To define the long-term abdominal consequences of the TRAM flap procedure, 150 consecutive patients were evaluated 5 to 7.5 years postoperatively. Of 137 surviving patients, 135 (98.5 percent) returned a questionnaire (68 single pedicle, 63 double rectus harvest, and 4 single pedicle with contralateral microvascular augmentation) and 132 (96.4 percent) were examined and tested. By questionnaire, 64 percent noted overall improvement of the abdomen, 72 percent noted improved abdominal appearance, and 20 percent noted improved posture. Decreased abdominal strength was noted by 46 percent, and decreased exercise ability was noted by 25 percent. These figures were higher after double rectus harvest (60 and 35 percent) than after single rectus harvest (35 and 16 percent) (p = 0.005 and p = 0.014, respectively). Activities of daily living were rarely (4.0 to 5.8 percent) affected. Three of the patients had uncomplicated pregnancies and deliveries (two vaginal, one cesarean section). Situp performance was worse comparing postoperative patients with unoperated controls (p < 0.0005) and comparing double rectus harvest with single rectus harvest patients (p < 0.0005). Comparing double rectus harvest patients with direct abdominal closure and those closed with mesh, there was a trend toward poorer situp performance in the mesh subgroup; however, this was not statistically significant. On examination, a classic post-TRAM hernia was not encountered in any patient, but three single-pedicle patients had asymptomatic diffuse bulges through the fascial harvest site, visible only on straining to do a situp. Eight patients (seven bilateral and one single pedicle) had varying degrees of abdominal laxity, but only one had operative correction of diffusely attenuated abdominal fascia following pregnancy and delivery. Examiners' ratings of aesthetic abdominal appearance were higher for postoperative patients than for unoperated controls (p = 0.05). The vast majority of patients considered the TRAM procedure worthwhile (93 percent) and continued to recommend it to others (96 percent).