Introduction: This is the first study to use the redefined WHO parameters for obesity to define complication rates and associated co-morbidities using the pedicled TRAM flap. Methods: 112 women underwent breast reconstruction using a pedicled TRAM flap at UTMB over a twelve year period. The patients were divided into four groups: ideal weight (BMI 19-24.9), overweight (25-29.9), obese (30-39.9) and morbidly obese (>40). Complications included fat necrosis, hematoma/seroma, hernia, flap loss, wound infection, DVT and PE. Co-morbidities such as HTN, vascular disease, DM, COPD, and tobacco were considered. Results: The complication rate for all patients was 42%. In the ideal group (N=30), the rate was 27%; overweight group (N=38), 39%; obese group (N=38), 47%; and morbidly obese group (N=6), 100%. Statistics comparing ideal group versus the overweight and obese group was not significant (p=0.27 and p=0.083). The morbidly obese group showed significance (p<0.01), however, the sample size was much smaller. In the obese group, patients with numerous co-morbidities showed a greater complication rate than those with few or no co-morbidities (p=.21). Conclusion: The TRAM flap may be used successfully in overweight and certain obese patients. One approach to risk stratification for surgery in obese patients is the number of co-morbidities.