BACKGROUND The latissimus dorsi musculocutaneous flap has reemerged as an effective method for both immediate and delayed breast reconstruction. However, the technique is not without disadvantages, as the quality of the aesthetic result can at times be less than desired and complications at the donor site can be troublesome. It is proposed that modifications related to surgical technique and the use of higher quality expanders and implants can improve the aesthetic results while minimizing the incidence and severity of complications. METHODS Five technical modifications in surgical technique, including orientation of the skin island along the relaxed skin tension lines, harvesting the deep layer of fat with the flap, cutting the thoracodorsal nerve, partially dividing the insertion of the muscle, and using a staged expander/implant sequence, are included in an overall surgical strategy designed to reconstruct the breast in both delayed and immediate settings. RESULTS As a result of these technical modifications, a thin line and smooth donor-site scar is created in the back. The flap advances completely to the breast because of the partial release of the insertion of the muscle, and the volume provided by the flap is increased by keeping the deep layer of fat attached to the flap. This more effectively softens the contours of the reconstructed breast. Breast animation is minimized as a result of sectioning of the thoracodorsal nerve, and the consistency and quality of the result are improved by using a staged tissue expander/implant strategy. CONCLUSIONS With advancements in surgical technique and improvements in tissue expander and implant design, outstanding results can be obtained using the latissimus dorsi flap in breast reconstruction.