All these flaps incorporate the lower abdominal skin and fatty tissue from the region of the umbilicus superiorly, down towards the pubic region inferiorly. This tissue is harvested in an elliptical fashion and the incision is closed similar to a tummy tuck. The main difference is what is included with this fat and skin tissue flap for the different named procedures. A pedicled TRAM (transverse rectus abdominus myocutaneous) flap consists of the underlying rectus muscle with the overlying skin and subcutaneous fat. The blood supply for this pedicled flap, or a flap that has its blood supply still in continuity without being detached, actually comes from above by the rib cage. In this case, the superior epigastric artery and vein are the blood supply for this flap. The tissue is tunneled into the chest defect from underneath the abdominal flap and across the inframammary fold. The free TRAM flap is similar except for the blood supply which is divided and re-attached into the chest. The vessels used for re-attachment of the flap’s blood supply is based upon the inferior epigastric artery and vein. In this case, a small amount of the rectus muscle is also still attached to the overlying skin and subcutaneous tissue. The DIEP (deep inferior epigastric artery perforator) flap is one step more refined than the free TRAM in that \\u201cno muscle\\u201d is taken with the flap. The same artery and vein are still used and the overlying fascia still has to be entered to get to the vessels. The SIEA flap is based upon the superficial inferior epigastric artery that is in a superficial fatty layer in the lower abdomen. Usually, this artery and its accompanying vein can be used to support the blood supply to the flap and this eliminates entering the abdominal wall fascia to get to the vessels.