Introduction: Ipsilateral compared to contralateral rotation of the TRAM flap has aesthetic advantages by maintaining the xiphoid and medial IMF contour. Our purpose was to evaluate the safety of this technique. Methods: We retrospectively evaluated a single surgeon's experience with 32 consecutive contralateral and 58 consecutive ipsilateral TRAM flaps. With a six month minimum follow-up, the rates of partial and total flap loss, fat necrosis, and major/minor complications were compared using chi-square analysis and multiple logistic regression was used to assess the effects of procedure type on complication rates, while controlling for potential confounding variables. Results: Comparing ipsilateral to contralateral pedicle TRAM patients, the rate of a major complication was 19.0% and 18.8%, respectively, p = 0.68; a minor complication was 53.5% vs. 53.1%, respectively, p=0.98; fat necrosis was 19% vs. 25%, respectively, p=0.50; and partial flap loss was 12% vs. 15.6%, respectively, p=0.75. When controlling for potential confounders, the type of pedicle TRAM flap had no significant effect on the above complications. Conclusion: The ipsilateral pedicle TRAM flap appears as safe as the contralateral technique for breast reconstruction. Given the increased pedicle length and preservation of both the medial IMF and xiphoid hollow, we prefer the ipsilateral pedicle technique.