The incidence of postoperative abdominal bulge, hernia, and the ability to do sit-ups was reviewed in a series of 268 patients who had undergone free TRAM (FTRAM) or conventional TRAM (CTRAM) flap breast reconstruction. Minimum follow-up was 6 months. Patients were divided into four groups: unilateral FTRAM (FT1P; n = 123), double-pedicle bilateral FTRAM (FT2P; n = 45), single-pedicle CTRAM (CT1P; n = 40), and double-pedicle or bilateral CTRAM (CT2P; n = 60). The incidence of abdominal bulges (3.8 percent) and hernia (2.6 percent) was similar in the four groups. Synthetic mesh, however, was required for reinforcement of donor site closure twice as often in the CTRAM patients. The ability to perform sit-ups was greatest in the FT1P group (63.0 percent), slightly lower in the CT1P group (57.1 percent), still lower in the FT2P group (46.2 percent), and lowest in the CT2P group (27.1 percent; p = 0.0005). Patients reconstructed with an FTRAM flap were more likely to be able to do sit-ups (58.3 percent) than were those reconstructed with a CTRAM flap (38.2 percent; p = 0.0074). Patients who had only one muscle pedicle used were more likely to be able to do sit-ups (61.7 percent) than were those who had two muscle pedicles used (35.6 percent; p = 0.0003). We conclude that the incidence of abdominal bulge or hernia is relatively independent of the type of TRAM flap used and the number of muscle pedicles harvested. On the other hand, postoperative abdominal strength, as measured by the ability do sit-ups, is influenced significantly by both of these factors.