flaps and was treated empirically with antibiotics with resolution of the erythema. All breasts have remained soft and appear natural. Using free TRAM flaps and adjustable saline breast implants allows selected women to undergo immediate breast reconstruction without the need for prolonged tissue expansion or back scars. Aesthetic results are excellent and the immediate use of an implant does not appear to pose a risk to the success of the free tissue transfer.