Introduction: Transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flaps are the most common abdominally based breast reconstruction procedures. Each technique has its advantages and disadvantages; however, how morbidity relates to satisfaction is not well-understood. Our aim was to compare complications and patient-reported outcomes following pedicled TRAM (pTRAM), free TRAM (fTRAM), and DIEP flaps to guide flap selection. Methods: A systematic literature search was conducted, and 2 independent reviewers identified comparative studies of abdominally based flaps. Data were extracted on patient characteristics, complications, and patient-reported outcomes. Meta-analyses were conducted using random effects modeling with the DerSimonian and Laird method. Results: The search retrieved 5090 articles, of which 18 were included in this review. pTRAM flaps trended toward a higher risk of abdominal bulge/hernia compared with DIEP flaps, particularly in low-volume hospitals. While fTRAM flaps had a higher risk of abdominal morbidity compared with DIEP flaps, relative risk decreased when obese patients were excluded and when only muscle-sparing fTRAM flaps were compared. Muscle-sparing flaps had a higher risk of flap loss than fTRAM flaps. Compared with DIEP flaps, pTRAM flaps were associated with lower general satisfaction but comparable emotional well-being. Conclusions: Our findings indicate that safety and satisfaction following abdominally based breast reconstruction depend on flap type and patient characteristics. When possible, DIEP or muscle-sparing fTRAM flaps should be performed for obese patients to decrease the risk of abdominal bulge/hernia. Although pTRAM flaps are associated with a greater risk of flap loss, they are still an appropriate option when microsurgery is not available.