Abdominal Flaps (TRAM or DIEP)

The benefit of TRAM and DIEP flaps is that a large and ptotic (droopy) breast can be created and the reconstructed breast has the look and feel of a normal breast and will not go hard in the future, unlike implant-based reconstructions.

The abdomen is the best source of tissue to reconstruct a larger breast. It uses the same tissue that is removed during a tummy tuck which is an added benefit of this procedure. This does mean that only patients who have excess lower abdominal tissue will be candidates for a TRAM or DIEP flap. The scarring on the abdomen is the same as that following tummy tuck and runs from one hip to the next (often this can be hidden in a bikini) and around the belly-button.

* This lady has had a right DIEP flap breast reconstruction with a nipple reconstruction and fat grafting to her reconstructed breast following a right mastectomy for breast cancer. She has had no surgery to her left breast and is shown here nearly 2 years following her original surgery.
* This lady has had mastectomy of both breasts as she carries the BRCA2 gene and immediate breast reconstruction with free DIEP flaps from her abdomen followed by bilateral nipple reconstruction. She is shown here a year following her original surgery.
* Please note that results may vary from person to person


A free flap is one of the most technically demanding operations that plastic surgeons perform. Only surgeons specifically trained in microsurgery are able to do this surgery and these are few and far between. The blood vessels to the abdominal tissue are divided and reconnected in the chest using the operating microscope. This is time consuming and takes longer than a pedicled TRAM flap. The main benefits are that less rectus abdominis muscle is taken with the flap (no muscle is taken with a DIEP) and so there is less chance of hernia, bulge or weakness in the abdomen. The blood supply to the transferred tissue is also better and so there is less chance of parts of the flap dying, whiich usually manifests itself as hard lumps, or fat necrosis. The drawback is that the surgery is longer and there is a risk that the microvascular anastamosis may fail. In this situation, the patient needs to return to theatre for urgent re-exploration to salvage the flap. In approximately 5% of cases, the flap cannot be salvaged and needs to be removed.

Pedicled TRAM Flap

A pedicled TRAM flap involves raising the abdominal tissue and leaving the muscle attached at the upper end (it is totally free in a free flap). It is then tunnelled in to the breast defect to reconstruct the breast. The blood supply to a pedicled TRAM is not as good as that of a free flap. This means that a smaller breast is created and there may be more problems with some parts of the flap not surviving and fat necrosis. Because the blood supply is not as good with a pedicled flap, some muscle is always taken with the flap and there is no perforator based equivalent (like a DIEP flap).

Limitations and Complications

Truncal instability – the rectus abdominis muscle is an important stabiliser of the trunk and loss of this muscle may affect this, particularly in patients who suffer from back pain.

Abdominal wall weakness / bulge / hernia – harvest of the rectus muscle along with the anterior rectus sheath can result in a bulge or hernia if the resulting closure of the sheath weakens. This may require operative repair, usually with a prosthetic mesh.

Upper abdominal bulge – the part of the muscle that is tunnelled from the abdomen in to the breast may create a bulge in the upper abdomen. This only occurs in pedicled TRAM flaps.

Flap loss – if the blood supply to the reconstructed breast is inadequate, then some of it may die. This may manifest itself as some of the skin going darker and eventually black, which may need to be removed. If the fat dies rather than the skin, this causes hard lumps called fat necrosis. These will soften in time, but may need to be removed if they are persistent. It is important to distinguish fat necrosis from recurrence of the breast cancer, so any hard lumps should be examined by your doctor.

Wound breakdown – there will be wounds on the abdomen and the breast. In cases of immediate reconstruction, the mastectomy skin may be thin and occasionally breaks down leaving raw patches. These can be left to heal but may need skin grafting. Wound breakdown is much more common in smokers and overweight patients (BMI over 30).

Asymmetry – Asymmetries can be addressed by augmenting the reconstructed breast or by performing a mastopexy (uplift), reduction or augmentation to the opposite breast.

  • What is the difference between a DIEP and TRAM flap?

    Plastic surgeons have always had an understanding of the blood supply to the skin to allow them to safely move tissue from one place to another. In situations where the blood supply to the skin comes through the underlying muscle, the muscle is traditionally taken with the skin to allow it to be safely transferred with its blood supply. The advances in the knowledge of the circulation to the skin, together with the growth of microsurgery have led to so-called ‘perforator flaps’. These involve removing only the tissue that is required, ie skin and fat, and leaving the muscle behind. They are more technically demanding operations but it is better for the body to have the muscles left behind.
    A TRAM flap involves removing the rectus abdominis muscle (the six pack) to allow safe transfer of the lower abdominal skin and fat to the breast.. A DIEP flap is a perforator flap and it involves removing only the skin and fat of the lower abdomen and leaving the muscle behind to prevent the weakness and bulge that can be associated with a TRAM flap. A free DIEP flap is considered the gold standard in breast reconstruction. Sometimes a suitable perforator to the skin and fat cannot be found, in which case some muscle may need to be taken, this is a free TRAM flap (or muscle sparing free TRAM flap).