Patients are well informed and seek autogenous breast reconstruction. The motivating factors include a preference for autologous tissue reconstruction and the complementary improvement in body contour, safety concerns surrounding implants, and implant-related complications in the setting of previous radiation therapy. In this article a variety of perforator flaps from donor sites that include the trunk (thoracodorsal artery perforator and intercostal artery perforator), abdomen (deep inferior epigastric artery perforator and superficial inferior epigastric artery), and buttock (superior gluteal artery perforator and inferior gluteal artery perforator) are described. Flaps from the trunk can be pedicled for partial breast reconstruction, and free flaps from the other donor sites can completely restore a natural-looking breast. The information obtained from preoperative CT and MRI can direct the surgeon toward the most successful operative plan. However, the decision as to which flap may be most appropriate for an individual patient is complex. This article reviews pertinent surgical anatomy, preoperative planning, intraoperative decision making in flap elevation, and reported outcomes.