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How do DIEP flaps differ from TRAM flaps?

Differences Between TRAM flap and DIEP Flap Part 1


The field of Medicine is a very large and complicated one. With so many specialties and subspecialties, it is almost impossible for any one person, even medical professionals who have dedicated their careers to its practice, to know about all of them. That is why I am not surprised when not just our patients, but even medical professionals and physicians from other specialties, are confused about the differences between TRAM and DIEP flaps.

Differences between TRAM flap and DIEP Flap.

The TRAM and DIEP flaps borrow tissue from a similar part of the body (the lower abdomen). But, this is where the similarities end, and the long list of differences begins:


  • The blood supply. For any tissue flap to survive, it must be based on a blood supply that can sustain that tissue’s vital needs, such as the delivery of oxygen and nutrients into and the clearance of toxic byproducts made by cells out of the flap. This blood supply is carried into a flap by an artery and transported out of the flap by a vein.
    • A traditional TRAM flap is based on blood vessels that have to travel a long distance, all the way from the chest down to below the belly button. While these vessels can bring blood to and from the tissue in that location, it’s a long haul.
    • The DIEP flap, on the other hand, is based on blood vessels that travel a short distance from the nearby groin region. These vessels are the dominant source of blood to the skin and fat of the lower abdomen.
    • This difference in blood supply is why side effects which reflect poor delivery of oxygen and nutrients, such as fat necrosis, occur more often in TRAM flaps than in DIEP flaps.
  • The way the tissue is moved. In plastic surgery, there are several different ways to move tissue from one part of the body (a donor site) to a new part of the body (the recipient site).
    • The traditional TRAM flap is based on a pedicle, or leash, of muscle through which the arteries and veins to the island of skin and fat travel. In this operation, the flap remains connected to the body by the upper end of the six-pack muscle. The flap is then rotated from the lower abdomen upward, and passed under the skin of the upper abdomen, to deliver it to the chest where it used to reconstruct the breast.
    • In the DIEP flap, the skin, fat, and blood vessels are carefully removed from the lower abdomen. While the blood vessels are followed through the six-pack muscle, the muscle, and its nerves, are kept largely intact and no muscle is removed. Once freed up, the tissue is literally transplanted to the chest where the artery and vein are connected to recipient vessels on the chest. This part is done under a microscope and can be technically quite challenging.
    • The main difference here is that the TRAM flap sacrifices the six-pack muscles, while the DIEP flap SPARES them. This potentially has major implications on the abdominal wall in terms of core strength and the likelihood for bulges or hernias after surgery.

Many other differences between DIEP flaps and TRAM flaps exist, so please visit our blog often for the next part in this series of blogs. As always, if you have questions or comments, please send them our way as we are always interested in hearing from our readers: [email protected]

About the Author

Ergun Kocak

Dr. Ergun Kocak, MD, MS, is a board-certified plastic surgeon who specializes in plastic and reconstructive surgery of the breast using DIEP, SIEA GAP, TUG, PAP, and direct-to-implant, in Columbus and Cincinnati, OH.
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