Tram Versus Diep Flaps in Autologous Breast Reconstruction: Donor-Site Morbidity, Flap Outcomes, And Patient-Reported Results

Abstract

Autologous breast reconstruction using lower abdominal tissue remains one of the most important options after mastectomy. The transverse rectus abdominis myocutaneous flap and the deep inferior epigastric perforator flap both provide reliable volume, natural contour, and durable long-term reconstruction. However, they differ substantially in abdominal wall morbidity, operative complexity, flap perfusion, and patient selection. The TRAM flap may be pedicled, free, or muscle-sparing, and outcomes vary considerably according to subtype. Pedicled TRAM flaps are technically reliable but sacrifice more rectus abdominis muscle and are associated with higher rates of abdominal bulge, hernia, and need for mesh repair. Free and muscle-sparing TRAM flaps reduce some donor-site morbidity while preserving robust flap perfusion. DIEP flaps preserve the rectus muscle and anterior rectus sheath to a greater extent, generally reducing abdominal wall complications and improving abdominal well-being, especially compared with pedicled TRAM. However, DIEP reconstruction requires perforator dissection, microsurgical expertise, longer operative time, and may be associated with perfusion-related complications in selected anatomy. Current evidence suggests that DIEP is generally preferred when perforator anatomy and surgical expertise allow, while muscle-sparing or free TRAM remains valuable when flap volume, perfusion reliability, or anatomy favors inclusion of muscle. This review summarizes the anatomical basis, indications, outcomes, donor-site morbidity, flap complications, patient-reported outcomes, and practical decision-making between TRAM and DIEP flaps.