The DIEP flap was introduced in 1989 and first reported for use in breast reconstruction in 1994. The TRAM flap was introduced a decade before the DIEP flap. Those actively doing TRAM and free TRAM flaps have occasionally encountered a situation where the technical raising of a conservative sized flap went well, yet there was a large area of flap necrosis.

Recently, with the introduction of the DIEP flap, reports have questioned its reliability and the need for drainage through the superficial venous system. The superficial inferior system, on the other hand, is often quite small making microsurgical transfer difficult.

I wish to report an algorithm for preoperative planning a reliable free autologous abdominal flap breast reconstruction.

All patients undergo Doppler exam for possible DIEP flap breast reconstruction. In addition, the superficial epigastric system is listened for at the inferior border of the proposed flap. With experience, one will be able to discern a loud sound that can be followed as a large useful perforator. Similar conclusions can be drawn for the superficial system.

In situations where the perforators were large and the superficial system was small, DIEP flap without any augmentation was appropriate. In situations where the perforators were few, low in volume and small, and the superficial system was loud and large, the superficial system was most appropriate for transfer. With the experience gained from having done over 200 DIEP flap breast reconstructions, the determination of the dominant system was able to be made over the last nine months preoperatively by Doppler exam and confirmed with intraoperative findings.

Clinical conclusion is that the DIEP system is the dominant blood supply to the lower abdominal skin and subcutaneous tissue most of the time, but in a few predictable situations, the superficial system is a better system for free flap transfer.