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The DIEP flap represents further evolution of the free TRAM flap procedure. Both the DIEP flap and the free TRAM use the same abdominal skin and fat to reconstruct the breast, and the same blood supply – the deep inferior epigastric artery – to provide blood supply. The difference is that in the DIEP flap, the rectus abdominis muscle is completely spared whereas in the free TRAM a variable amount ranging from a sliver to a substantial patch of it is taken with the flap.

In some studies, the DIEP flap is associated with less pain, quicker recovery and less abdominal wall weakness than the free TRAM flap although other studies show very little difference between these procedures. The free TRAM, because of the inclusion of muscle, can support a larger flap in heavier patients or when the goal is to reconstruct a larger breast.

Depending on the pattern of circulation from the deep inferior epigastric artery, the DIEP flap may take longer to perform than the free TRAM while in other cases the operative time is very similar. Hospitalization tends to be 1 to 2 days faster with the DIEP flap and recovery 1 or 2 weeks faster but this is certainly variable between patients.

The SIEA flap represents further refinement of the free TRAM. Many individuals have a blood vessel called the superifical epigastric artery that travels above the abdominal wall muscles and also provides blood supply to the skin and fat used for a TRAM or DIEP flap. The superficial epigastric artery (SIEA) and vein (SIEV) are not always present or of adequate size for surgery, and are more susceptible to injury following previous abdominal surgery. However, when present, an SIEA flap can be raised without ever violating the abdominal wall muscles. While the DIEA flap preserves muscle, the muscle wall must still be split to retrieve the deep inferior epigastric artery. In the SIEA flap, this muscle is never touched.

The obvious advantage of the SIEA flap is minimal abdominal wall weakness – the least of any of the operations using abdominal wall tissues. The disadvantages include the fact that the appropriate anatomy may not be present or may be inadequate. Also, this flap tends to create smaller breasts, has a higher rate of blood flow problems, as well as some other technical restrictions.

Often the blood vessel anatomy is reviewed with a CT angiogram prior to surgery if a DIEP or SIEA flap is considered. This is particularly true if there is a history of previous abdominal surgery. Also, even if the CT scan identifies adequate blood vessels, there is no guarantee that a DIEA or SIEA flap will be performed. The quality of these vessels as well as a host of other considerations are made in the operating room at the time of surgery to ultimately determine whether one of these flaps is the safest option for a patient versus a free TRAM procedure, or in some cases a pedicled TRAM procedure.

To find out which form of breast reconstruction is right for you, learn more about the different types of flaps, review photos, or testimonials, please visit us online at


Browse a photo gallery of Washington University Physician patients' before and after photos of breast reconstructions.

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