Introduction: The internal mammary IM vessels are our first choice for free flap breast reconstruction. This may result in pain and thoracic deformity. Our efforts in reducing morbidity took us to adopt an algorithm in free flap breast reconstruction and also to salvage compromised free flaps. Material and Methods: The IM perforators are looked for during the undermining of breast skin. If no suitable perforator is found, the pectoralis major PM muscle is split at the level of the 4th rib. The PM muscle is dissected cranially to look for a good size perforator. The internal mammary vessels will be considered for the microanastomosis in case the perforator is small. The IM perforator can also be used as an additional recipient vein in case of congested free flap or venous thrombosis. The thoracodorsal TD vessels are used as an additional blood supply or drainage in case a large flap is indicated. The thoracodorsal vessels are spared if a latissimus dorsi flap is needed as a secondary procedure. Thoraco-acromial vessels are considered as a life-boat for a flap with late venous thrombosis. Results: This protocole was used on our patients between June 1999 and Dec 2001. Breast reconstruction with free flaps was done on 218 patients with perforator flaps. IM, TD and thoraco-acromial vessels are used on 180 patients (82%), 10 (4.5%)and in one case (0.5%) respectively. IM perforators were successfully used in 27 cases (12.5%) but a revision of arterial thrombosis occurred in one case, resulting in partial flap necrosis. Operative time was decreased by 60 minutes by limiting the dissection of recipient vessels and of the main pedicle of the flap. Conclusion: Using IM perforators as recipient vessels spare the IM vessels for eventual cardiac bypass surgery, avoiding recipient site morbidity and decreasing the postoperative discomfort.