A hole in the diaphragm requiring an exogenous material for repair is exceedingly unusual. Unfortunately, many nearby potential flap options for this role have frequently already been violated by prior thoracotomies. The ipsilateral superior-pedicled lower transverse rectus abdominis musculocutaneous (TRAM) flap could then be an important maneuver for salvage. Via a tunnel leading into the chest cavity, a deepithelialized TRAM flap can readily reach basilar thoracic defects, and[U0292] thus is particularly suited as an autogenous patch for the diaphragm.