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The field of breast reconstruction has undergone tremendous advancement over the years both in terms of prosthesis-based reconstruction as well as autologous breast reconstruction. In the modern era, the abdomen represents the most commonly used donor site for autologous breast reconstruction. The traditional transverse rectus abdominis myocutaneous (TRAM) flap has been gradually replaced with musclesparing flaps of the abdominal musculature in hopes of minimizing donor site morbidity. The muscle-sparing TRAM, deep inferior epigastric perforator (DIEP) flap, and superficial inferior epigastric artery (SIEA) flap have gained in popularity, with the DIEP representing the gold standard in autologous microvascular breast reconstruction. However, in certain circumstances a traditional DIEP may not be possible, and modifications and alternate donor sites have to be considered. The goals pursued by any breast reconstruction should consider the following aspects: symmetry, shape, ptosis, natural movement, softness and sensitivity. This review aims to discuss the evolution and innovation in the abdominal donor site as well as to introduce alternate donor sites that can be used for free tissue breast reconstruction. Our purpose is to analyze the various alternative options that can be used in breast reconstruction considering the advantages and the disadvantages of each flap. This review can help plastic surgeons to construct an algorithm for choosing the appropriate alternative free flap for breast reconstruction when the DIEP flap is not available.

Autologous breast reconstruction beyond the DIEP: a narrative review of autologous breast reconstruction options beyond the DIEP flap