TRAM Flap vs DIEP Flap: What’s the Difference?

By: Dr. Minas Chrysopoulo


Up until a few years ago, the TRAM flap was the gold standard in breast reconstruction after mastectomy. The TRAM has now been surpassed by the DIEP flap for that honor. For patient's researching their reconstructive options after mastectomy, it is important to understand the concept of TRAM surgery and how it has evolved into today's cutting edge DIEP procedure.

There are three main forms of the TRAM flap operation commonly performed by plastic surgeons:

1) The Pedicled TRAM flap: this was the first operation to describe use of one of the rectus abdominus muscles (sit-up muscle) for breast reconstruction. The surgery begins with an incision from hip to hip. Then, the lower abdominal tissue below the belly button (skin, fat and one of the abdominal muscles) is tunneled under the upper abdominal skin to the chest to create a new breast.

Recovery from the surgery can be difficult and painful. Long-term, the patient has to adapt to the loss of some abdominal strength (up to 20 %). As with any surgical procedure there is the possibility of complications. These include delayed healing, fat necrosis (part of the tissue turns hard due to poor blood supply), abdominal complications such as bulging and/or hernia, and loss of the reconstruction altogether (rare).

2) The Free TRAM flap: this procedure uses the same abdominal tissue as the pedicled TRAM except that the tissue ("flap") is disconnected from the patient's body, transplanted to the chest, and reconnected to the body using microsurgery. The main advantage of the free TRAM over the pedicled TRAM is a better blood supply and therefore less risk of healing problems and fat necrosis.

Since the tissue is disconnected and transplanted to the chest, there is also no tunneling under the skin as there is with the pedicled procedure and no subsequent upper abdominal bulge around the rib cage area (which is typically seen with tunneling).

3) The Muscle-Sparing Free TRAM flap: this operation is associated with all the benefits of the free TRAM but has fewer abdominal complications and side-effects (pain, bulging, hernia, strength loss) because the vast majority of the abdominal muscle is spared and left behind. The amount of muscle taken is typically very small (the size of a postage stamp). We will opt for a muscle-sparing free TRAM only in the extremely rare event that the patient's anatomy does not allow for a DIEP or SIEA flap.

4) The DIEP flap: This is the most advanced form of breast reconstruction surgery available today. Like the muscle-sparing free TRAM, the DIEP uses the patient's own abdominal skin and fat to reconstruct a natural, soft breast after mastectomy. Unlike the TRAM however, all the abdominal muscle is preserved.

Only abdominal skin and fat are removed similar to a "tummy tuck". Patients therefore experience less pain after surgery, enjoy a faster recovery and maintain their abdominal strength long-term. Since the abdominal muscles are saved, the risk of complications like abdominal bulging and hernia are also significantly lower. 

Abdominal Flap Breast Reconstruction Options

Learn More About DIEP Flap Breast Reconstruction


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  • Tina

    Having surgery end of March, trying to decide the best one for me.

  • PRMA Plastic Surgery

    Hi Tina, I would love to talk to you about your options. Feel free to give me a call at 210.447.7831 or email me at .(JavaScript must be enabled to view this email address). If you’d like to complete our virtual consultation to get a better idea of what type of surgery you are a candidate for, please follow this link: Let me know if you have any questions. -Brandy

  • Nicole

    I am interested in breast reconstruction. I am a breast cancer patient & I would love some more information as well as a consultation if possible.

  • PRMA Plastic Surgery

    Absolutely Pam! I will email you with some information today!

  • Cynthia

    Would love reconstruction, I have been lopsided for 8 years now. But @ 62, I may be too old….and it may be too expensive.

  • Cynthia

    Hello Cynthia! There are no age restrictions for breast reconstruction! We encourage you to give our office a call at 210-692-1181 and we can verify your insurance and provide you with a cost estimate as well as schedule your for a consultation with one of our surgeons to discuss all your options! Hope to hear from you soon!

  • Heidi Hagedorn

    I have do reconstruction & my left side is bad from radiation 8 Yrs ago. Which one would be good for me? I don’t want the one that takes my rib out.


    • PRMA

      Hey Heidi!  Typically for patients who have had prior radiation therapy, we recommend autologous flap breast reconstruction like the DIEP flap.  We believe the DIEP flap is today’s gold standard for breast reconstruction—especially when radiation is in the mix.  There is a common misconception about the rib being taken out during the DIEP.  This is actually not the case! 

      A very small portion of the rib is removed (1-2 centimeters) where it meets the sternum.  We do this because we need to get access to the blood vessels that will be providing blood flow to the tissue that is moved over from the abdomen to the chest. Removing this small portion of rib allows good exposure to the blood vessels which are very small and very delicate. There are some surgeons that do this procedure by going between the ribs instead of removing a portion of the rib. The problem with that is that it can potentially injure the blood vessels because of the limited exposure and it makes the connections of the blood vessels much more significant—adding more time to the surgery.

      The removal of the rib does not hinder the mechanics of the lungs so a woman would not experience any problems breathing after surgery. There is sometimes some pain that lingers in that area for a few weeks after surgery. Ultimately that pain resolves completely and the woman never really has any long term complications from the removal of that small portion of rib.

      Hope this info helps!

PRMA Plastic Surgery