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Microsurgical autologous breast reconstruction has evolved significantly over the last three decades. The muscle-sparing transverse rectus abdominis musculocutaneous (TRAM), deep inferior epigastric artery perforator, and superficial inferior epigastric artery flaps have been developed to minimize abdominal donor-site morbidity. Assuming that harvest of the superficial inferior epigastric artery flap has the same impact on abdominal wall morbidity as performing an abdominoplasty, the authors designed a matched-pair analysis comparing patients' abdominal wall strength after muscle-sparing TRAM flap reconstruction with that after abdominoplasty.A total of 104 patients were included in the study. Fifty-two TRAM flap patients were matched with 52 abdominoplasty patients for age and body mass index. Outcome measures included postoperative complications, particularly hernia and abdominal bulge formation. Two surveys were used to assess patient satisfaction as well as the impact of the procedure on everyday life.Both study groups were similar with regard to age, body mass index, past medical history, and postoperative complication rate, including hernia and abdominal bulge formation. Results were similar between the study groups, with the exception of a higher rate of satisfaction with the appearance of the abdominal scar among TRAM flap patients (p = 0.03) as well a lower likelihood of TRAM flap patients to engaging in sporting activities postoperatively (p = 0.01).In the present study, the muscle-sparing TRAM flap did not result in a higher rate of postoperative complications related to abdominal wall morbidity. Differences observed regarding the postoperative level of activity are unlikely to be related to the surgical insult to the abdominal wall.