DIEP | SIEA | TRAM Free Flap

DIEP | SIEA | TRAM Free Flap – Orange County | Newport

The pedicled TRAM flap remains the standard of care in the United States; however, Dr. Seify has experienced using advanced microsurgical techniques that are designed to provide women with more elegant, optimal solutions utilizing abdominal tissue. These options create better aesthetic results with less donor site complications. However, these procedures take longer to perform with a potential for different complications including total flap loss. The success rate for transferring tissue using these methods is extremely high when performed by Dr. Seify due to his experience in microsurgery as well as monitoring flaps. However, should blood vessel thrombosis(blood clots) occur in the flap that has been


The deep inferior epigastric perforator (DIEP) flap is based on the deep inferior epigastric vessels, an artery and vein at the bottom of the rectus abdominis muscle. These vessels are responsible for the main blood supply to the skin and fat in the lower abdomen. In the DIEP flap, the lower abdominal skin and fat is removed without the need to harvest any of the rectus abdominis muscle. Alternatively, blood supply is maintained through the perforator vessels which are teased out from the rectus muscle, using only a muscle incision. Dr. Seify will decide in the operating room how many perforators will be needed to allow for sufficient blood supply for the DIEP flap to survive.

After the DEIP flap is raised, a microscope is utilized to transplant the tissue to the receiving site of blood vessels on the chest wall. The tissue is utilized to create a breast shape without the need to tunnel underneath the skin as required for the TRAM flap.

In an effort to avoid using any muscle, it takes longer to harvest a DIEP flap than a TRAM flap. However, this results in the advantage of reducing injury to the abdominal wall muscle, which results in less pain, and a reduced risk of hernia formation when compared with TRAM flaps.


An additional option free flap that uses the skin and fat of the lower abdomen is the superficial inferior epigastric artery flap (SIEA). The SIEA flap requires no incision through the abdominal muscle due to the fact that it does not use the deep inferior epigastric vessels. With an SIEA flap, Dr. Seify makes incisions in the skin and fat only, allowing the flap to be transferred based on the superficial inferior epigastric vessels. This will allow for reduced postoperative pain, and eliminates the risk of hernia formation.

Just as with the DIEP flap, the SIEA flap is initially harvested and later transplanted to the chest wall and then a microscope is used to attach the flap vessels to a receiving set of blood vessels on the chest wall. The tissue is then used for Dr. Seify to create a breast shape.

In reality, only a small portion of patients are candidates for the SIEA flap due to the fact that the superficial vessels are extremely small, which limits flap volume, and increases the chance of flap loss. For some patients, these vessels may not be present any longer due to previous surgeries including cesarean section, abdominoplasty, or hysterectomy.

The TRAM free flap is like the DIEP flap because this type of flap is also based on the deep inferior epigastric vessels. In the TRAM free flap, Dr. Seify removes the the lower abdominal skin and fat with a small amount of rectus muscle. The portion of muscle removed contains the blood vessels within the flap.

Dr. Seify utilizing a microscope, prepares the TRAM free flap to be transplanted to a receiving set of blood vessels on the chest wall. Just as with the DIEP or SIEA flaps, the tissue is used to create a breast shape without the need to tunnel under the skin.

The advantages of this surgery when compared to pedicled TRAM flap are based on two major factors. First, a small amount of the rectus muscle is used so this results in less postoperative pain, and less risk of abdominal bulge or hernia formation. Secondly, the blood flow to the skin and fat is allowed to remain more productive than that of the TRAM flap. This allows for more abdominal tissue to be transferred safely and patients who are not suitable candidates for the TRAM flap method can usually be accommodated using this method.

The disadvantage of the TRAM free flap is that the small amount of muscle utilized still remains more than what is used in the DIEP or SIEA flap approaches in which no muscle is used at all. As a result, when compared to DIEP and SIEA flaps, the risk of abdominal weakness is somewhat higher when the TRAM free flap is performed.

Choosing the Abdominal Free Flap

For patients who are planning for breast reconstruction using abdominal microvascular free flaps, Dr. Seify will explain the risk and limitations of these methods. Ultimately, the final choice of using the free flap method depends on the patient’s anatomy. During surgery, the superficial vessels utilized for a SIEA flap can be performed without making incisions to the muscle or harvesting any muscle. The perforators from the deep system are exposed so that the DIEP flap can be elevated. Provided these perforator vessels are sufficient, the DIEP flap can be completed. If the perforator vessels are discovered to be insufficient, the operation can be converted to a free TRAM flap.

The required to surgery time for the abdominal microvascular free flap procedure can range from 5 to 7 hours for a unilateral breast reconstruction to 7 to 12 hours for bilateral breast reconstruction. The hospital stay is usually 3 to 5 days and the recovery could take up to several weeks before the ability to return to regular activity.

The length of surgery for abdominal microvascular free flaps can range from five to seven hours for one breast, and seven to twelve hours for both breasts. The hospital stay is typically three to five days, and the recovery can take several weeks before returning to a regular activity level. Secondary procedures following free flap breast reconstruction can be performed in approximately 3 months. However, if chemotherapy is indicated, additional surgery must be postponed until the completion of treatment. Once the patient has been medically cleared they can have revisions to the breast and abdomen performed and the nipple areola can be created. These procedures are typically performed on an outpatient basis and have rapid recovery.

Ideal candidates for abdominal microvascular free flap breast reconstruction include but are not limited to:

  • Patients desire for autogeneous reconstruction, and  to minimize muscle loss
  • Patients who have sufficient lower abdominal wall tissue to create one or both breasts
  • Patients who have less than optimal tissue at the mastectomy site
  • Patients who have been previously radiated
  • Patients who have had failed implant reconstruction
  • Patients who are having immediate reconstruction at the time of skin-sparing mastectomy
  • Patients who are having delayed reconstruction following prior mastectomy
  • Patients who would like reconstruction to fix a lumpectomy or quadrantectomy defect

Patients who are not an ideal candidate for abdominal microvascular free flap breast reconstruction include:

  • Patients who do not have sufficient lower abdominal tissue to create the flaps
  • Patients who have had previous abdominal surgical procedures such as abdominoplasty (a C-section scar is usually okay)
  • Patients who cannot tolerate anesthesia for long periods

See more procedures and treatments by Plastic Surgeon Dr. Hisham Seify in Newport Beach | Orange County