The latissimus dorsi myocutaneous flap has proved valuable in breast reconstruction after radical mastectomy. The procedure has been used often and successfully at the Breast Reconstruction Center of Memorial Sloan-Kettering Cancer Center. Since the axis of the mastectomy scar often varies, we have found that adjusting the orientation and location of the skin islands is necessary to achieve maximal coverage on the chest wall and to place the transposed skin without tension precisely where it is most needed. These different skin island designs may necessitate a scar on the back that is not covered by a brassiere. This paper discusses and illustrates with clinical examples modifications that produce superior reconstructive results.