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Background Abdominal CT angiograms (CTA) for patients undergoing DIEP free flap breast reconstruction have been shown to accurately detect the perforator anatomy, aid pre-operative planning, and decrease operative time. However, CTA incidental findings are common and can affect patient management and operative planning. We present the largest series of CTAs reviewed for “incidentalomas.” Methods All patients undergoing breast free flap reconstruction at Long Island Jewish Medical Center between 2009 and 2013 were eligible for inclusion. 250 randomly selected patients were included. Medical history, imaging studies, and perioperative details were reviewed. For determining incidentalomas, official radiology reports were examined in detail, and any abnormal findings were recorded. Results Of 250 patients included, 18 did not have a CTA; of these, 5 had an MR angiogram instead, resulting in 237 patients with abdominal imaging. Only 76 (32%) had a negative exam with no additional findings. Five patients required additional imaging for specific findings, all of which were found to be benign. One had a large ventral hernia which required repair prior to reconstruction, resulting in an 8 month delay. Only one patient had a diagnosis concerning for malignancy, renal cell carcinoma, which required a post-operative ablation by interventional radiology. Over 30 categories of benign abnormalities were seen; 63 patients had a single finding, while 98 had between two and five. Renal (18%) and liver (17%) findings were most common, followed by gynecological (uterine 14%, ovarian 8.9%) and diverticulosis (14%). Bone cysts, islands, and degenerative changes in the pelvis (8.4%) and spine (7.6%) were also common. Forty-three (17%) patients had a known genetic mutation, 30 of which were BRCA (14 unspecified, 11 BRCA-1, 5 BRCA-2). Within this subset, 40 had abdominal imaging, 19 of which were completely negative. Of the remaining, liver (17.5%) and renal (12.5%) findings were again most common, with only 3 (7.5%) benign ovarian findings, showing no statistical difference compared to non-mutation carriers. Conclusions Preoperative abdominal CTAs were found to have abnormalities in more than two-thirds of patients, the vast majority of which were benign. Only 3% required any further intervention, affecting the operative plan in only two cases. Patients with a genetic predisposition to breast cancer showed no greater risk of unusual CTA findings.