BACKGROUND: Deep inferior epigastric artery perforator (DIEP) flaps are widely used in autologous breast reconstruction and increasingly favored due to superior patient-reported outcomes. Preoperative imaging is central to efficient and safe DIEP flap planning, yet the optimal modality remains debated. While computed tomography angiography (CTA) is recommended by ERAS protocols, concerns over radiation exposure and cost have prompted interest in alternatives such as ultrasound (US) and magnetic resonance angiography (MRA). METHODS: A systematic review following PRISMA guidelines was conducted across five major databases, including clinical trials and observational studies published through 2025. Studies included patients undergoing DIEP flap reconstruction with preoperative imaging using CTA, US, MRA, or other modalities. Data extracted included imaging-to-surgical perforator correlation, operative time, complication rates, and flap outcomes. Meta-analyses and heterogeneity assessments were performed using STATA. RESULTS: Thirty-two studies encompassing 3238 patients were included. CTA was used in nearly all studies; US, MRA, SPY/ICG, and DIRT were evaluated in a subset. Pooled perforator utilization was highest with MRA (92%), followed by CTA (87%) and US (85%). Among 2967 patients with complication data, 410 (13.8%) experienced adverse outcomes. Complication rates differed significantly across strategies. Patients utilizing US alone experienced the highest complication rates (17.3%), compared to CTA alone (13.9%) and CTA and US (10.8%). The complication rate difference between US alone patients and CTA and US alone patients was statistically greater (RR = 0.63, p = 0.0123). The complication rates between CTA alone and US alone or CTA and US were not statistically different (US alone: RR = 0.81, p = 0.1040; CTA and US: RR = 0.78, p = 0.11). Complete flap loss occurred in 8.0% of complications, partial flap loss in 14%, and fat necrosis in 19%. CONCLUSION: CTA remains the most studied imaging modality for DIEP flap surgical planning, demonstrating high perforator utilization and low complication rates. Combining CTA with US may further improve outcomes by integrating anatomical precision with dynamic feedback. As newer, lower-risk imaging technologies emerge, comparative studies are needed to determine whether they can match or exceed the performance of CTA in DIEP reconstruction.