Purpose: In the present study, we compare the esthetic outcome in delayed autologous breast reconstruction, in the spectrum of irradiated chest wall, following two different abdominal flap inset. Patients and methods: Fifty women, candidates for microsurgical reconstruction with a free deep inferior epigastric perforator (DIEP) flap, participated in this prospective, randomized control study. In group-A (n=25) the flap was inset using the traditional single plane in front of the pectoral muscle. In group-B (n=25) the flap was inset in a dual plane lying simultaneously behind and in front of the pectoralis major at the upper and lower poles of the reconstructed breast, respectively. Photographic images were formulated to a PowerPoint presentation and cosmetic outcomes were assessed by means of a questionnaire and a visual analog scale. Results: The dual plane flap inset presented significant advantages over the traditional single plane because of a better scarring (85.6 +/- 1.3 vs. 73.6 +/- 1.2, P < 0.05), better transition from native and reconstructed tissues (90.2 +/- 1.5 vs. 81.5.6 +/- 1.6, P < 0.05), better outline of the breast (96.3 +/- 1.2 vs. 69.6 +/- 2.1, P<0.0001), and better overal breast appearance (86 +/- 1.5 vs. 72.2 +/- 1.9, P < 0.0001). Moreover, patient self-evaluation showed that dual plane reconstruction was associated with higher patient satisfaction without wearing brassiere (P=0.0016), and this could be attributed to the significantly greater fullness of the upper pole (P=0.0015) and significantly less ptosis with time (P=0.0014). Conclusion: The dual plane DIEP flap inset improves scar quality, advances the breast shape and fullness of the upper pole, and results in higher patient satisfaction. (C) 2015 Wiley Periodicals, Inc.