INTRODUCTION: The TRAM free-flap is our first choice for autologous breast reconstruction (ABR), however its use is precluded in cases of prior abdominoplasty or insufficient abdominal soft tissues. The superior gluteal free-flap (SGFF), although available in most women, is not widely accepted because it is more technically demanding. This study reviews our results and highlights the critical steps relevant to the successful use of this flap. METHODS: All patients who underwent SGFF breast reconstruction between 1991 and 2001 were identified, and a retrospective chart review was performed. RESULTS: One-hundred-six SGFF breast reconstructions were performed in the study population. Average age at the time of surgery was 44 years (range 18-70). Indications included breast cancer (76), Poland's syndrome (6), prosthesis-related complications (5), mastalgia/fibrocystic disease (2), and prophylaxis (17). Among cancer patients, the clinical stages were carcinoma in-situ (28%), stage 1 (9%), stage 2 (17%), stage 3 (20%), and unknown (26%). Flaps were unilateral in 64 patients, and bilateral in 21 patients (42 flaps). Perforator flaps were performed in 6 cases, while the remainder employed a muscle sparing technique. Fifty reconstructions (47%) were immediate and 56 (53%) were delayed. Recipient arteries were thoracodorsal (TD) 28%, internal mammary (IM) 68%, lateral thoracic (LT) 1%, and circumflex scapular (CS) 3%. Recipient veins were TD (27%), IM (57%), LT (2%), CS (3%), external jugular (EJ) 10%, and cephalic (1%). Complications included hematoma (4%), infection (3%), venous thrombosis (requiring revision of anastamosis, and selection of either EJ or cephalic veins as alternate recipient outflow vessels, due to size discrepancies) 8%, major flap necrosis (1%), fat necrosis (2%), pneumothorax (1%), and urinary tract infection (1%). One flap was lost to venous thrombosis and one flap was lost to post-operative trauma. The donor result was excellent in most patients with 2 minor wound problems. The average hospital stay for unilateral reconstructions was 5.1 days. The average hospital stay for 2 patients, who underwent simultaneous bilateral reconstructions, was 8 days. The average number of second stage revisions for unilateral and bilateral reconstructions was 1.3 and 1.6, respectively. CONCLUSIONS: Overall, the SGFF is a good source of soft tissue for ABR, and patient satisfaction is high. Flap elevation can be performed concomitantly with mastectomy. The SGFF is technically more difficult than the TRAM free-flap, mainly due to the delicate nature and large size of the superior gluteal vein, creating size discrepancies. Venous thrombosis is minimized by avoiding size mismatch; the EJ and cephalic veins serve as good alternative recipient veins. Using these guidelines, the incidence of flap loss should be very low.