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Differences Between TRAM Flap and DIEP Flap

Category: | Posted on: September 26, 2014 Updated on: June 29, 2020 | Author:

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.

TRAM Flap vs DIEP Flap: Know the difference

TRAM and DIEP flaps are the foremost techniques used for breast reconstruction after mastectomy. Both procedures borrow tissue from a similar part of the body: the lower abdomen. However, this is where the similarities end and the long list of differences begins.

The Blood Supply

For any tissue flap to survive, it must have a viable blood supply that can deliver oxygen and nutrients, as well as remove toxic byproducts. This blood supply is carried into a flap by an artery and transported out of the flap by a vein.

The blood vessels present in the flaps differ between TRAM and DIEP flaps:

  • A traditional pedicle TRAM flap is connected to blood vessels that have to travel from the chest down to the belly button. It’s a long haul even after the flap is transferred.
  • 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.

Type of Tissue Transferred

In plastic surgery, there are several different ways to move tissue from the donor site to the recipient site:

  • The traditional TRAM flap is based on a pedicle, or leash, of muscle through which the arteries and veins travel to the island of skin and fat. 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.
  • The advent of microsurgery eventually gave way to the muscle-sparing free TRAM flap technique. The abdominal muscle, its associated blood vessels, fat tissue, and skin are removed completely from the abdomen and transplanted to the breast. The blood vessels are reattached under a microscope.
  • 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 not removed. Once freed up, the tissue is literally transplanted to the chest where the artery and vein are connected to the recipient’s vessels on the chest. Just like free TRAM flaps, this part is done under a microscope and can be technically challenging.
  • The main difference here is that the TRAM flap sacrifices the six-pack muscles, while the DIEP flap SPARES them. The former has potentially major long-term implications on the abdominal wall.

Recovery and Long Term Effects on the Abdomen

Because of the location of both TRAM and DIEP flaps, many women are concerned about its effects on the midsection.

  • TRAM flap procedures affect the abdominal muscle, so future complications are a possibility. This includes, but is not limited to, a weakened abdomen, loss of core strength, and increased likelihood of bulges or hernia. The recovery from a TRAM flap procedure is also far more intensive. Still, the abdomen ends up looking smaller and flatter afterward.
  • DIEP flap breast reconstruction has been compared to a tummy tuck, as the abdomen also loses a large amount of fat and skin without touching the muscle. The suturing of the area where the flap was taken from also has a similar skin tightening effect as a tummy tuck.
  • In conclusion, both TRAM and DIEP flap reconstruction give you a smaller midsection, but the latter runs a minimal risk of affecting abdominal strength in the future. As a bonus, recovery time from DIEP flap procedures is much shorter and easier.

The sensation on the breasts

Breast reconstruction surgery patients often wonder if breast reconstruction can restore sensation to their breasts.

  • TRAM flaps do not have the capability to maintain nervous connections. This is due to the muscles attached to the pedicle or the free flap does not have any associated nerve cells.
  • During DIEP Flap procedures, a sensory nerve that provides feeling to the former lower abdomen can be included in the transplant. Like blood vessels, these nerves are reconnected via microsurgery.
  • Unless the patient had a nipple-sparing mastectomy, neither procedure can restore sensation to reconstructed nipples and areola. This holds true whether the nipples are reconstructed via skin grafts, skin flaps, or medical tattoos.

These are the major differences between TRAM and DIEP flaps.

Regardless of your reconstruction choice

Always choose a board-certified plastic surgeon to attain the best results.

As always, if you have questions or comments, you may write it down in the box below or send them our way as we are always interested in hearing from our readers: info@mwbreast.com.



About the Author


Dr. Ergun Kocak, MD, 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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*Our blog entries are written in order to further educate our patients and raise awareness towards topics related to plastic surgery. Any solutions offered on this blog are intended to help possible patients develop educated decisions before undergoing a consultation with our doctors.

2 thoughts on “Differences Between TRAM Flap and DIEP Flap”

  • Avatar Saundra

    I had TRAM surgery over 20 years ago and have had ongoing abdominal swelling. I exercise 5-6 times a week. Crunches etc seem to make it worse and I start experiencing pain. Do I just need to come to grips that I will never have a flat stomach again?

    • Pankaj Tiwari, MD Pankaj Tiwari, MD

      Unlike the DIEP flap which spares the rectus (six-pack) muscles, the TRAM procedure uses these muscles to carry the tissue to the chest area for the reconstruction. A common consequence of the TRAM procedure is abdominal wall bulge and/or hernia. In some cases, the bulge/hernia can be repaired, but this is best done by a specialized abdominal wall and hernia repair team that has multiple specialties, such as plastic surgery and general surgery, involved. We would encourage you to find such a team in your area for consultation.

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