Muscle sparing abdominal flaps are an improved method of autologous microsurgical breast reconstruction that offer preservation of abdominal wall integrity. Flap choices include the Deep Inferior Epigastric Perforator (DIEP) flap and the Superficial Inferior Epigastric Artery (SIEA) flap. The anatomic variability of SIEA anatomy and perforator variability in the DIEP flap pose a considerable challenge and flap success may depend enormously on the choice of vessels. Therefore an intra-operative algorithm for flap selection can increase the reliability of the chosen flap and decrease the operative time. We present our intra-operative algorithm for step-by-step vessel and flap selection that was applied to 100 muscle sparing abdominal flaps. Pre-operative evaluation with an 8 mHz handheld Doppler was performed to obtain a road map for vessel location and size. The intra-operative algorithm that was applied for unilateral breast reconstruction is as follows:

The aim of the algorithm presented is to provide a clinically relevant decision tree for improvements in harvesting of muscle sparing abdominal flaps for breast reconstruction.