Although the use of the latissimus flap has remained stable or decreased in frequency over the past few years, inclusion of the subcutaneous adipose tissue to circumvent the need for an implant has become a popular option, especially in obese patients. If immediate breast reconstruction is being performed, a tissue expander can be placed at the time of the mastectomy under the muscle. If used in skin-sparing mastectomy, a small central skin island is designed and the flap is usually placed directly under the skin. Patients who have tissue expanders placed under the latissimus dorsi flap usually undergo tissue expansion starting at 2 weeks when the incisions are healed. The autologous tissue of the reconstructed breast is a perfect recipient for microdroplet fat grafting, which can often restore skin suppleness and soften the reconstruction following radiotherapy. The markings should be done in a standing position after evaluation of the quantity of tissue which is available for the flap.