Purpose: No consensus exists on the ideal technique to maximise abdominal wall function following bilateral autologous breast reconstruction (BR). We aimed to systematically identify strategies that minimise abdominal wall weakness, bulge and hernia rates. Methodology: A systematic review was performed using PRISMA guidelines to compare abdominal wall function following BR with abdominal flaps. 144 consecutive patients (288 flaps) who underwent bilateral abdominal-based flap BR between 2020 – 2023 were included. Surgical strategy groups were divided into: conventional single perforator DIEP with intramuscular split, medial/lateral paramuscular approach to pedicle dissection, robotic-assisted DIEP harvest, multiple perforator DIEP, SIEA flap, or muscle-sparing TRAM flap. Pre-/post- abdominal function, bulge and hernia rates and pre-/post-BREAST-Q data were evaluated. Results: Forty-one articles met the criteria for inclusion. DIEP and SIEA flaps yielded superior abdominal function compared to pedicled, free, and muscle-sparing TRAM flaps. In the series, bulge and hernia rates were 3% using more invasive techniques and 0% in SIEA, robotic-assisted and medial para-muscular pedicle dissection. These less invasive techniques demonstrated greater improvement in physical wellbeing abdomen module (BREAST-Q) and abdominal function compared to more invasive techniques. Conclusion: Less invasive flap types such as DIEP and SIEA flaps yield superior abdominal muscle function outcomes compared to TRAM flaps, both in the literature and according to our experience. More sensitive muscle function tests are needed to identify any additional utility of novel minimally invasive techniques such as robotic-assisted DIEP and medial para-muscular pedicle dissection.